Suction Diathermy Research Articles

Comparison of the efficacy and safety of conventional curettage adenoidectomy with those of other adenoidectomy surgical techniques: a systematic review and network meta-analysis

ObjectivesThere is a lack of robust evidence in regards to whether the intra and post-operative safety and efficacy of conventional curettage adenoidectomy is better than those of other available surgical techniques. Therefore, this study was conducted as a systematic review and network meta-analysis of published randomized controlled trials (RCTs) with the aim of comparing the safety and efficacy of conventional curettage adenoidectomy with all other available adenoidectomy techniques.Materials and methodsA systematic search of published articles was performed in 2021 using databases such as PubMed/Medline, EMBASE, EBSCO, and the Cochrane Library. All RCTs that compared conventional curettage adenoidectomy with other surgical techniques and were published in English between 1965 and 2021 were included. The quality of the included RCTs have been assessed using Cochrane Collaboration Risk of Bias Tool.ResultsAfter screening 1494 articles, 17 were identified for comparing several adenoidectomy techniques and were eligible for quantitative analysis. Of those, 9 RCTs were analyzed for intraoperative blood loss, and 6 articles were included for post-operative bleeding. Furthermore; 14, 10, and 7 studies were included for surgical time, residual adenoid tissue, and postoperative complications respectively. Endoscopic-assisted microdebrider adenoidectomy yielded a statistically significantly greater estimate of intraoperative blood loss compared with conventional curettage adenoidectomy (mean difference [MD], 92.7; 95% confidence interval [CI] 28.3–157.1), suction diathermy (MD, 117.1; 95% CI 37.2–197.1). Suction diathermy had the highest cumulative probability of being the preferred technique because it was estimated to result in the least intraoperative blood loss. Electronic molecular resonance adenoidectomy was estimated to be more likely to result in the shortest surgical time (mean rank, 2.2). Participants in the intervention group were 97% less likely to have residual adenoid tissue than children in the conventional curettage group (odds ratio 0.03; 95% CI 0.01–0.15); therefore, conventional curettage was not considered an appropriate technique for complete removal of adenoid tissue.ConclusionThere is no single technique that can be considered best for all possible outcomes. Therefore, otolaryngologists should make an appropriate choice after critically reviewing the clinical characteristics of children requiring adenoidectomy. Findings of this systematic review and meta-analysis may guide otolaryngologists when making evidence-based decisions regarding the treatment of enlarged and symptomatic adenoids in children.

Comparison Between Different Approaches Applied in Pediatric Adenoidectomy: A Network Meta-Analysis.

Adenoidectomy is a surgical procedure most frequently performed by otolaryngologists. However, there are no universally accepted guidelines for the choice of the surgical approach in specific circumstances. Therefore, a network meta-analysis (NMA) is needed to summarize existing studies and provide more evidence-based medical guidelines. A systematic search of the literature was conducted in the Cochrane Central Register of Controlled Trials, PubMed, and EMBASE databases from inception to 31 July 2021. A network meta-analysis of operating time, intraoperative blood loss, postoperative pain score, and incidence of postoperative residual tissue was performed. A total of 20 studies with 2329 patients were included. Four common surgical approaches, including powered vacuum shaver adenoidectomy (PVSA), plasma field ablation adenoidectomy (PFAA), curettage adenoidectomy (CUA), and suction diathermy adenoidectomy (SDA), were compared for operative time, intraoperative blood loss, postoperative pain score, and incidence of postoperative residual tissue. There were no significant differences between the surgical techniques for the 3 endpoints, operative time, intraoperative blood loss, and incidence of postoperative residual tissue. The data showed lower postoperative pain scores for PFAA than for CUA (MD = -3.45, 95% CI [-6.01, -0.95]). There were no significant differences in other surgical approaches for postoperative pain scores. There were no significant differences between PVSA, PFAA, CUA, and SDA for operative time, intraoperative blood loss, and incidence of postoperative residual tissue. PFAA had advantages over CUA for postoperative pain scores.

Endoscopicaly assisted microdebrider adenoidectomy versus conventional curettage adenoidectomy

Background: Adenoidectomy by conventional method is an old procedure. Several new techniques discovered in this field as an electronic molecular resonance, suction diathermy, microdebrider, endoscopy, and laser. Objectives: to assess advantages of endoscopic assessed microdebrider adenoidectomy over the conventional method intra and post operative. Patients and methods: 218 patients were scheduled for adenoidectomy were divided into two groups) underwent conventional curettage, group B (106 patients) underwent endoscopic assessed microdebrider. Follow up for 2 weeks ended by endoscopic evaluation. Results: This study included 218 patients (110 males and 108 females) aged 2 years till 14 years, divided randomly into two groups group A 112 patients group B 106 patients. This study reported statistically longer time of operation in group B than group A (13.7 for group B ± 3.5 versus 3.5 ± 1.3). Blood loss was statistically more in group A ((26.7 ± 7.5 for group A versus 17. 9 ± 5.2). Adenoid tissues remnants in group A were statistically higher than group B (27.4 % ± 11.6 for group A versus 1.7% ± .86). Regarding pain it was significantly lower in group B in the six day (4.2 ± 1.2 for group A versus 2.3 ± .5). Conclusion: endoscopic assessed adenoidectomy is significantly better than conventional adenoidectomy regarding blood loss, post operative remnants and post operative pain.

Comparative study of Adenoidectomy by Endoscopic Transoral Suction Coagulation Versus the Traditional Method

Background: Adenoidectomy is one of the most common procedures performed by otorhinolaryngologists. Previously, suction cautery was used for haemostasis following curettage adenoidectomy. Whereas more recently, the entire procedure has been performed using this technique, and it has now been accepted as a suitable technique, especially in the pediatric population. Objective: To compare two different techniques for adenoidectomy, one is traditional adenoidectomy and the other is the endoscopic transoral adenoidectomy by suction diathermy. Patients and methods: This study included 100 patients (62 males and 38 females) attended to the Otorhinolaryngology Outpatient Clinic of Al-Azhar University Hospital in Assiut and diagnosed as adenoid hypertrophy through the period from November 2019 to March 2020. Results: The average operative time of traditional method was 9.9 minutes (range: 7 to 12 minutes), which is longer than that of adenoidectomy by suction diathermy where it was7.2 minutes (range: 4 to 10 minutes) also the intra operative blood loss was markedly lower in adenoidectomy by suction diathermy. It was 5.7 ml (range: 3 to 7 ml) while it was 27.3 ml (range: 21 to 32 ml) in the traditional method. Post-operative complications in our study include post-operative hemorrhage, velopharyngeal insufficiency and recurrence, which was higher in the traditional method. Post adenoidectomy healing time was 14 days for the traditional method (range: 13 to15 days), which is shorter than that of suction diathermy where it was 18 days (range: 17 to 20 days). Conclusion: Adenoidectomy by endoscopic transoral suction diathermy is more safe and effective than adenoidectomy by traditional curatte in treatment of patients with hypertrophied adenoid with less complication.

Cold versus hot adenoidectomy: A prospective, randomized controlled trial

ObjectiveAdenoidectomy can be performed using the cold method (mainly adenoid curettes) or the hot method (suction diathermy). Both techniques have similar intra and postoperative outcomes. However, the long-term clinical outcome of improving sleep disorder symptoms has not been well established. The objective of this study was to compare outcomes of hot method and cold method adenoidectomy one year following the surgery. Study designA prospective, randomized, single-blinded study of children under age 16 years who underwent adenoidectomy during the years 2014–2017. Patients were randomized to hot or cold adenoidectomy techniques. SettingA tertiary health care referral center. Subjects and methodsThe final analysis included 58 children, mean age 5.9 years (range 1.2–15). The primary outcome was change in the Pediatric Sleep Questionnaire (PSQ) scores one month and one year after surgery. The secondary outcome was complication rate. ResultsClinical and demographic parameters were similar between the patients in the hot method group (n = 30) and the cold method group (n = 28). Adenoid size and estimated bleeding were similar between the groups. At one month after surgery, PSQ score was improved by a mean + 0.31 in the hot method group compared to +0.32 in the cold method group (p = 0.54). Improvement in PSQ scores was greater following hot than cold adenoidectomy at one year after surgery (+0.31 points vs. +0.22 points, p = 0.009). ConclusionHot adenoidectomy is associated with better outcome than the cold technique, as reflected by PSQ scores one year after the surgery.

Suction diathermy adenoidectomy: audit of current practice in a tertiary care hospital

<p class="abstract"><strong>Background:</strong> Adenoidectomy is conventionally performed using adenoid curette as a blind procedure. Suction diathermy adenoidectomy is a technique of ablating the adenoid tissue using thermal energy and removing it by suction. This audit aims to study the efficacy and complications of this technique in a tertiary care center.</p><p class="abstract"><strong>Methods:</strong> Retrospective analysis of hospital database was conducted. Twenty-seven patients who underwent suction diathermy adenoidectomy were identified and hospital records studied. Parents were contacted and enquired regarding improvement in child's symptoms.</p><p class="abstract"><strong>Results:</strong> No instances of postoperative complications identified. All except 2 parents were completely satisfied with the improvement in their child's symptoms. Two children had occasional mouth breathing.</p><p class="Standard"><strong>Conclusions:</strong> Suction diathermy adenoidectomy is a feasible alternative to conventional adenoidectomy with few complications and minimal rate of recurrence.</p>

Debride and Conquer: A New Angle in Endoscopic Removal of Antrochoanal Polyps

Objective: Antrochoanal Polyps can be problematic to remove fully due to their location and instruments available. Method: Using a combination of paediatric and adult sized instruments, viewed with 30 and 70 degree endoscopes, we could partially remove the polyp through a large middle meatal antrostomy (MMA). Being unable to reach the remaining stalk, despite proceeding to an inferior antrostomy (IA), we realised the need for a more acute-angled instrument. By curving the monopolar Valleylab suction diathermy (MVSD), mimicking the curved microdebrider, we inserted this through our MMA. With an endoscope and a curved ball probe through the IA, we further increased the angle of the MVSD and cauterised the base of the polyp. Results: Clinically the polyp appeared to be fully resected. Conclusion: Consideration must be given to the infraorbital nerve and its relation to the base of the polyp. With this in mind, it is a safe technique.

ADENOIDECTOMY BY DIFFERENT TECHNIQUES (COMPARATIVE STUDY)

Background: Adenoidectomy is one of the most common pediatric ambulatory procedure in the world, multiple techniques are present for adenoidectomy with relative advantages and dis advantages of each technique. Objectives: Providing a comparative study of adenoidectomy by electrocautary with suction diathermy, conventional and microdebrider techniques. Patients and Methods: Randomized prospective study included 60 child patients with age ranged from (3-12y) of both genders (28 males and 32 females), all suffering from hypertrophied adenoid tissue, presented clinically with mouth breathing, snoring, partial nasal obstruction and/or discharge and evidenced radiologically with plain X-ray film lateral view to the nasopharynx. All cases presented to Al-Azhar University Hospitals (Al-Hussin & Sayed galal) during the period from July 2018 to December 2018. Results: The mean blood loss in suction diathermy technique was (5.56ml) while in conventional and microdebrider techniques were 43.45ml and 31.90ml respectively and this found to be of highly statistical significance. Also in complete of removal of adenoid tissue there were significant statistical difference between conventional and microdebrider (p-value:0.02) also between conventional technique and suction diathermy technique (p-value < 0.03) but as regard operative time there was highly significant statistical difference between conventional and microdebrider (p-value < 0.001). Conclusion: The suction diathermy adenoidectomy is the technique of choice in lowering intraoperative blood loss compared to other tow techniques, also sharing microdebrider technique in visibility of the surgical field and completeness of resection, when the cost and availability are affordable it will be the gold standard technique for adenoidectomy, the conventional technique have a disadvantages of bleeding, traumatic and incomplete of resection but still cheapest, simplest and most available one.

Estimation of Coagulation Profile and Platelet Counts in Type 2 Diabetic Patients

Background: Adenoidectomy is one of the most common pediatric ambulatory procedure in the world, multiple techniques are present for adenoidectomy with relative advantages and dis advantages of each technique. Objectives: Providing a comparative study of adenoidectomy by electrocautary with suction diathermy, conventional and microdebrider techniques. Patients and Methods: Randomized prospective study included 60 child patients with age ranged from (3-12y) of both genders (28 males and 32 females), all suffering from hypertrophied adenoid tissue, presented clinically with mouth breathing, snoring, partial nasal obstruction and/or discharge and evidenced radiologically with plain X-ray film lateral view to the nasopharynx. All cases presented to Al-Azhar University Hospitals (Al-Hussin & Sayed galal) during the period from July 2018 to December 2018. Results: The mean blood loss in suction diathermy technique was (5.56ml) while in conventional and microdebrider techniques were 43.45ml and 31.90ml respectively and this found to be of highly statistical significance. Also in complete of removal of adenoid tissue there were significant statistical difference between conventional and microdebrider (p-value:0.02) also between conventional technique and suction diathermy technique (p-value < 0.03) but as regard operative time there was highly significant statistical difference between conventional and microdebrider (p-value < 0.001). Conclusion: The suction diathermy adenoidectomy is the technique of choice in lowering intraoperative blood loss compared to other tow techniques, also sharing microdebrider technique in visibility of the surgical field and completeness of resection, when the cost and availability are affordable it will be the gold standard technique for adenoidectomy, the conventional technique have a disadvantages of bleeding, traumatic and incomplete of resection but still cheapest, simplest and most available one.

A prospective observational study of 50 paediatric suction diathermy adenoidectomy cases to determine the potential safety of a 2-h discharge time: Our Experience.

A prospective observational study of 50 paediatric suction diathermy adenoidectomy cases to determine the potential safety of a 2-h discharge time: Our Experience.

Suction diathermy adenoidectomy performed in the district general hospital

Adenoidectomy is often carried out in children for conditions such as nasal obstruction, otitis media with effusion, and obstructive sleep apnoea. Traditionally, it is performed as a blind procedure with a St Clair Thomson curette. An acceptable alternative technique is suction diathermy adenoidectomy. This study aimed to ensure that the complication rate of this latter technique was within published rates and national guidelines. A retrospective case note review was conducted, and information regarding surgery, indications and complications was collected. Post-operative haemorrhage was recorded for 2 of 121 patients (at days 10 and 11 post-operatively): 1 returned to the operating theatre and the other was managed conservatively. Two patients were diagnosed with infection post-operatively and managed with oral antibiotics. A further four patients re-presented with pain; in all cases, this was recorded as secondary to tonsillar fossa infection, rather than being pain related to adenoidectomy. Given the rare but serious potential complications, the authors support National Institute for Health and Clinical Excellence guidance, which recommends that only surgeons with specific training perform this technique. By using the standard procedures for clinical governance, it is possible to ensure safe practice of even little-used techniques.

A novel method of teaching adenoidectomy using suction diathermy

Methods which aid and enhance the teaching of surgical procedures to trainees are beneficial to both trainer and trainee. In this article, we suggest a simple way of performing suction diathermy which allows the trainer to provide a template for the trainee to reproduce. Related articles have suggested the use of additional equipment, such as an endoscope; however, the method we describe requires no additional technical elements. Thus, it represents a sound and efficient teaching tool.

Troublesome bleeding at mediastinoscopy.

We present in this video a case of troublesome bleeding at mediastinoscopy. Video Mediastinoscopy is a vital part of the pre-operative evaluation of patients prior to lung resection. A full staging mediastinoscopy with lymph node sampling from stations 2L, 2R, 4L, 4R, and 7 are key to competent staging and for the avoidance of lobectomy or pneumonectomy in patients with N2 disease for which there is little or no benefit with surgery alone (1,2). The case presented in the video is just such a case (Video 1), with a 67 years old patient who has a right upper lobe T2aN0M0 adenocarcinoma. The PET scan was negative in the mediastinum but we embarked on a staging mediastinoscopy for the reasons highlighted above. Video 1 Troublesome bleeding at mediastinoscopy Surgeons will often be most concerned about accidental biopsy of the major vessels including the innominate artery anteriorly, superior vena cava on the right, the left and right pulmonary artery distally, or the aorta to the left, but often the most troublesome bleeding does not come from these major structures. For example, bleeding may occur an exception to that comes when a malignant lymph node has eroded through a major structure and thus pulling on the node disrupts the structure behind which there is an already weakened vessel wall. Thus extra caution should be taken when the mediastinoscopy is performed to confirm already suspected established or extensive N2 disease rather than to look for micrometastases. One additional caution is paid to the azygous vein. This vessel joins the SVC from posteriorly and it lies close to the 4R lymph nodes. In this video, all these structures were easily identified and avoided. However, a very large bronchial artery was encountered, which in our experience causes troublesome bleeding much more often than the major structures. We note that with some additional aforementioned equipment available and some experience, these can often be successfully addressed without resorting to sternotomy. In our case, early efforts were made to avoid the bronchial artery but as we were reaching over this artery to reach station 7 it started to bleed, perhaps at the site of a side branch to it. We used the suction diathermy to control it initially and then placed and adrenaline soaked swab over it to attempt to vasoconstrict the vessel. While waiting for the adrenaline soaked swab to work, we continued the mediastinoscopy, taking samples from 4R and 4L. On removal of the swab, the vessel was still bleeding significantly. But during that time we had brought into theatre a 5 mm endoscopic clip applicator which fits easily down the mediastinoscope. Then, using the suction diathermy to control the bleeding, we eventually managed to achieve hemostasis with a 5 mm clip. We continued with the procedure and took samples from station 7 before exiting the mediastinum, leaving behind a surgicel haemostat for further haemostasis.

Suction diathermy as an adjunct to endoscopic removal of inverted papilloma

No Obstract.

Adenoidectomy Technique in the United Kingdom and Postoperative Hemorrhage

To investigate the incidence of postoperative hemorrhage and its risk factors after adenotonsillectomy. A prospective cohort study as part of the National Prospective Tonsillectomy Audit. National Health Service and private hospitals in England and Northern Ireland. National Prospective Tonsillectomy Audit methodology was followed with a nonrandomized prospective observational cohort methodology and data collection. A total of 33,921 patients underwent tonsillectomy; of these, 9900 underwent adjunctive adenoidectomy. Traditional curette adenoidectomy (without any diathermy use at all) was performed in 6871 patients. Suction diathermy technique was used in 1489 patients. Hemorrhage rates were calculated for these main adenoidectomy technique groups and compared by calculation of risk ratios. Both early and late hemorrhage rates for suction diathermy were found to be 0.07% (n = 1 in each case). In the traditional curette group, these rates were 0.3% (n = 19) and 0.2% (n = 14), respectively. The risk ratio for hemorrhage overall was 3.6 for curette adenoidectomy compared with suction diathermy (95% confidence interval, 0.86-14.9; P = .06). The data suggest comparable hemorrhage rates in both adenoidectomy technique groups and fail to demonstrate diathermy usage as a risk factor for hemorrhage following adenoidectomy despite a clear interaction between diathermy usage and subsequent hemorrhage in tonsillectomy. Use of suction diathermy in adenoidectomy appears to have a similar safety profile to conventional techniques and may offer additional benefits over traditional adenoid curettage. Further clinical and laboratory-based research into the complex interaction between diathermy usage and both adenoid and tonsillar tissue is warranted.

Monopolar Suction Diathermy Adenoidectomy: Technical Note

Monopolar suction diathermy allows controlled resection of the adenoids in a near bloodless field. In this article the author describes some technical points to make the procedure safe.

Bacteremia during Adenoidectomy: A Comparison of Suction Diathermy Adenoid Ablation and Adenoid Curettage

Transient bacteremia is induced by adenoidectomy when the integrity of the nasopharyngeal membrane is broken. The aim of this study was to determine the incidence of bacteremia in patients undergoing adenoidectomy, to identify the causative organisms, and to compare the incidences of bacteremia between the two techniques suction diathermy and curettage. A prospective single-blind randomized trial was performed. Sixty-four patients between the ages of 2 and 13 years who were undergoing adenoidectomy were included in the study. Exclusion criteria included antimicrobial therapy in the immediate preoperative period and concurrent respiratory tract infection or pyrexia. Patients were randomized in the anesthetic room to either suction diathermy or curettage. Venous blood samples for culture were obtained 30 seconds after the procedure began (intraoperative sample) and 2 minutes after removal of the adenoid tissue (postoperative sample). Postoperative complications were recorded, and all patients were followed in the outpatient department. Twenty-six patients underwent adenoidectomy by suction diathermy, and 38 underwent adenoidectomy by curettage. In the suction diathermy group, 38.5% of intraoperative and 19.2% of postoperative blood cultures had a positive result for bacteremia. In the curettage group, 31.6% of intraoperative and 23.6% of postoperative blood cultures had a positive result for bacteremia. There was no significant difference between the two groups. The techniques were equivalent in terms of postoperative complications. Gram-positive cocci were the most commonly isolated organisms. A transient bacteremia exists after pediatric adenoidectomy, but does not correlate with symptoms or signs. Neither suction diathermy adenoidectomy nor curettage adenoidectomy offers a particular advantage in terms of decreasing the incidence of bacteremia.

Adenoidectomy techniques: UK survey

To determine (1) the preferred adenoidectomy technique among UK ENT consultants, and (2) the need for revision adenoidectomy following the standard technique of blind curettage with digital palpation. Postal questionnaire. We included 539 consultant members of the ENT-UK. Commonly used adenoidectomy techniques, and whether revision adenoidectomy was considered a problem. The response rate was 66.6 per cent (359 respondents). Twenty-seven respondents did not perform adenoidectomy, while 332 did. A total of 312/332 respondents (94 per cent) believed that adenoidectomy had a role in the treatment of chronic serous otitis media. The majority of respondents (232/332; 69.9 per cent) reported examining the postnasal space digitally at adenoidectomy. The preferred routine adenoidectomy technique was blind curettage for 263 respondents (79.2 per cent), suction diathermy ablation for 27 (8.1 per cent) and curettage under direct vision (using a mirror) for 13 (3.9 per cent). In response to the question 'Do you recognise the need for revision adenoidectomy as a problem?', 205 (61.7 per cent) respondents replied 'never', 39 (11.7 per cent) 'rarely', 54 (16.3 per cent) '< 2 per cent' and 36 (10.8 per cent) '>2 per cent'. The most commonly used adenoidectomy technique in the UK is digital palpation followed by blind curettage, according to this postal questionnaire survey. Few respondents reported performing adenoidectomy under direct vision: only 10 per cent used a mirror during the procedure and only 8 per cent used an endoscope.

Treatment of chronic nasopharyngitis with monopolar suction diathermy

Chronic nasopharyngeal infection is rare. To our knowledge, no effective treatment for this condition has previously been described. This report documents our experience of using suction ablation diathermy in this clinical setting. We performed a prospective review of four patients aged 23-65 years (two men and two women) who presented with chronic nasopharyngitis. Initial medical management consisted of regular saline irrigation plus a 14-day course of doxycycline 100 mg daily, combined with rifampicin 200 mg twice daily. When this proved unsuccessful, patients subsequently received a four-week course of omeprazole 40 mg daily, also unsuccessfully. Given these treatments' lack of success, surgery was undertaken. Following suction diathermy ablation, nasopharyngeal crusting took four to six weeks to settle. After this, all patients ceased to cough up crusts or infected mucus. Chronic nasopharyngitis is uncommon. If medical management fails, suction ablation diathermy is a useful surgical treatment option.

Partial adenoidectomy by suction diathermy in children with cleft palate, to avoid velopharyngeal insufficiency

Objectives Adenoidectomy is indicated for the relief of paediatric nasal obstruction, sleep-disordered breathing and otitis media with effusion (OME). Velopharyngeal insufficiency (VPI) is a rare complication. The main risk factor is the presence of pre-existing velopharyngeal closure-impaired mechanisms, including submucosal or overt cleft palate. Despite possible benefits, adenoidectomy is frequently withheld in such children to avoid VPI. This study aims to demonstrate the efficacy and safety of partial adenoidectomy using suction diathermy in children who previously underwent overt cleft palate repair during infancy, to allow selective resection of tissue and symptom resolution without producing VPI. Methods Since 1994, 18 patients with previously corrected overt cleft palate have undergone partial adenoidectomy at this centre, for the treatment of nasal obstruction or sleep-disordered breathing, with or without OME. Three had existing VPI following their cleft correction surgery. Selective resection of the adenoid was performed transorally under indirect vision, using a malleable suction coagulator. This allowed exposure of the posterior choanae, leaving the remaining adenoid bulk intact. Results Patients were followed up at 4 weeks, and subsequently at regular intervals (total follow up 30–180 months, median 92 months), including perceptual speech assessment in all cases. All demonstrated symptomatic improvement with respect to the original indications for surgery. None developed worsening hypernasal speech or other features of VPI, and there were no cases of symptomatic adenoidal re-growth. Conclusions Partial adenoidectomy, employing a variety of methods, has been used successfully in children with submucosal cleft palate. This study demonstrates the safe and effective use of suction diathermy to enable partial adenoidectomy in children who have previously undergone surgical correction of overt cleft palate, allowing symptom resolution without producing VPI.