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(1)

Adenotonsillectomy in the Treatment of

Secretory Otitis Media

David F. Austin, MD

Idaho Falls, Idaho

Introduction

The fundamental hypothesismotivatingthis paper is that

secretoryotitismedia inchildrenis a manifestation of

recur-rentorchroniccatarrhaldiseaseof theupperrespiratorytract

whoseepicenterusuallyliesinthenaso-pharynx. Becauseof

this belief,treatment for resistant patientshas beenT

&

A or

adenoidectomy rather than the use of ventilating tubes.

Thirty years of treating secretory otitis by what some may

consider an alternate approach is the subject of this

manu-script.

The author's earlyexperiencewithusinga PE tubeinonly

one ear led to a formal study of the efficacy of PE tube use

whencombinedwithadenoidectomy oradenotonsillectomy.

This study included31

childrenwithchronicbilateralsecre-tory otitis treated by T

&

A.

At the time of surgery,one ear

wasintubated,theotherservedasacontrolwithnotreatment.

Using audiometric criteria, it was found that there was no

significantdifferencebetweentheintubatedandcontrolears

after a six to eight week follow-up.

Documentedalso aretwoseriesof childrensufferingfrom

chronic secretory otitis all of whom were resistant to prior

ENTor pediatricmanagement. Ten percentneededT and A

surgerywithouttube insertion and were followedforat least

I year. Audiometrywas usedtomeasuretheresultofthcrapy

whichwassuccessfulinmorethan90 percentofthc patients.

The mode of therapy used for the non-surgically treated

children is detailed. This togetherwithjudicious indication

of T and A surgery has reduced the need for pressure

equalizing tubes to less than 5 percent of my patients.

Early in my practice, the use of ventilation tubes for

catarrhal otitis media was barely beginning. Such devices

were hand-made and their efficacy had not been measured.

Since tonsillectomyand adenoidectomy was then the

stan-dard treatmentfor recurrentor chroniccatarrhalear disease,

I chose to insert a ventilation tube in only one car of those

children withmiddleear effusion. I wasgreatlysurprisedto

findinmyinitialpatientsthatnotonlydidbothearscleartheir

effusion, the un-operated ear recovered first. After the next

nine patients had exhibited the same pattern, I abandoned

intubation of the middle ear as a standard treatment for

Reprints Requests to: Idaho ENT. PA, 21160 Channing Way . Suite 202,

Idaho Falls, Idaho 113404.

Volume 73, Number 6

catarrhalotitismedia,dependinginsteadupontonsillectomy

adenoidectomyfor these patients.

Ten years later, the use of ventilation tubes for catarrhal

otitis was widespread. Only a few voicesexpressedcaution

or suggested controlled study to establish their efficacy.

It

was with great difficulty that a more controlled experiment

similarto thatdescribedabove wasinstitutedinour teaching

program.

It

was felt that to withholdtreatmentfrom one ear

in a bilateraldisease would be improper. Almost a year was

required to collect a series of 31 patients with adequate

preoperativeevaluation,a tonsillectomyandadenoidectomy

with unilateral tube insertion,and a minimum audiometric

follow-upof 6 weeks. The resultsofthisstudyare presented,

Datahasbeencollectedand reviewedon425childrenseen

in private practice for treatment of secretory otitis and for

whom priormedicalor surgicaltreatmentwas unsuccessful.

Surgery (adenoidectomy or adenotonsillectomy) was

per-formed

on approximatelyone-thirdof thesepatient.

Eighty-three patientswho werefollowedfora minimumof one year

(53 with complete audiometricdata) are reported.

The purposeof reportingeach of these studies, the

short-term, resident program study together with the long-short-term,

personal patient group, is to document an approach to the

controlof secretoryotitiswhichdoes notrelyon theinsertion

of a ventilationtube into the middle ear,

.

T &

A with Unilateral Tube Insertion:

Methodology

The design of this experiment was relatively simple. A

seriesofchildrenforwhomtonsillectomy andadenoidectomy

had been scheduled and who were known to have bilateral

catarrhal otitis was selected. On the day of admission

standard pure-toneair and bone audiometrywas performed.

Following theT

&

A, a Oared polyethyleneventilationtube

wasinsertedintoeithertherightor leftear selectedaccording

to the chart number: even number for the right car, odd

number for the left. All surgery was performed by first-or

second-year residents,fiveresidentssharing thecase loadof

31 patients, A follow-up of three months was attempted, a

minimum of one month follow-up was required. At each

follow-upvisit the ear was inspectedto determine the status

(2)

AUSTIN

Table 1.

Patient Data for Unilateral Tube Study

of the ventilation tube and the audiometry was repeated. At

the end ofa year, the study was terminated. Only

31

patients

had been entered into the series since it was felt by the

residents that the standard of practice at that time required

bilateral surgery -

this, in spite of the patient results

reported below. Although its efficacy is unclear, ventilation

tube insertion continues as the most frequently performed

operation by our specialty."

Number of Patie nts

Mea n Follow-up (audiometric)

Mean Follow-up (otoscopy)

Tube OK

Tube Extruded

31

1.6 mos.

1.9 mos.

23 (1.5 mos.)

8 (2.9 mos .)

60 50

29.9

13.2

16

Intubated Ear

1.9

30

26.6

14.4

12.2

Control Ear

o

·10 ·20

Hearing Results - tube study

Intubated Ears (N

=

31)

30 t- - t- - I- - It ~ ~ ~ --I- - -A

10t- -+-- . ~ I - - -+-'I--I- -~ """,,-l-- - I'\.~ -I- ---l

Figure 1. Hea ring res ults of the PE tube study forintubated

ea rs showing the change in bone-air gap pre-op to post-op.

Figure 2. Hearing results of the PE tube study for

non-intubated ears sh owing the chan ge inbone -airgap pre-op to

post-op.

Hearing Results - tube study

50

Non-intubated Ears (N = 31)

1-

preop - poslop

I

40

~

~

-'

I

30

/

X

\

20

/

/

\

,

10 ,

~

o~~

·20 ·10 0 10 20 30 40 60 bonlHir gap (dB)

Results of Unilateral Tube Study

Table 2.

Mean Preoperat ive Bone-Air Gap (dB)

Mean Postoperative Bone-Air Gap (dB)

Mea n Improve men t in Hea ring (dB)

Mean Diffe rence Between Ea rs (dB)

Tonsillectomy and Adenoidectomy Alone:

Methodology

In my private practice. approximately one-third of

chil-dren seen with catarrhal otitis are advised to have

tonsillec-tomy and adenoidectonsillec-tomy. This procedure is indicated for

those children with persistent effusion for longer than three

Results:

Since the unoperated ear serves as a

Measurement

control for the operated ear, the results

could be studied several ways. The

differ-ence between the paired ears is a sensit ive

statistical measurement. The unilateral

study groups may be used to measure the

effect of tonsillectomy and adenoidectomy

Student t = p>.t (no significant difference)

alone, or tonsillectomy and adenoidectomy

plus tube insertion, on secretory otitis.

Finally, the differences between the two groups can be

meas ured to reinforce the findings of the paired comparison.

Tables I and 2 summarize the study data that are illustrated

in figures I, 2, 3 and 4. Statistical evaluation of the data of

table 2 Student tests show no significant differences (p>O.I)

between the operated and unope rated ears (figures I and 2).

Chi-square analysis documented in table 3 showed that the

incidence of resolution of the problem was the same with or

I

20

without the use of a ventilating tube. Similarly, there was no

significant difference found by comparing changes in the

hearing of each ear of the individual patients (therapeutic

efficiency) as determined by student analysis (p>O. I) and

demonstrated graphically in figure 3. Figure 4 illustrates the

inter-ear hearing difference following the surgery. The

indicated 2 dB bias in favor of the intubated ear is not

statistically significant (p>O.I) and improvement is equa lly

probable with or without tube insertion.

Evaluation ofthe individual data revealed poor results in

10

patients

(32%).

Ofthese.

2 (6%)

were bilateral. 5

(16%)

were in the unoperated ear, and 3 (10 %) were in the

operated ear. In the final ana lysis,

29

of

3

I patients

(93%)

were benefitted by at least unilateral improvement of

hearing as measured over the short term . In my op inion, all

were benefitted by the tonsillectomy and adenoidectomy.

The study served to reinforce the thought that tube

inser-tion is not the on ly efficacious procedure available for the

long-term solution of the problem of recurrent or chronic

secretory otitis.

(3)

ADENOTONSILLECTOMY IN THE TREATMENT OF SECRETORYOTITIS MEDIA 30 20

I

50 6O r- - -.- - -r- - --, ,- - ..,...- -- -~-- ,__ ____.

Hearing Results - tube study

Inter-ear Difference

10

o

·10 dB ·20 ·30 ·40

Hearing Results -tube study

Change in Hearing (dB)

30f----:-

I

I

I

I

I

11-

I----+-+

10

Figure 3. Hearing results of the PE tube study showing the

change in air conduction for intubated versus non-intubated

ear. Analysis shows no statistical difference.

Figure 4. Hearing results of the PE tube study showing the

difference in air conduction between paired ears. The 1.9

difference favoring intubated ears proved to be insignificant

on statistical analysis.

;(2

=

0.4 133; p

=

.48 (no significant differen ce)

Table 3.

X2 Distribution of Results of Unilateral Tube

Study

months in spite of adequate treatment or for those children

with more than three recurrences during the school year.

Eighty-three patients who had been followed for one yearor

longer were included in this study, as indicated in table 4.

Fifty-three patients had pre- and post-operative audiometric

testing, the results of which are summarized in table 5.

Since this data was originally

presented,'

chart study was

undertaken of patients seen in my new locus. Although

follow-up was not adequate for similar analysis, the

inci-dence of surgical treatment (33%) and of treatment failure

requiring subsequent tube insertion (8%) was the same.

Tube

No Tube

~

26

24

Unchanged

5

7

Table 4.

Patient Data for T

&

A Series

Patients

Number

Table 5.

Hearing Results of T

&

A Series

' Eleventotal episo des ( 1.9/palient)

"Two patie nts required I tube

insertion

eac h

Hearing Result (dB)

27 .9

9.8

18.1

Measurement

Mean preoperative bone-air gap

Mean postoperative bone-air gap

Mean improvement in hearing

With catarrhal otitis media

425

Having tonsillectomy and adenoidectomy

125

Followed for more than 1 year

83

With complete audiometry

53

With recurrent episodes following T

&

N ·b.

8

Results

Figure 5 illustrates the resultsof thehearingtestsofali i06

ears tested. Figure 6 compares the therapeutic efficiency of

T & A alone with that of the tube study reported above.

Statistical evaluation using Student' s allows the conclusion

that the only significant difference between patient groups

is that the private patients having T & A had a better hearing

result than did the resident surgical cars without tube

inser-tion (p<O. I). Since the groups are not homogeneous, this

inference is probably not justified. Undoubtedly.

differ-ences insurgicaltechnique and post-operative management

had an effect on the results noted when comparing these

series of patients.

Eight patients (10%) had recurrent episodes of effusion

during the periodofobservation. Altogether, II recurrences

were seen (1.4 per patient), and in two of these patients a

single tube insertion was performed. This represents an

incidence of 2.4 percent of these patients requiring tube

insertion and an incidence of 0.6 percent of all patients

presenting withcatarrhalotitis. Inthree patients. previously

placed tubes were removed during the surgery and one

patient required myringoplasty to repair a persistent

(4)
(5)

,

10 0 lS ,1 1 '114010011 1 l'~ " . III lIllYANn OMPANY

N

(6)

Control 26% 15% LoracarlJef 15% 8% 10,1 % Other major Enterobacteriaceae

·Primarily inthediaper areainyoung children.

Loracarbef (L) vs Amoxicillin (A) in Acute Otitis Media (Europe)

Efficacy: A study of acute otitis media performed in

a population with a lower incidence of ,B-Iactamase-producing organisms than that usually seen in US trials compared loracarbef to arnoxicill in, USing very strict evaluability and microbiologic/clinical response criteria at the 10-to16-day posttherapy follow-up, the following presumptive bacterial eradication/clinical cure outcomes (success rates)were obtained:

EaIIJQgen %Due toPathooen IN - 291) ~

S.pneumoniae 51 .5% LequivalenttoA

H.influenzae 29.2% L14% greater than A

M.calarrhalis 15.8% L31%greater than A

S.pyogenes 3.4% LequivalenttoA Overall 100,0% LequivalenttoA Loracarbef (L) vs Doxycycline(0) in Acute Maxillary Sinusitis (Europe)

Efficacy: Astudy of acute maxillary sinusitis performed in a population with a lower incidence of f3-lactamase-producing organisms than that usually seen in US trials compared loracarbef with doxycycline. Using very strict evaluability (sinus-puncture) criteria and microbiologic/clinical response criteria at the 1- to 2-week posttherapy follow-up, the following presumptive bacterial eradicat ion/clin ical cure outcomes (success rates) were obtained :

~ %Due toPathogenlN= 210l ~

S.pneumoniae 47.6% Lequivalent toD

H.influenzae 41.4% Lequivalent toD

M.calalTha/is 11.0% Lequivalent toD Overall 100.0% Lequivalentto D Loracarbef (L) vs Cefaclor (C) in Uncomplicated Cystitis StUdy (US)

Efficacy: A study of cystitis compared loracarbef

with cefaclor. Using very strict evaluability criteria and microbiologic/clinical response criteria at the 5-to 9-day posttherapy follow-up, the following bacterial eradication rates were obta ined:

EaIIJQgen %Due toPathogenIN= 1861 Eradication Bate

t.

coli 77.4% L4%greater thanC

(L =80%) Other major 12.5% Lequivalent toC

Enterobacteriaceae (L =61

%1

S.saprophyticU5 3.8% Lequivaient toC Loracarbef (L) vs Ouinolone (0) in Uncomplicated Cystitis (Europe)

Efficacy: A study of cystit is compared loracarbef

with an oral quinolone. Using very strict evaluability criteria and microbiologic/clinical response criteria at the 5- to 9-day posttherapy follow -up, the following bacterial eradication rates were obtained:

EaIIJQgen %Due toPathogen IN = 189) Eradication Rate

t.

coli 82.0% L7%less than Q

(L=81%) L32% less thanQ IL=50%) Clinical Studies:

Loracarbef (L) vs ,B-Lactamase Inhibitor (C) in Acute Otitis Media (US)

Efficacy: A study of acute otitis media performed in

a population with a significant incidence of fJ-lactamase-producing organisms compared loracarbef with a f3-lactamase inhibitor. Using very strict evaluability and microbiologic/clinical response criteria at the 10- to 16-day posttherapy follow-up, the following presumptive bacterial eradication/clinical cure outcomes (success rates)were obtained:

eID!!Q9lill %Due toPathogensIN = 204) ~

S.pneumoniae 42.6% Lequivalent toC

H.influenzae 30.4% L9%less thanC

M.calalThalis 20.6% L19%less thanC

S.pyogenes 6.4% Lequivalent toC Overall 100.0% L12%less lhanC

Safety: The incidenc es of the most common

adverse events were clinically and statistically significantly higher in the control group versus the loracarbef group.

Event Diarrhea Rash"

PV2734 AMP [010694J

Additional information available to the profession on request from Eli Lilly and Company, Indianapolis, Indiana 46285.

~

g~1 Carolina,Puerto Rico00985EllLillyIndustrles,lnc ...." A Subsidiary of EliLilly andCompany

Indianapolis, Indiana46285

Lorabid'. (Ioracarbef)

L00354-CLK840100FZ3 ©1994, ELI LILLY AND COMPANY 14 10 Duration(daYSI 15mglkg/day q12h (divided doses) 15mg/kg/day q12h (divided doses) Impetigo ADULTS ("t3 years) Secondary Bacterial 200-400 q12h Infecllon ofAcute Bronchills Acule Baclerial 400 q12h Exacerbation ofChronic Bronchitis Pneumonia 400 q12h

Renal excretion of ,B-Iactams is inhibited by probenecid and resulted in about an 80% increase in the AUC for loracarbef.

Safety and effectiveness have not been determined in pregnancy, lactation, and infants under 6 months of age. Caution should be exercised in prescribing Lorabid for these patients.

In geriatric patients who received the usual recommended adult doses in clinical studies, efficacy and safety were comparable to results in nongeriatric adult patients .

Adverse Reactions: Most adverse reactions in clinical trials were mild and transient. Only 1.5% of pat ients d iscontinued because. of drug-related reactions the most common of which were diarrhea, abdominal pain, and skin rashes.

All Patients

The incidence of the following adverse events was less than 1%, except as otherwise noted:

Gastrointestinal: Diarrhea, 4.1%; nausea, 1.9%; vomit ing, 1.4%; abdominal pain , 1.4 % ; and anorexia.

Hypersensitivity: Skin rashes (1.2%), urticaria, pruritus, and erythema multiforme .

Central Nervous System: Headache (2.9 %) , somnolence, nervousness, insomnia, and dizziness.

Hemic and Lymphatic Systems: Transient throm-bocytopenia, leukopenia, and eosinophilia.

Hepatic: Transient elevations in AST (SGOn, ALT (SGPn, and alkaline phosphatase .

Renal : Transient elevations in BUN and creatinine. Cardiovascular System: Vasodilatation. Genitourinary: Vaginitis: (1.3%), vaginal moniliasis (1.1%).

Pediatric patients

The incidences of several adverse events were sign ificantly different in the pediatric population versus the adult population respectively as follows : Diarrhea (5.8% vs 3.6%); nausea (0.0% vs 2.5%) ; vomiting (3.3% vs 0.5%); anorexia (2.3% vs. 0.3%); headache (0.9% vs. 3.2%) ; somnolence (2.1% vs 0.4%); rhinitis (6.3% vs 1.6%); rash (2.9% vs 0.7%).

8=LactamAntimicrobial Class Labeling; Although not observed in Lorabid clinical trials,t~e

following have been reported in patients treated with ,B-Iactam antibiotics:

Adverse Reactions - Anaphylaxis,

Stevens-Johnson syndrome , serum-sickness-like reactions, aplastic anemia, hemolytic anemia, hemorrhage. aqranulocytosls, toxic epidermal necrolysis, ren!'!1 dysfunct ion, toxic nephropathy, andhepatic dysfunction, including cholestasis , and seizures.

Altered Laboratory Tests-Increased prothrombin

time, pos itive direct Coombs' test, elevated LDH, pancytopenia, and neutropen ia.

Overdosage: Hemodialysis has been shown to be effective in hasten ing the elimination of loracarbef from plasma in patients with chron ic renal failure. Dosage and Administration: Lo rab id is administered orally either at least 1 hour prior to eating or at least 2 hours after eating.

PharyngitlsfTonsillitis 200 q12h 10 Sinusitis 400 q12h 10 ISeaClinical StudiesandIndications and Usage for further

information.)

Uncomplicated Skin and 200 q12h Skin Structure Infections

Uncompllcaled cystitis 200q24h 7

(SeeClinical Studiesand Indications and Usage for further

Informalion.1

Uncomplicated 400 q12h 14 pyelonephritis

Population/Infection Dosage(mg)

INFANTS AND CHILDREN(6months to12yrs)

AcuteOtilisMedia" 30mglkg/day q12h 10 (divided doses)

(SeeClinical Studiesand Indications and Usaga for further

information.) PharyngitlsfTonsillilis

"Clin ical studies of otitis med ia were conducted with the suspension formulat ion only. Therefore, the capsule should not be substituted for the suspension in the treatment of otitis media.

Lorabid- (Ioracarbef)

Lorabid'

(Ioracarbef)

Pulvules", 200 mg and 400 mg

For Oral Suspension, 100 mg or 200 mg/5mL (50-mL and loo-(50-mL size)

Brief Summary. Consult the package insert for complete prescribing information.

Indications and Usage: Lorabid is a synthetic

f3-lactam antibiotic of the carbacephem class for oral admin istration. Lorabid is indicated in the following mild to moderate infect ions caused by suscept ible strains of designated microorganisms.

Secondary Bacterial Infection of Acute Bronchitis

caused by Streptococcus pneumon iae. Haemophilus influenzae (inclUding

f3-lactamase-producing strains), or Moraxella (Branhamella)

catarrhalis (including fJ-lactamase-pro d ucing

strains).

Acute Bacterial Exacerbations of Chronic Bronchitis caused by S. pneumoniee, H. influenzae (including fJ-lactamase -producing

strains), or M. catarrha/is (inclUding f3-lactamase-producing strains).

Pneumonia caused by S .pneurnoniee, or H. i n fl u e nzae (non- fJ-lactamase -prod ucing

strains only).

Otitis Media' c aused by S.pneumoniae, H. influenzae (including fJ-lactamase-producing

strains), M. catarrha/is (inclUding fJ-lactamase-producing strains), or Streptococcus pyogenes.

Acute Maxillary Sinusitis' caused by S.

pneumoniae, H. influenzae

(non-O-Iactamase-producing strains only), or M. catarrhalis (including f3-lactamase-producing strains).

"NOTE: In a patient population with significant numbers of fJ-lactamase-producing organisms, loracarbef's clinical cure and bacteriological eradication rates were somewhat less than those observed with a product containing a f3-lactamase inhibitor. Lorabid 's decreased potential for toxicity compared to products containing fJ-lactamase inhibitors along with the susceptibility patterns of the common microbes in a given geograph ic area should be taken into account when considering the use of an ant imicrobial (see CLINICAL STUDIES section).

Pharyngitis and Tonsillitis caused byS.pyogenes.

(The usual drug of choice in the treatment and prevention of streptococcal infections, including the prophylaxis of rheumatic fever, is pen icillin administered by the intramuscular route. Lorabid is generally effective in the erad ication of S.

pyogenes from the nasopharynx; however, data

establishing the efficacy of Lorabid in the subsequent prevention of rheumatic fever are not available at present.)

Uncomplicated SkIn and Skin Structure Infections caused by Staphylococcus aureus

(including penicillinase-producing strains) orS.

pyogenes. Abscesses should be surgically drained

as clinically indicated .

Uncomplicated Urinary Tract Infections (cystitis)

caused by Escherichia coli or Staphylococcus

sspropttyticus'.

NOTE: In considering the use of Lor ab id in the treatment of cystitis, Lorabid 's lower bacterial erad ication rates and lower potential for toxicity should be weighed against the increased eradication rates and increased potential for tox icity demonstrated by some other classes of approved agents (see CLINICAL STUDIES section).

Uncomplicated Pyelonephritis caused byE.coli.

"Althoug h treatment of infections due to this organism in the organ system demonstrated a clinically acceptable overall outcome, efficacy was studied in fewer than 10 infections.

Contraindication: Known allergy to loracarbef or cephalosporin-class antibiot ics.

Warnings: Because cross-hypersens itivity can occur among fJ-lactams, Lorabid should be given caut iously to pen icillin-sens itive pa tients and discontinued if an allergic reaction occurs .

Pseudomembranous colitis has been reported with nearly all antibacterial agents and should be considered in differential diagnosis of ant ibiotic-associated diarrhea. ,

Precautions: Lorabid may be administered to pat ients with impaired renal funct ion . Total da ily dosage should be reduced in patients with known or suspected renal imp airment because of the possibil ity of high and/or prolonged plasma concentrations.

Loracarbef should be given cautiously to patients receiving diuretics concurrently.

Prolonged use may result In overgrowth of nonsusceptible organisms.

Loracarbef should be given cautiously to patients with a history of colitis .

(7)

ADENOTONSILLECTOMY IN THE TREATMENT OF SECRETORY OTITIS MEDIA 30 20 10

o

·10 dO ·:>0 -40 30 E

i

20 50

o

! - !::::::1' == ===r ~ -

-·10

T and A

vs.

'lube Study

Hearing Change (dB)

I

Figure 5. Hearing results for the T and A study showing the

change in bone-air gap pre-op to post-op.

Figure 6. Compared the hearing results ofthe T and A study

to those of the tube study. There is no stast ical difference

between these curves , suggesting that adenoidectomy was

the principal factor in affecting the change in hearing.

ration at the site ofa tube placement. In reviewing my present

patients (n= I02), the incidence of recurrent disease requiring

intubation is 8 percent.

Adenoidectomy Technique

Direct examination ofthe nasopharynx has shown that one

effect of adenoid hyperplasia is restriction of posteriorward

mobility of the torus tubaru s,preventing adequate opening of

the tubal orifice. Since the adenoid is in actuality a paired

lymphoid mass, the common method of performing

adenoidectomy with a basket adenotome remov es but a

portion of the central masses, leaving behind the culprit

lateral masses. To effectively remove this lateral tissue,

smaller adenotomes and curettes, directed laterally. should

be used, followed by the use of a triangular punch forceps

controlled by direct visualization of the adenoid and torus

tubarus. Lateral and superior retraction of the velum are

required, which negates the suspension method

ofpharyn-geal exposure. Good coaxial illumination is another

essen-tial requirement for the proper performance of this

proce-dure.

Since the te aching of tonsillectomy and

adenoidectomy is usually relegat ed to senior residents in

our training programs, and since pedi atric opinion often

relegates tonsillectomy and adenoidectomy to the

"need-less surgery" status, our specialty needs to make a special

effort to insure that this important surgical therapy is not

forgotten or becomes obsolescent.

Medical Management

The most significant aspect ofcare of the catarrhal child is

medical. The initial evaluation must include investigation of

environmental, immunologic, infectiou s, and nutritional

fac-tors. Both past and familial history are significant. My

personal observation is that the child with chronic catarrhal

disease or with chronic tonsillitis and adenoiditis is often

nutritionally deficient with a delayed growth pattern. Raw

milk is often an offending nutrient either through allergy or

through exce ssive intake preventing a balanced diet. The

practice of bottle propp ing is widespread and leads to

Eusta-chian reflux . Mothers of these children should be educated

in the importance of nutrition in the maintenance of good

health. The use of nutritional supplements, especially

vitamin C, are advi sed. Many good habit of nasal hygiene

are of prime importance. It may well be that the reduction

in the incidence of secretory otitis after age 8 is partially

due to the acquisition of the habit of nose blowing at this

stage of life . In any case, every child and his parents are

instructed in the technique ofself-inflation of the ears. The

importance of this maneuver in the evacuation of effusion

from the middle-ear and the prevention of recurrence is

emphasized at each visit and the child is tested for success in

learning the technique. Only a few are unable to learn the

necessary skill. When acute nasal congestion prevents

inflation. decongestants are prescribed. Appropriate

antibi-otics are used in the presence of acute suppurative infection .

Discussion

While the benefits of indicated ton sillectomy and

adenoidectomy are obvious to both parent arid physician.

statistical assessment of this benefit has eluded scientific

validation until recent years.4.9.11.15With the exception ofone

paper,' these studies show that both PE tube insertion and

adenoidectomy will bring short-term relief. TIle use of

adenoidectomy with or without concomitant tube insertion

provides long-lasting relief as the benefit of tube insertion

alone has disappeared after one year.

This paper is not being offered to provide validation to

these well-controlled and documented studies, but rather to

(8)

AUSTIN

describe and support an alternative to the use of ventilation

tubes in the treatment of the catarrhal child. It needs to be

emphasized at this point that even though adenoidectomy

seems to be a primary antagonist to the pathogenesis of

catarrhal otitis, the majority of the patients have evidence

of chronic and/or recurrent tonsillitis as well and thus

require removal of this diseased lymphoid tissue in

con-junction with the adenoidectomy. It is only recently that

'the negative effects of chronically infected lymphoid

tis-sue have been studied and which suggest that

tonsillec-tomy may be beneficial toward complete resolution of the

disease

state.'

Statements such as "even though infected,

tonsils and adenoids are important to health and shouldn't

be removed" or

"he'll

outgrow it" should be now assigned

to the category of "old-wife's tales" and the positive value

of T & A accepted by our pediatric peers.

It should be emphasized that medical treatment directed

at pathogenesis is extremely significant in the control of

this problem. It is important to note that three-fourths of the

children did not require surgery for resolution of the

catarrhal process. This fact is often ignored by those who

hurry to insert PE tubes. It is interesting that an early paper

on the use of ventilating tubes in secretory otitis

I

described

their need in approximately seven percent of cases, a figure

similar to their use in my private patients. These children

were followed over time and the medical measures

signifi-cantly reduced not only the incidence ofacute otitis but also

the incidence of acute

URI.

Smyth? and

Sade"

have both reviewed the recent

litera-ture on this topic. Although their conclusions are different,

their analysis of the problem is cogent and perceptive. The

reader is advised to peruse both of these papers.

Hopefully, the published studies of George Gates, Maw

and others will spread to our peers and colleagues the value

ofsurgery when applied to the large number ofchildren not

responding to conservative measures.

In

my opinion there

are far too many ears intubated unnecessarily. Appropriate

patient care would avoid many of these procedures.

Chil-dren who have demonstrated a more severe form of otitis

by persistence ofeffusion or multiple recurrence should be

considered candidates for adenoidectomy. When evidence

of chronic tonsillar infection is present, tonsillectomy

should be included in the treatment plan. The use of

multiple tube placement alone indicates the

non-effica-cious nature of this modality in this group of children.

Conclusion

The fundamental hypothesis motivating this paper is that

secretory otitis media in children is a manifestation of

recurrent or chronic catarrhal disease of the upper

respira-tory tract whose epicenter usually lies in the naso-pharynx.

Because of this belief, treatment for resistant patients has

been T & A or adenoidectomy rather than the use of

ventilating tubes.

In

only a few ofthe patients reported was

374

it necessary to insert a ventilation tube, nor have any of

these children later developed the sequelae of scarring,

retraction, chronic perforation or cholesteatoma, the

re-ported complications of ventilating tube

insertion."

References

1. Armstrong BW. Chronic secretory otitis media: diagnosis and treatment. South Med J 1957; 50:540-6. '

2. Austin OF. Adenoidectomy for secretory otitis media. Arch Otolaryngol Head Neck Surg 1989; 114:936-39.

3. Bernstein JM. Park BH. Defective

irnmunoregulation

in children with chronic otitis media. Otolaryng Head Neck Surg 1986; 94 :334-9.

4. Black NA. Sanderson CF. Freeland AP, et al. A

randomized

controlled trial of surgery for glue ear. BMJ 1990; 300(6739): 1551-6. 5. Dempster JH, Browning GG, Gatehouse SG. A randomized study

of the surgical management of children with persistent otitis media with effusion associated with a hearing

impairment,

J Laryngol Otol 1993; 107(4):284-9 .

6. Gates GA . Folbre TW. Indications for adenotonsillcctorny, Arch Otolaryng Head NeckSurg1986; 112:501-2.

7. Gates GA, Avery CA, Prihoda TJ, et al. Effectiveness of adenoidectomy and tympanostomy tubes in the treatment of chronic otitis media with effusion. N Engl J Med 1987; 317: 1444-51. 8. Gates GA, Avery CA, Prihoda TJ. Effect of adenoidectomy upon

children with chronic otitis media with effusion. Laryngoscope 1988; 98 :58-63 .

9. Gates GA. Muntz HR, Gaylis B. Adenoidectomy and otitis media . Ann Otol Rhinol Laryngol Suppl 1992; 155:24-32.

10. Gunderson T, Tonning FM. Kveberg KH. Ventilating tubes in the middle ear. Arch Otolaryng, 1984; 110:783-4.

II. Mandel EM. Bluestone CD, Takahashi H, et al. Effect of adenoidectomy on eustachian tube function. Preliminary results of a randomized clinical trial. Adv Otorhinolaryngol1992; 47 :227-31. 12. Maw AR. Herod F. Otoscopic. impedance, and audiometric find-ings in glue ear treated by adenoidectomy and tonsillectomy. Lancet 1986: 8495 :1399-1402 .

13. Maw AR, Parker AJ. A model to refine the selection of children with otitis media with effusion for adenoidectomy. Clin Otolaryngol

1993; 18(3):164-70.

14. Maw AR, 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(6880):756-60.

15. 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( 15):2066-73.

16. Sade J. Luntz M. Adenoidectomy in otitis media. A review . Ann Otol Rhinol Laryngol 1991; 100(3):226-31.

17. Smyth GO. Toynbee Memorial Lecture 1992: facts and fantasies in modem otology: the car doctor's dilemma. J Laryngol Otol 1992; 106(7):591-6.

18. U.S. National Center for Health Statistics, Bethcseda, Maryland. 1986.

Additional Reading

Books on Children's Nutrition

(Recommended by American Academy of Pediatrics)

I. Sloan S. The care and feeding of healthy kids . Accent Books 1985. 2. Smith LH. Foods for healthy kids. Berkley 1984.

3. Coffin LA. Children's nutrition. A consumers guide . Capra Press 1984.

4. Spoek B. Baby and child care. Pocket Books (A Classic) 1962.

References

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