In recent years, as people pay more attention to children’s sleep and breathing disorders, the consultation rate of children with adenoid hypertrophy is gradually increasing. However, from the children we see, most of them have been diagnosed with adenoid hypertrophy in the past, and most of their parents have been told that they need to undergo surgical treatments. Some parents have even brought their children to major hospitals repeatedly, but they are not able to make up their mind to undergo surgical treatments. If children with enlarged adenoids do not receive the correct treatment in time, many sequelae will occur. Due to long-term respiratory obstruction and open-mouth breathing, children with adenoid hypertrophy experience physiological adaptive muscle feedback, causing changes in head position, which in turn causes passive deep spreading of the soft tissues of the neck and face and changes in the development of the skeleton, leading to abnormal development of the maxillofacial region and the appearance of adenoidal facies. Pulmonary artery constriction and increased pulmonary artery pressure due to insufficient alveolar ventilation and hypoxemia caused by airway obstruction. The enlarged adenoids block the pharyngeal opening of the Eustachian tube, leading to secretory otitis media. Due to the obstruction of the posterior nostrils, the nasal mucus is not easy to flow back, which can aggravate the child’s sinusitis and make sinusitis prolonged and difficult to cure. More importantly, long-term sleep hypoxia has adverse effects on the child’s physical and intellectual development. With the growing research on obstructive sleep apnea syndrome in adults, it has been found that children with adenoid hypertrophy have partially wasted nasal function due to open-mouth breathing, leading to developmental disorders of the nasal cavity and excessive narrowing of the nasal cavity in adults. Abnormal jaw development ratio due to open-mouth breathing is also an important cause of pharyngeal stenosis in adults with obstructive sleep apnea syndrome. Zhang Liqiang, Department of Otorhinolaryngology, Qilu Hospital, Shandong University One of the main reasons influencing children with adenoid hypertrophy to undergo surgical treatment is because parents are concerned about the decrease in immunity after surgical removal of adenoids and tonsils.Amoros et al. reported that the serum IgA and IgG concentrations decreased after adenoidal body-scraping surgery in children but were not less than the normal range of fluid immunity in pediatrics, and that immunoglobulin levels began to recover 4 months after the surgery in some children. Bock concluded that, due to the compensatory effect of other peripheral immune organs, after tonsillectomy, although the immunoglobulin level decreased, it was not lower than the normal range and recovered after a certain period of time, therefore, although tonsillectomy can cause changes in some aspects of the humoral immune system, these changes are not clinically significant and will not cause diseases of immune disorder. cause immune disorders to occur. Surgery for enlarged adenoids should be evaluated on its own merits. Surgical removal of the adenoids should be considered when the benefits of immunization are outweighed by the risks associated with adenoid enlargement. In less severe cases, conservative treatments such as sleeping on the side, nasal steroids, and aggressive treatment of sinusitis can be used. Polysomnography is preferred to facilitate scientific and objective assessment of sleep. In addition, in our clinical practice, we found that, due to long-term mouth breathing in children with adenoid hypertrophy, the nasal cavity is often disused developmental disorders, which is mainly manifested in the majority of children with adenoid hypertrophy inferior turbinate is not large, and the children with inferior turbinate hypertrophy intraoperatively found that adenoid hypertrophy is not very serious. Therefore, for children with inferior turbinate hypertrophy, conservative treatments such as nasal steroids can be considered. Children with severe sleep disorders should be treated with surgery. Adenoidectomy is usually performed after the age of 3 to 4 years, but in children with severe symptoms, surgery should be performed as early as possible without age limitations. Currently, there are three main types of adenoidectomy in our clinic. The first is the transnasal approach, which is suitable for simple adenoid hypertrophy. The child’s position is lying down, the operator stands on the right side of the child, and the endoscopic monitor is placed in front of the child’s head. The procedure was performed in a conventional endoscopic sinus surgery manner. The mucosa of both nasal cavities was fully converged, and the inferior turbinates of both sides were moved outward by appropriate fracture in case of nasal stenosis. A 0-degree nasal endoscope was introduced into one nasal cavity and a cutting suction device was introduced into the other nasal cavity for adenoidectomy. After adenoidectomy, cotton pads were inserted into the nasal cavity to stop bleeding, and if there was an active bleeding point after removing the cotton pads, hemostasis was achieved by electrocoagulation with an electric knife. Before the end of the procedure, a piece of hemostatic damask was placed between the nasal septum and inferior turbinate to prevent postoperative nasal adhesions. The advantage of the transnasal approach is that the endoscope provides adequate access to the adenoidal tissue, allowing accurate visualization of the details of the removal of adenoidal tissue by the cutting suction, and is particularly advantageous in the removal of adenoids protruding into the posterior nostrils, where complete removal of the upper adenoidal tissue is assured. It is easier to deal with bleeding from adenoidal trauma and allows for simultaneous management of nasal obstructive factors such as inferior turbinate hypertrophy. The disadvantages of the transnasal route are that access to instruments and endoscopes is more difficult in patients with a deviated septum or more narrowly developed nasal cavity, and postoperative nasal adhesions can occur, making the lens susceptible to blood staining in cases of heavy bleeding. As the soft palate is close to the posterior pharyngeal wall, the lower adenoid tissue is poorly exposed, and it is slightly difficult to remove and stop bleeding. If tonsillectomy is performed at the same time, it is also necessary to change the lying position to the backward head tilt position during the operation. The second type of operation is the transoral route, which is suitable for the case of simultaneous adenoid and tonsillectomy. After completion of general anesthesia, the patient is placed in the flat position with shoulder pads and head tilted back, the operator sits at the cephalad end of the patient, and the nasal endoscopic monitor is placed on the right side of the patient. The cotomizer was used to expose the oropharynx, and after routine tonsillectomy, the nasopharynx was exposed by drawing the catheter along the nasal cavity from the oropharynx, pulling up the soft palate, and introducing a 70-degree nasal endoscope from the oral cavity to expose the nasopharynx, and searching for locating the posterior nasal aperture along the catheter and exposing the bilateral rounded pillows to the lateral side. First, the cutter suction tip was directed backward toward the round pillows, and the adenoid tissue adjacent to the round pillows was excised along the medial side of the round pillows, exposing the contour of the round pillows, and then the adenoids obstructing the posterior nostrils were excised in the direction of the posterior nasal aperture, paying attention to the fact that because part of the adenoid tissue may protrude into the posterior end of the nasal cavity, the tip of the cutter suction tip needed to be extended to the nasal cavity through the nasal cavity to the lower turbinate and the adenoids, and the adenoids were pushed to the nasopharynx to remove some of them from the side of the nasal cavity toward the nasopharynx. Nasopharyngeal resection. Otherwise, if the adenoids are removed from the nasopharynx to the posterior end of the nasal cavity, the posterior end of the inferior turbinate, posterior end of the middle turbinate, or posterior end of the nasal septum will be easily injured due to the adenoids blocking the posterior end of the nasal cavity, which will cause uncontrollable rhinorrhea or lead to stenosis of the posterior nostrils. In the same way, the adenoid tissue near the contralateral rounded occiput and at the posterior nostril is removed. Finally, the adenoids at the posterior end of the nasal septum and the middle part of the nasopharynx are removed. If the adenoids are excessively enlarged and interfere with the operation, the expanded tissue in the middle of the adenoids can be superficially excised first, and then the operation can be continued as described above. Following this order of operation allows for a clear field of view when removing adenoid tissue in key areas such as the round pillows and posterior nostrils, and does not affect the judgment of the depth of resection due to the high amount of blood in the operative field. Moreover, the medial adenoid tissue of the rounded occiput is not very thick, so the depth of resection can be easily located, and then the resection along this level to the middle part of the resection can prevent the resection level from being too deep, which may cause serious bleeding or injury to the prevertebral muscles. When using the cutter-attractor, do not press the cutter-attractor tightly against the adenoid tissue for excision, but leave the adenoid tissue slightly and use the suction of the cutter-attractor to remove the tissue that is sucked into the tip of the cutter. If the suction cutter is pressed against the tissue, it is not easy to control the depth of excision, and it is easy to damage the blood vessels in the deeper part of the adenoids, resulting in more difficult to control bleeding. In order to control the depth of excision, when using the cutting suction device, the mouthpiece, the patient’s teeth or the back edge of the hard palate can be used as a pivot point of the cutting suction device, so that the suction device can be held stable, preventing the depth of excision suddenly deep and shallow. After the adenoidectomy is completed, the nasopharynx is compressed with a cotton ball or a small piece of gauze through the oropharyngeal filling. After 1-2 times of repetition, if there is active bleeding, the electric knife can be used to stop bleeding by electrocoagulation. The assistant can hold the mirror to expose the field of operation, and the operator can use one hand to suction the blood with the suction device, and then the other hand can use the electric knife to rapidly and gently click the bleeding point to stop the bleeding. After that, pressure can be applied for several minutes to stop the bleeding. Before the end of the operation, the field should be fully exposed to the posterior end of the middle turbinate and inferior turbinate, with no adenoids remaining at the posterior nostrils, the round pillows intact, and the nasopharyngeal airway spacious and free of active bleeding. If a plasma system is used to remove the adenoids, the order of removal is slightly different from that of the cutting suction. Because plasma surgery is essentially bloodless, it allows for contoured removal of the adenoids, and the depth of removal can be deeper than that of the cutter-attractor, resulting in a more complete removal of the adenoids. Plasma excision of adenoids can be performed from the lowermost part of the adenoids to the superficial layer of the prevertebral fascia, and then along that level in a bottom-up, left-to-right sequence. Stop bleeding whenever there is active bleeding. A common problem encountered with plasma surgery is clogging of the cutter head. When using it to remove tissue, be careful to move the cutter head slightly away from the adenoid tissue, rather than pressing it firmly against the tissue. When using the side of the blade to remove the tissue, the back of the blade is moved so that it meets the adenoid tissue to minimize the blockage of the blade. Plasma surgery maximizes the prevention of postoperative recurrence because it is a bloodless procedure with a clear field of vision and precise removal. Plasma surgery takes longer to remove the adenoids than cutting suction, but the total operative time is similar to that of cutting suction due to the elimination of compression to stop bleeding. Currently, the high cost of the plasma cutter head limits its widespread use and popularization. The transoral path for removing adenoids has a wide field of view, which can clearly see bilateral round pillows and posterior nostrils in the same field of view, the lens is not easy to be stained with blood, there is no need to enter and exit the endoscope frequently, the operation space is spacious, and the resection and hemostasis are all more convenient. Since the operation does not pass through the nasal cavity, there will be no postoperative complications such as nasal adhesion. The patient’s postoperative symptoms improve quickly. Compared with the transnasal route, when removing the adenoid tissue deep into the posterior end of the nasal cavity, the details of the resection are not as clearly observed as in the transnasal route due to the fact that the endoscope is farther away from the area and the cutting suction tip of the cutter is backward toward the operator’s field of view. The third approach: the combined transoral and nasal approach. The position is the same as the second surgical approach. 0 degree nasal endoscope is introduced into the posterior nostril through the nasal cavity, and the curved head cutting suction device is extended to the posterior nostril through the oropharynx for resection. This surgical method is a joint application of the first and second surgical methods, which overcomes the shortcomings of the transoral route to the posterior nostril adenoid resection that can not visualize the details of the spacious operation space and clear vision. However, since the endoscope needs to pass through the nasal cavity, it is easy to be blood-stained when the patient has a deviated nasal septum or a narrow nasal cavity. Although the postoperative nasal mucosal reaction is less severe than the first surgical method, there will still be mucosal swelling. Therefore, this approach may be used in older children with spacious nasal passages. Adenoidectomy requires special attention to avoid damage to the mucosa of the pharyngeal orifice of the Eustachian tube and the management of bleeding. Nasal endoscopic adenoidectomy avoids damage to the pharyngeal opening of the Eustachian tube because it can be performed under direct vision. Clinical experience has shown that secretory otitis media due to adenoid hypertrophy is mostly caused by the narrowing of the Eustachian tube pharyngeal opening due to the compression of the adenoids on the rounded occiput. After surgical removal of the adenoids, the compression of the occiput is relieved, and the Eustachian tube pharyngeal orifice becomes patent. In most cases, the occiput itself does not need to be treated. Theoretically, removal of some of the lymphatic tissue in the medial part of the occiput will not affect the integrity of the mucosa of the pharyngeal opening of the Eustachian tube, and there will be no atresia of the pharyngeal opening. However, when the trauma of the medial part of the occiput forms a scarring adhesion with the trauma of the adenoid body, the pharyngeal tube can be abnormally open, which is difficult to deal with. There are usually two sites where adenoid surgery tends to bleed. One is located in the parietal wall of the nasopharynx near the posterior nostril. There are small adenoid blood-supplying arteries distributed bilaterally and symmetrically in this area. If they are removed too deeply, they bleed easily. The other is located on the posterior pharyngeal wall at the junction of the nasopharynx and oropharynx. Dilated small blood vessels are sometimes seen at this site. It has little effect on the nasopharyngeal airway because it corresponds anteriorly to the active soft palate. It is not necessary to remove too much of the adenoid tissue in this area. Bleeding is easier to control because of the low location of the bleeding and the ease of hemostasis by electrocoagulation from the oropharyngeal route. Adenoid trauma bleeding sometimes using electrocoagulation hemostasis the more coagulation the more bleeding, such a situation has the following reasons. First, the bleeding point is buried in the deep part of the tissue, and it is difficult to directly electrocoagulate the bleeding point from the surface. Therefore, when removing the adenoids, the cutting suction device should not be tightly pressed on the tissue, but should slightly leave the surface of the tissue so as not to injure the deep blood vessels. This type of hemorrhage should be coagulated after the suction device has been used to detect the exact point of bleeding deep in the tissue, and requires good coordination between the assistant and the operator. Another situation is that the blood is not sucked out cleanly during electrocoagulation, which affects the hemostatic effect. Generally speaking, as long as the operation field is clear, the bleeding point is clear, electrocoagulation can achieve better results. If the repeated electrocoagulation bleeding is getting more and more, we can consider controlled hypotension after compression hemostasis, if necessary, compression cotton ball with ephedrine or pay renin, can achieve better results. Our experience shows that most traumatic bleeding can be effectively controlled by local patient compression alone. In general, intraoperative wound bleeding is related to the age of the patient and the local inflammatory state. Older children are more prone to bleeding than younger children, and since the adenoids tend to atrophy in older children, the removal of the glands can be slightly more conservative to prevent excessive bleeding. If the adenoids are more inflamed and often irritated by more pus and snot, surgery can be performed after the inflammation has been adequately controlled, which can also reduce bleeding.