Use of adenoidectomy and adenotonsillectomy in children with otitis media with effusion.

Abstract

We conducted a prospective study of 48 children, aged 2 to 14 years, who had persistent bilateral otitis media with effusion, enlarged adenoids, and a bilateral conductive hearing loss. Half of these patients underwent adenoidectomy and the other half adenotonsillectomy. All patients were followed every 2 weeks for up to 6 months. At 2 months postoperatively, the overall success rate in terms of the resolution of middle ear effusion was 85.1%. Success rates were 82.6% in the adenoidectomy group and 87.5% in the adenotonsillectomy group; the difference was not statistically significant. Our findings demonstrate that both adenoidectomy and adenotonsillectomy are effective for the treatment of persistent otitis media with effusion, and they confirm the findings of other studies. Based on our findings and those of other investigators, we offer a four-step approach to the management of these children.

Introduction

The prevalence of otitis media with effusion (OME) peaks between the ages of 2 and 5 years. (1) Half of all children aged 3 to 5 years have at least one effusion per year, (1,2) and between 28 and 38% of preschool children experience a recurrence of OME. (3-6) Approximately 50% of effusions resolve spontaneously within 2 months, but 5% result in a bilateral conductive hearing loss that persists for at least I year and that can cause subsequent language impairments and learning difficulties. (2,4) Others have reported spontaneous resolution at 2 to 3 years in 31% of patients with untreated OME. (7,8) Among the factors that can hinder the resolution of OME are parental smoking, atopic disease, recurrent acute infection, and an enlargement of the adenoids. (1,2,9)

Persistent OME (glue ear) is a common cause of hearing loss in children. In the United Kingdom, five of every 1,000 children require surgery for this condition at an annual cost of 30 million [pounds sterling] ($43 million U.S.). (2,10) In the United States, the cost of such surgery reaches $2 billion per year. (11) Children with persistent bilateral OME are more likely to experience language impairments, which can lead to learning and behavioral problems. (2,4,6,12,13) These problems can continue to affect the academic performance and development of these children well into the future.

There is controversy regarding the treatment of OME. Treatment options range from medical therapies to different types of surgical procedures. Some of the controversy stems from the fact that the combination of decongestants, antihistamines, and mucolytics is ineffective. (11) Another reason is that although antibiotics and corticosteroids clear effusions, the recurrence rate is high once treatment is discontinued. (11) Several surgical procedures reduce OME-induced hearing loss, but they do not always cure persistent bilateral effusion. (14)

Many questions regarding treatment still need clear scientific answers, and there is a need to know how to approach a child with persistent OME. In this study, we attempted to determine the effectiveness of both adenoidectomy and adenotonsillectomy in a group of children with persistent bilateral OME who had failed medical treatment and who had no history of ear surgery. Based on our experience and that of other researchers, we offer our recommendations for a four-step approach to the management of children with chronic OME and enlarged adenoids.

Patients and methods

We studied 48 children, aged 2 to 14 years (mean: 5.8), who had persistent bilateral middle ear effusion, a bilateral conductive hearing loss of 2 to 12 months' duration (mean: 5.1), enlarged adenoids, and a history of snoring at night (table). No patient in this study had rhinorrhea. Patients were diagnosed and selected for surgery on the basis of their history, otoscopic examination, audiometry and tympanometry results, postnasal space x-ray findings, and their failure to respond to at least 3 months of medical treatment.

Twenty-four of these patients had a history of recurrent tonsillitis, and they were chosen to undergo adenotonsillectomy. The other 24 patients were selected to undergo adenoidectomy.

Otoscopically, the tympanic membrane was dull and immobile in all but four patients; in two of these patients, the tympanic membrane was difficult to see, and in the other two, the membranes were retracted. X-rays of the postnasal space revealed that all patients had a narrowing of the nasopharynx as a result of an enlargement of the adenoids. All pre- and postoperative clinical examinations and evaluations were performed by an experienced otorhinolaryngologist (Q.A.K.).

Audiometric testing was performed in soundproof rooms with an Interacoustics clinical audiometer (model AC5). We used a visual-reinforcement audiometry technique for the younger children and a conventional technique for the older ones. Audiograms showed that there were significant air-bone gaps (>10 dB at three or more frequencies) in all patients. Tympanometry was performed with an Interacoustics tympanogram (model AT2). Tympanograms were flat (type B) in all patients.

All surgeries were performed with the patients under general inhalational endotracheal tube anesthesia. Postoperative followup was performed every 2 weeks for up to 6 months. Criteria for success included a subjective improvement in hearing, findings on otoscopic examination, closure of the air-bone gap, and type A (peak) tympanography results. All successful cases were identified as such within 2 months of surgery. All patients who failed surgery underwent a repeat postnasal space x-ray 6 months postoperatively.

Results

Overall, the surgical success rate was 85. 1% (table). In the adenoidectomy group, there were 19 successes (82.6%) and four failures (17.4%) (one patient in the adenoidectomy group was lost to followup). In the adenotonsillectomy group, there were 21 successes (87.5%) and three failures (12.5%). The difference in success rates between the two types of surgery was not statistically significant (p>0.05).

The four failures in the adenoidectomy group all experienced a recurrence of adenoids. The three failures in the adenotonsillectomy group were attributed to a recurrence of adenoids, the onset of sinusitis, and persistent middle ear effusion in one patient each.

Discussion

The removal of the adenoids is presumed to eliminate the mechanical obstructing effect of this tissue and/or the source of nasopharyngeal infection. The failure of medical treatment to remedy chronic OME can probably be attributed to the mechanical effect that the adenoids have on the eustachian tube opening. The simultaneous removal of the tonsils is considered to be a viable option when a patient with OME has concomitant chronic tonsillitis.

Our findings demonstrate that both adenoidectomy and adenotonsillectomy are useful surgical procedures for treating persistent OME. We found no statistically significant difference in the success rates of the two procedures.

Our results are in accordance with those of other studies. (15-19) For example, Maw studied 103 children aged 2 to 12 years who still had persistent bilateral OME after undergoing a 12-week course of antihistamine treatment. (17) These children were randomly assigned to one of three groups: an adenoidectomy group, an adenotonsillectomy group, and a nonsurgical control group. During surgery, one ear was intubated while the other served as a further intrapatient control ear to gauge the degree of clearance and thus to help determine surgical success or failure. At 12 months of followup, the combined success rate for the adenoidectomy and adenotonsillectomy groups was 71%, compared with only 26% for the control group--a highly significant difference (p<0.001). There was no statistically significant difference in success rates between the two surgical groups.

Others have reported that the addition of myringotomy with tube insertion to adenoidectomy or adenot(msillectomy does not improve outcomes. (17-19)

Recommendations

In light of our findings and those of other investigators, we recommend a four-step approach to the management of children with chronic OME and enlarged adenoids:

Step 1. First-line management should entail observation and screening by otoscopic and tympanometric examination every 2 to 4 weeks over a period of 2 to 3 months.

Step 2. Medical therapy should be prescribed for those patients in whom spontaneous resolution does not occur. Treatment should consist of decongestants, antihistamines, and antibiotics for 2 to 3 months.

Step 3. For children who have failed repeated medical therapy, we recommend adenoidectomy or adenotonsillectomy as the first-line surgical procedure. Either procedure reduces the morbidity caused by recurrent OME.

Step 4. Myringotomy with tube insertion should be the procedure of last resort. Its benefits are limited, and it carries a significant risk of complications, including otorrhea, permanent perforation, scarring, and retraction with adhesions.

Finally, the otolaryngologist should seriously consider prescribing a hearing aid for children with chronic OME and conductive hearing loss until their disease has subsided. Such assistance might help these children avoid the language and speech difficulties that can hinder their performance and development.

Table. Characteristics and outcomes of patients in the adenoidectomy
and adenotonsillectomy groups

Variable                    Adenoidectomy          Adenotonsillectomy

No. children                     24                        24
Age range (yr)                 2 to 14                  3 to 13
Mean age (SD *)          5.7 ([+ or -] 3.05)      5.9 ([+ or -]  2.65)
Mean duration of                                          4.8
  hearing loss (mo)
No. successes (%)       19 (82.6 ([section]))          21 (87.5)
No. failures (%)        4 (17.4 ([section]))          3 (12.5 (#))
No. recurrences (%)     4 (17.4 ([section]))            1 (4.2)

Variable                    Entire group                p Value

No. children                     48
Age range (yr)                 2 to 14
Mean age (SD *)         5.8 ([+ or -]  2.83)       p>0.05 ([dagger])
Mean duration of                 5.4               p>0.05 ([dagger])
  hearing loss (mo)
No. successes (%)      40 (85.1 ([paragraph]))     p>0.05 ([dagger])
No. failures (%)       7 (14.9 ([paragraph]))      p>0.05 ([dagger])
No. recurrences (%)    5 (10.6 ([paragraph]))

* Standard deviation.

([dagger]) Not statistically significant.

([section]) Based on 23 patients; one patient was lost to followup.

([paragraph])  Based on 47 patients; see footnote above.

(#) One failure was attributed to a recurrence of adenoids, one to
sinusitis, and one to persistent middle ear effusion.

References

(1.) Maw AR, Bawden R. Factors affecting resolution ofotitis media with effusion in children. Clin Otolaryngol 1994;19:125-30.

(2.) De Melker RA. Treating persistent glue ear in children. BMJ 1993 ;306:5-6.

(3.) Casselbrant ML, Brostoff LM, Cantekin El, et al. Otitis media with effusion in preschool children. Laryngoscope 1985:95: 428-36.

(4.) Cotton RT. The surgical management of chronic otitis media with effusion. Pediatr Ann 1991 ;20:628, 631-7.

(5.) Bonding P, Tos M. Grommets versus paracentesis in secretory otitis media. A prospective, controlled study. Am J Otol 1985:6:455-60.

(6.) Roberts JE, Sanyal MA, Burchinal MR, et al. Otitis media in early childhood and its relationship to later verbal and academic performance. Pediatrics 1986;78:423-30.

(7.) Maw AR, Parker A. Surgery of the tonsils and adenoids in relation to secretory otitis media in children. Acta Otolaryngol Suppl 1988;454:202-7.

(8.) leiberman A, Bartal N. Untreated persistent middle ear effusion. J Laryngol Otol 1986;100:875-8.

(9.) Paradise JL. Does early-life otitis media result in lasting developmental impairment? Why the question persists, and a proposed plan for addressing it. Adv Pediatr 1992;39:157-65.

(10.) Black NA, Sanderson CF, Freeland AP, Vessy MP. A randomised controlled trial of surgery for glue ear. BMJ 1990;300:1551-6.

(11.) Berman S, Roark R, Luckey D. Theoretical cost effectiveness of management options for children with persisting middle ear effusions. Pediatrics 1994;93:353-63.

(12.) Rach GH, Zielhuis GA, van den Broek P. The influence of chronic persistent otitis media with effusion on language development of 2- to 4-year-olds. Int J Pediatr Otorhinolaryngol 1988; 15:253-61.

(13.) Zielhuis GA, Rach GH, van den Broek P. Screening for otitis media with effusion in preschool children. Lancet 1989;1:311-4.

(14.) Couriel JM. Glue ear: Prescribe, operate, or wait? Lancet 1995;345:3-4.

(15.) Maw R, Bawden R. Spontaneous resolution of severe chronic glue ear in children and the effect of adenoidectomy, tonsillectomy, and insertion of ventilation tubes (grommets). BMJ 1993;306:756-60.

(16.) Paradise JL, Bluestone CD, Rogers KD, et al. Efficacy of adenoidectomy for recurrent otitis media in children previously treated with tympanostomy-tube placement. Results of parallel randomized and nonrandomized trials. JAMA 1990;263: 2066-73.

(17.) Maw AR. Chronic otitis media with effusion (glue ear) and adenotonsillectomy: Prospective randomised controlled study. Br Med J (Clin Res Ed) 1983;287:1586-8.

(18.) Austin DF, Idaho IF. Adenotonsillectomy in the treatment of secretory otitis media. Ear Nose Throat J 1994:73:367-9, 373-4.

(19.) Gates GA, Avery CA, Prihoda TJ, Cooper JC Jr. Effectiveness of adenoidectomy and tympanostomy tubes in the treatment of chronic otitis media with effusion. N Engl J Med 1987;317: 1444-51.

From the Department of Otolaryngology (Dr. Abdul-Baqi) and the Department of Community Medicine (Dr. Shakhatreh), Faculty of Medicine, Jordan University Hospital, Amman; and the Department of Otolaryngology, Zarqa Hospital (Dr. Khader), Amman, Jordan.

Reprint requests: Dr. Khader J. Abdul-Baqi, University of Jordan, Box 13001, Amman 11942, Jordan. Phone: [phone], ext. 2848; fax: [phone]; e-mail: [e-mail]