Rhinological and Otological Society, Inc.
C 2011 The American Laryngological,
Incidence of Revision Adenoidectomy in Children
Christopher R. Grindle, MD; Ryan C. Murray, MD; Sri K. Chennupati, MD; Patrick C. Barth, MD;
James S. Reilly, MD
Objective/Hypothesis: Adenoidectomy is a frequently performed procedure in the pediatric population. Revision rates
and indications for a second procedure in children are scarce.
Study Design: Retrospective cohort study.
Methods: Patient records at a multistate pediatric healthcare system were searched for all CPT codes that included
adenoidectomy in children less than 12 years of age for a 5-year period (2005–2010). A subset of patients was identified for
whom the same CPT codes appeared more than once in this 5-year period. The indication, age, gender, adenoid size, and tech-
nique of adenoidectomy were recorded.
Results: A total of 23,612 occurrences of the CPT codes were identified. The subset of patients with multiple CPT codes,
indicating revision adenoidectomy, included 304 records (1.3%). Mean age at first procedure was 2.8 years (SD ¼ 1.7 years).
Mean age at second procedure was 4.7 years (SD ¼ 1.99 years). Mean interval between procedures was 1.8 years (SD ¼ 1.1
Conclusions: Revision adenoidectomy occurs at a rate of 1.3%. Reasons for revision include persistence symptoms rang-
ing from adenoiditis to recurrent otitis to obstructive sleep apnea.
Key Words: Adenoidectomy, microdebrider, coblation, monopolar electrocautery, revision surgery.
Level of Evidence: 2b.
Laryngoscope, 121:2128–2130, 2011
Adenoidectomy and adenotonsillectomy continue to
be among the most commonly performed surgical proce-
dures in the United States. Estimates place the number
of adenoidectomies and adenotonsillectomies performed
in the United States in 2006 at 129,540 and 506,788
adenotonsillar hypertrophy, upper airway resistance syn-
drome, obstructive sleep apnea, chronic adenoiditis,
chronic otitis media with effusion, and chronic rhinosi-
adenoidectomy. These include nonvisualized curettage,
curettage with digital palpation, curettage with visual-
ization, suction monopolar electrocautery, microdebrider,
endoscope assisted, and Coblation adenoidectomy. Multi-
ple studies have reported a 70–100% improvement of
quality of life and symptoms.2–7
Many clinicians observe that there are children who
do regress after initial adenoidectomy. Studies have sug-
exist for performing
gested that regrowth of adenoid tissue may occur in 19
to 26% of children.8Some of these children may require
This study examined a large population of children
to determine the rate of revision adenoidectomy.
MATERIALS AND METHODS
After obtaining appropriate institutional review board ap-
proval, the medical records of a multistate, pediatric healthcare
system were searched for occurrences of CPT codes associated
with adenoidectomy in children <12 years of age (42,820 adeno-
tonsillectomy <12 years, 42,830 adenoidectomy <12). The
records were searched over a 5-year period (January 2005–
March 2010). Revision adenoidectomy was defined as two occur-
rences, at separate dates, of an adenoidectomy code for the
same medical record number. This subset of patients was fur-
ther analyzed. Data were extracted from the available operative
notes within the electronic medical record for indications for
procedures, surgical technique used for adenoidectomy, and size
of adenoids. Size was subjectively graded and reported based
upon a numerical scale. An adenoid size of 1þ denotes 0–25%
obstruction of the choanae, 2þ denotes 25–50% obstruction, 3þ
denotes 50–75% obstruction, and 4þ denotes 75–100% obstruc-
tion. There were four separate adenoidectomy techniques used
by surgeons in this study.
There were 23,612 records identified for adenoidec-
tomy or adenotonsillectomy in children less than 12.
Search for second occurrence of CPT code showed 304
records, giving a revision rate of 1.3%. All adenoidecto-
mies were performedat
hospital. Mean age at first procedure was 2.8 years (SD
¼ 1.7 years). Mean age at second procedure was 4.7
From the Connecticut Children’s Medical Center (C.R.G.), Hartford,
Connecticut, U.S.A. Nemours–AI duPont Hospital for Children (R.C.M.,
P.C.B., J.S.R.), Wilmington, Deleware, U.S.A.; and Drexel University College
of Medicine (S.K.C) Philadelphia, Pennsylvania, U.S.A. Thomas Jefferson
University (C.R.G., R.C.M., P.C.B, J.S.R.), Philadelphia, Pennslyvania, U.S.A.
Editor’s Note: This Manuscript was accepted for publication March
The authors have no financial disclosures for this article.
The authors have no conflicts of interest to disclose.
Send correspondence to Dr. Christopher R. Grindle, Division of
Otolaryngology—Head and Neck Surgery, Connecticut Chiildren’s Medi-
cal Center, 282 Washington Street Hartford, CT 06106.
Laryngoscope 121: October 2011Grindle et al.: Revision Adenoidectomy in Children
years (SD ¼ 2.0 years). Mean interval between proce-
dures was 1.8 years (SD ¼ 1.1 years).
The operative reports of 99/304 patients were avail-
able via the electronic medical record for further, detailed
review. Mean size of adenoidal tissue at initial procedure
was 3.5 (SD ¼ 0.59). Mean size of adenoidal tissue at revi-
sion procedure was 1.76 (SD ¼ 0.95) (Table I). Indications
for procedure are listed in Table II). The most common
indications were adenoid hypertrophy (77 vs. 63%), per-
sistent otitis media (42 vs. 20%), and obstructive sleep
apnea (10 vs. 13%).
Technique for initial adenoidectomy was monopolar
electrocautery in 55/99 cases (56%). Microdebrider was
used in 22/99 cases (22%), curette was used in 21/99
cases (21%), and Coblation was used in only 1/99 cases
We have reported a need for revision adenoidectomy
of 1.3% for a large population of children under 12 years
of age. The initial procedure was performed at 2.8 years
of age and the reoccurrence of symptoms were noted by
4.7 years. The causes of regrowth and the indications for
revision surgery appear similar to the indications for the
As a component of Waldeyer’s ring, the adenoid tis-
sue is situated in the nasopharynx and consists of fronds
of lymphoid tissue. Size increases in this tissue during
the first 12 years of childhood is well reported and may
be the result of genetic factors, viruses, bacteria, and
other allergens. The symptoms associated with adenoid
hypertrophy include upper airway obstruction, obstruc-
rhinosinusitis, and chronic otitis media with effusion.
Adenoidectomy is successful for most in relieving these
There are, however, some patients who develop
recurrent or persistent symptoms and seek revision ade-
adenoidectomy is lacking. A 2008 study by Monroy
et al.9of over 13,000 adenoidectomies over an 11 year
period showed a 0.55% revision rate. A 2008 study by
Joshua et al.2on long-term follow-up after adenoidec-
adenoidectomy, but suggested that adenoid regrowth or
persistence may be related to the ‘‘surgical difficulty
encountered by the indirect access to the adenoid pad’’
and adenoid tissue that ‘‘lacks discrete borders.’’ Other
etiologies proposed for recurrence of symptoms after ade-
on rates ofrevision
noidectomy include persistence of tubal tonsil tissue10
Various methods have been employed to perform
adenoidectomy. These range from nonvisualized curet-
tage to endoscope assisted, adenoidectomy. A recent
study11surveyed the practice patterns of 120 pediatric
otolaryngologists and found that the most common tech-
nique was monopolar electrocautery (26%), followed by
curette with cautery touch-up (23%), microdebrider with
cautery touch-up (20%), and Coblation (7%). The authors
also noted an increase in the use of cautery, microde-
brider, and Coblation over the past 15 years and a
decrease in the use of curette techniques. We observed
similar trends; however, the microdebrider technique
was used in a higher percentage of our study population.
Multiple reports are critical of the curette technique
of adenoidectomy. Nonvisualized curette technique with
digital palpation to confirm completeness of adenoid re-
moval reported residual adenoid tissue in 80% of
cases.12Endoscopic evaluation immediately after curet-
tage has shown residual adenoid tissue in >60% of
patients.13Other groups have advocated the use of
transnasal endoscopy and microdebrider to remove re-
Monopolar electrocautery has gained popularity as
a method of adenoidectomy11and is noted to be a pre-
cise, safe method of adenoidectomy, suitable for all ages.
Cautery adenoidectomy reduces operative time and min-
imizes blood loss compared to curettage. Criticisms of
this technique are the introduction of the complications
of neck pain and torticollis associated with cautery sur-
operative time and reduced blood loss as compared to
traditional curette. The disadvantages noted with micro-
debrider is the need for additional equipment and
increased cost.15Additionally, the fixed angle of the
microdebrider blade (19?) and its fixed length may pre-
clude its effective use in older children and adolescents.
Coblation adenoidectomy has gained popularity as
an alternative to electrocautery surgery. This technology
uses dissociation of isotonic saline between two electro-
des to break molecular bonds between tissues. Coblation
allows for tissue dissection at lower temperatures (60
and 70?C) compared to the 400?C of electrosurgery.11
primary and secondary
Demographics of Revision Adenoidectomy patients.
Mean age at initial adenoidectomy 2.84 years (SD ¼1.69)
4.67 years (SD ¼ 1.99)
1.8 years (SD ¼1.1)
3.5 (SD ¼ 0.59)
1.83 (SD ¼ 1.12)
Mean age at revision adenoidectomy
Mean interval between procedures
Initial adenoid size
Adenoid size at revision
Indications for Adenoidectomy.
Initial (N ¼ 99)% Revision (N ¼ 100)
Sinusitis—1 1%Sinusitis—0 0%
Laryngoscope 121: October 2011Grindle et al.: Revision Adenoidectomy in Children
hemorrhage rates comparable to MEC coupled with a
lower incidence of postop dehydration.16Disadvantages
with this technique include need for additional equip-
ment and increased cost.
Whichever method used for the adenoidectomy pro-
surgeons must strive for complete removal of adenoid
tissue from the area of the choanae and the eustachian
tube at initial surgery so as to minimize the risk of
regrowth of adenoid tissue and recurrence of symptoms.
Because the rate of revision adenoidectomy is low, irre-
spective of technique used, a strengths of this study
include the large size of the patient population. The
1.3% revision rate observed in a multistate pediatric
heathcare system with with 15 otolaryngologists forcasts
the number of patients who may require a second opera-
tionon his/her adenoids,
preexisting condition, or comorbid conditions. Limita-
tions of this study include its retrospective design.
Adenoidectomy remains a needed and commonly
performed procedure in children. Regrowth of adenoid
tissue with recurrence of symptoms is rare. We found
the incidence of revision adenoidectomy in children to be
1.3%. Indications for revision are typically recurrence or
persistence of initial presenting symptoms.
1. Bhattacharyya N, Kin HW. Changes and consistencies in the epidemiology
of pediatric adenotonsillar surgery, 1996–2006. Otolaryngol Head Neck
2. Joshua B, Bahar G, Sulkes J, et al. Adenoidectomy: long-term follow-up.
Otolaryngol Head Neck Surg 2006;135:576–580.
3. Nieminen P, Tolonen U, Lopponen H. Snoring and obstructive sleep apnea
in children: a 6-month follow-up study. Arch Otolaryngol Head Neck
4. Shintani T, Asakura K, Kataura A. The effect of adenotonsillectomy in
children with OSA. Int J Pediatr Otorhinolaryngol 1998;44:51–58.
5. Wolfsensberger M, Haury JA, Linder T. Parent satisfaction 1 year after
adenotonsillectomy of their children. Int J Pediatr Otorhinolaryngol
6. De Serres LM, Derkay C, Sie K, et al. Impact of adenotonsillectomy on
quality of life in children with obstructive sleep apnea. Arch Otolaryngol
Head Neck Surg 2002;128:489–496.
7. Suen JS, Arnold JE, Brooks LJ. Adenotonsillectomy for treatment of ob-
structive sleep apnea in children. Arch Otolaryngol Head Neck Surg
8. Lesinskas E, Drigotas M. The incidence of adenoidal regrowth after ade-
noidectomy and its effect on persistent nasal symptoms. Eur Arch Oto-
9. Monroy A, Behar P, Brodsky L. Revision adenoidectomy—a retrospective
study. Int J Pediatr Otorhinolaryngol 2008;72:565–570.
10. Emerick KS, Cunningham MJ. Tubal tonsil hypertrophy. Arch Otolaryngol
Head Neck Surg 2006;132:153–156.
11. Walner DL, Parker NP, Miller RP. Past and present instrument use in pedi-
atric adenotonsillectomy. Otolaryngol Head Neck Surg 2007;137:49–53.
12. Ark N, Kurtaran H, Ugur S, et al. Comparison of adenoidectomy methods:
examining with digital palpation vs. visualizing the placement of the cu-
rette. Int J Pediatr Otorhinolaryngol 2010;74:649–651.
13. Regmi D, Mathur NN, Bhattarai M. Rigid endoscopic evaluation of con-
ventional curettage adenoidectomy. J Laryngol Otol 2011;1:53–58.
14. Pagella F, Matti E, Colombo A, et al. How we do it: a combined method of
traditional curette and power-assisted endoscopic adenoidectomy. Acta
15. Elluru R, Johnson L, Myer C. Electrocautery adenoidectomy compared with
curettage and power-assisted methods. Laryngoscope 2002;112:23–25.
16. Glade RS, Pearson SE, Zalzal GH, et al. Coblation adenotonsillectomy: an
improvement over electrocautery technique. Arch Otolaryngol Head
Neck Surg 2006;134:852–855.
Laryngoscope 121: October 2011 Grindle et al.: Revision Adenoidectomy in Children