Spontaneous resolution of severe chronic glue ear in children and the effect of adenoidectomy, tonsillectomy, and insertion of ventilation tubes (grommets).

Abstract

Objective-To measure the time to spontaneous resolution of severe chronic otitis media with effusion (glue ear) in children and study the effects of adenoidectomy, adenotonsillectomy, and ventilation tubes (grommets).Design-Randomised controlled study over 12years. Setting-Paediatric otorhinolaryngology clinics and in-patient unit.Subjects-228 children aged 2-9 years with pronounced hearing loss from glue ear and persistent bilateral middle ear effusions confirmed on three occasions over three months.Interventions-Children were randomly allocated to adenotonsillectomy, adenoidectomy, or neither procedure. In all groups a Shepard type ventilation tube was inserted in one randomly chosen ear. Follow up was annually for five years and then less often for up to seven years four months. For analysis the two operated groups were combined.Main outcome measures-Otoscopic clearance of fluid, change in tympanogram, and improvement in mean audiometric hearing threshold.Results-Survival analysis showed appreciable otoscopic and tympanometric resolution of fluid with ventilation tubes alone and adenoidectomy alone compared with no surgery. Further improvement was seen after combination ofboth treatments.Mean audiometric hearing thresholds improved with fluid resolution. Resolution was delayed in younger children and in those whose parents smoked, irrespective of treatment. Whereas a single insertion of a Shepard tube resolved the glue for a mean (SD) period of 9.5 (5.2) months, the effect of adenoidectomy was sustained throughout follow up.Conclusions-Treatment of glue ear considerably shortened the time to fluid resolution, combined adenoidectomy and tube insertion being better than either procedure alone. Resolution was longer in younger children and those whose parent(s) smoked, irrespective oftreatment.

Role of Adenoidectomy in Otitis Media and Respiratory Function

“…Thus, the adenoid has a critical location in the nasopharynx in close proximity to the eustachian tubes, which serve as the entry of pathogenic microbes into the middle ear. Removal of an enlarged or chronically infected adenoid by adenoidectomy has been reported to be effective in the resolution of chronic otitis media with effusion in children older than 4 years of age [2][3][4]. Adenoidectomy also has been reported to be effective in the treatment of children with recurrent otitis media who previously received tympanostomy tubes [5].…”

Adenoidectomy and tympanostomy tubes in the management of otitis media

“…A chronic nasopharyngeal infection may promote middle-ear infection by providing a source of pathogenic microbes that may constantly regurgitate to the middle ear through the eustachian tubes [39]. This may explain why adenoidectomy was found to be beneficial in studies of children who were mainly older than 4 years and who had previously received one or several sets of tympanostomy tubes [41], and in children who had suffered from prolonged middle-ear effusion [42,43]. It may be presumed that these children had infections starting in their infancy, allowing a chronic infection to develop in their adenoids.…”

Aggressive and Ineffective Therapy for Otitis media

“…These results, however, were on the conservative side of avoiding inappropriate surgery. If the AHCPR recommendation for surgery is applied to the data reported by Kleinman et al [95] in JAMA, a rather trivial exercise, one reaches the astonishing result that Brown et al [98] 142 Otorhinolaryngol Nova 1998;8:136-147 [106] 1986 150 NS, T, A, ATo Bonding and Tos [107] 1985 193 MA, TA Black et al [108] 1986 100 NS, M, T, A, MA, TA Gates et al [109] 1987 578 M, T, A, TA Ruckley and Blair [110] 1988 36 MA, TA Mandel et al [111] 1989 109 NS, M, T Zielhuis et al [112] 1989 52 NS, T Paradise et al [113] 1990 99 NS, A Black et al [114] 1990 149 NS, M, T, A, MA, TA Le et al [115] 1991 44 NS, M, T Mandel et al [116] 1992 111 NS, M, T Dempster et al [117] 1993 78 NS, T, A, TA Maw and Bawden [118] 1993 228 NS, T, A, ATo Paradise [119] 1992 only 398 cases out of 6,429, or 6%, conform with the AHCPR definition of appropriate indication for surgery.…”