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Adenoid and otitis media with effusion—mini review
International Congress Series 1257 (2003) 207 – 211
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Adenoid and otitis media with effusion—mini review Haruo Takahashi a,*, Akihiko Fujita b, Kyosuke Kurata c, Iwao Honjo d a Division of Otorhinolaryngology, Department of Translational Medical Sciences, Nagasaki University Graduate School of Biomedical Sciences, Sakamoto 1-7-1, Nagasaki 852-8501, Japan b Department of Otolaryngology, Kansai Denryoku Hospital, Osaka, Japan c Kawaicho Matsuzaka, Mie, Japan d Nishisakuragicho, Matsugasaki, Sakyo-ku, Kyoto, Japan
Abstract. Although favorable effect of adenoidectomy on otitis media with effusion (OME) has been already established by several randomized clinical trials, the mechanism how OME is improved by adenoidectomy has not yet been fully clarified. In this paper, the mechanism was discussed from the viewpoints of Eustachian tube function (ETF) and sinusitis by reviewing our clinical studies carried out over 15 years. Comparison of ETFs between children with and without adenoid hypertrophy revealed no significant differences. Passive opening pressure (POP) of the Eustachian tube (ET) showed no significant improvement immediately after adenoidectomy compared to that before surgery. Comparison of ETFs between adenoidectomized and non-adenoidectomized children revealed significant improvement only in the active ventilatory function in adenoidectomized group 6 months after surgery. Improvement of sinusitis was observed more frequently in adenoidectomized children than in non-adenoidectomized children 6 months after surgery. ETF (active ventilatory function) was significantly better in those whose sinusitis was improved by adenoidectomy than in those whose sinusitis was not improved. These results indicated that OME might be improved after adenoidectomy as the inflammatory environment in the nasopharynx is improved owing to elimination of an infectious focus. D 2003 Elsevier B.V. All rights reserved. Keywords: Adenoid; Eustachian tube; Otitis media with effusion (OME); Sinusitis; Tonsil
1. Introduction Favorable effects of adenoidectomy on otitis media with effusion (OME) have been already established by three randomized clinical trials [1 –3]. We also examined them and confirmed its favorable effect as well [4,5]. However, the mechanism how OME is improved by adenoidectomy has not yet been fully clarified. Possible mechanisms include release of the Eustachian tube (ET) from compression by a mass of adenoid and elimination of infection and inflammation in the nasopharynx and ET by removing an infectious focus. To resolve this question, we have clinically investigated the relationship between adenoid and the ET function (ETF) and between adenoid and sinusitis [4– 7]. * Corresponding author. Tel.: +81-95-849-7349; fax: +81-95-849-7352. E-mail address: [email protected] (H. Takahashi). 0531-5131/ D 2003 Elsevier B.V. All rights reserved. doi:10.1016/S0531-5131(03)01174-9
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Fig. 1. Comparison of passive opening pressure of the Eustachian tube between positive and negative compression of tubal orifice by adenoid through endoscopic observation (76 ears).
In this paper, the mechanism was discussed from the viewpoints of ETF and sinusitis by reviewing our clinical studies carried out over 15 years. 2. Relationship between the adenoid and ETF [6] We examined ETF of children with OME in two groups: one group was with hypertrophic adenoids that endoscopically appeared to compress the ET, and the other group was with those that did not appear to compress the ET. There was no difference
Fig. 2. Comparison of positive middle-ear pressure equalizing function of the Eustachian tube between positive and negative compression of tubal orifice by adenoid through endoscopic observation (73 ears).
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either in the passive opening pressure (POP) or in the active ventilatory function during swallowing between these two groups (Figs. 1 and 2). 3. Effect of adenoidectomy on ETF After tympanostomy tube insertion, we compared POP before and immediately after adenoidectomy in children with OME and adenoid hypertrophy in the operating theater. We found no difference in the pressure, indicating no difference in the passage of the tube [4,6]. The next trial was to compare the ETFs chronologically after two kinds of surgeries: one was tympanostomy tube insertion and adenoidectomy, and the other was tympanostomy tube insertion only [4,5]. There was no difference in POP either at 2 or 6 months after the surgeries. But in the active ventilatory function represented by positive middle-ear pressure equalizing function, adenoidectomized group showed significantly better results at 1 week and 6 months after surgery. 4. Effect of adenoidectomy on sinusitis [4,5,7] We compared the rate of improvement in sinusitis between adenoidectomized and nonadenoidectomized groups 6 months after surgery. All of the participants had both sinusitis and OME before surgery. The adenoidectomized group showed better improvement of sinusitis than the non-adenoidectomized group. We also endoscopically followed up the conditions of the nasopharynx after adenoidectomy in OME children [7]. Within a month after adenoidectomy, inflammatory findings such as edema or nasal discharge were still frequently observed, but they eventually subsided and a normal finding as well as probably reactive hypertrophy of the peritubal tonsils had gradually increased up to 6 months after adenoidectomy. 5. Relationship between improvement of sinusitis and improvement of ETF after adenoidectomy [4] Improvement ratio of an ETF (positive middle-ear pressure equalizing function) was compared between two groups: one consisted of children with OME and sinusitis whose sinusitis improved after adenoidectomy, the other consisted of those whose sinusitis had not improved. Improvement of the ETF was significantly better in the group with improved sinusitis than in the group without improvement. These results may indicate that children whose sinusitis is improved by adenoidectomy are more likely to have improvement in their ETFs. 6. Discussion The present results, that the size of the adenoid did not make any difference in the ETFs and that adenoidectomy did not immediately lower the POP, suggested that the adenoid did not appear to influence the passage of the ET as a mass; in other words, the adenoid did not compress the ET at the pharyngeal orifice of the ET. However, an active ETF (positive middle-ear pressure equalizing function) was significantly improved by
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Fig. 3. Incidence of adenoid hypertrophy and sinusitis in children with OME (100 children).
adenoidectomy. The better result at 1 week after surgery may have been influenced by postoperative antibiotics treatment, because the treatment is usually longer after adenoidectomy than after tympanostomy tube insertion only. In contrast, the better result at 6 months after surgery cannot be explained by such an artifact, and it was considered a substantial improvement by adenoidectomy. Consequently, the result that the ETF showed improvement as late as 6 months after adenoidectomy allowed us to speculate that the improvement may have resulted from some indirect factors caused by adenoidectomy rather than from a direct effect such as relief of compression on the ET by a mass of adenoid. To obtain some clue to clarify this, we turned our attention to the condition in the nose, because in our observations, as many as 70% of children with OME had both adenoid hypertrophy and sinusitis (Fig. 3). Sinusitis was found to be significantly improved by adenoidectomy, and inflammatory conditions in the nasopharynx were also found to subside around 6 months after adenoidectomy. Furthermore, improvement of the ETF was found to correlate well with the improvement of sinusitis after adenoidectomy. It is, therefore, very likely that adenoidectomy improves the ETF by diminishing inflammatory conditions in the nasopharynx, including sinusitis, and that OME may be improved through the improvement in the ETF and sinusitis. We would like to further confirm these results from other aspects such as a bacteriological one. References [1] A.R. Maw, Chronic otitis media with effusion (glue ear) and adenotonsillectomy: prospective randomized controlled study, Brit. Med. J. 287 (1983) 1586 – 1588. [2] G.A. Gates, C.A. Avery, T.J. Prihoda, Effect of adenoidectomy upon children with chronic otitis media with effusion, Laryngoscope 98 (1988) 58 – 63. [3] J.L. Paradise, C.D. Bluestone, K.D. Rogers, F.H. Tailor, D.K. Colborn, R.Z. Bachman, B.S. Bernard, R.H. Schwarzbach, Efficacy of adenoidectomy for recurrent otitis media in children previously treated with tympanostomy-tube placement, JAMA 263 (1990) 2066 – 2073. [4] A. Fujita, H. Takahashi, I. Honjo, Etiological role of adenoids upon otitis media with effusion, Acta Otolaryngol. (Stockh.) (Suppl. 454) (1988) 210 – 213.
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[5] H. Takahashi, A. Fujita, I. Honjo, Effect of adenoidectomy on otitis media with effusion, tubal function, and sinusitis, Am. J. Otolaryngol. 10 (1989) 208 – 213. [6] H. Takahashi, M. Hayashi, I. Honjo, Adenoid and Eustachian tube function, Oto-rhino-laryngol. Tokyo 30 (1987) 43 – 46 (in Japanese). [7] H. Takahashi, I. Honjo, A. Fujita, K. Kurata, Effects of adenoidectomy on sinusitis, Acta Oto-rhino-laryngol. Belg. 51 (1997) 85 – 87.
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Adenoid and otitis media with effusion—mini review Haruo Takahashi a,*, Akihiko Fujita b, Kyosuke Kurata c, Iwao Honjo d a Division of Otorhinolaryngology, Department of Translational Medical Sciences, Nagasaki University Graduate School of Biomedical Sciences, Sakamoto 1-7-1, Nagasaki 852-8501, Japan b Department of Otolaryngology, Kansai Denryoku Hospital, Osaka, Japan c Kawaicho Matsuzaka, Mie, Japan d Nishisakuragicho, Matsugasaki, Sakyo-ku, Kyoto, Japan
Abstract. Although favorable effect of adenoidectomy on otitis media with effusion (OME) has been already established by several randomized clinical trials, the mechanism how OME is improved by adenoidectomy has not yet been fully clarified. In this paper, the mechanism was discussed from the viewpoints of Eustachian tube function (ETF) and sinusitis by reviewing our clinical studies carried out over 15 years. Comparison of ETFs between children with and without adenoid hypertrophy revealed no significant differences. Passive opening pressure (POP) of the Eustachian tube (ET) showed no significant improvement immediately after adenoidectomy compared to that before surgery. Comparison of ETFs between adenoidectomized and non-adenoidectomized children revealed significant improvement only in the active ventilatory function in adenoidectomized group 6 months after surgery. Improvement of sinusitis was observed more frequently in adenoidectomized children than in non-adenoidectomized children 6 months after surgery. ETF (active ventilatory function) was significantly better in those whose sinusitis was improved by adenoidectomy than in those whose sinusitis was not improved. These results indicated that OME might be improved after adenoidectomy as the inflammatory environment in the nasopharynx is improved owing to elimination of an infectious focus. D 2003 Elsevier B.V. All rights reserved. Keywords: Adenoid; Eustachian tube; Otitis media with effusion (OME); Sinusitis; Tonsil
1. Introduction Favorable effects of adenoidectomy on otitis media with effusion (OME) have been already established by three randomized clinical trials [1 –3]. We also examined them and confirmed its favorable effect as well [4,5]. However, the mechanism how OME is improved by adenoidectomy has not yet been fully clarified. Possible mechanisms include release of the Eustachian tube (ET) from compression by a mass of adenoid and elimination of infection and inflammation in the nasopharynx and ET by removing an infectious focus. To resolve this question, we have clinically investigated the relationship between adenoid and the ET function (ETF) and between adenoid and sinusitis [4– 7]. * Corresponding author. Tel.: +81-95-849-7349; fax: +81-95-849-7352. E-mail address: [email protected] (H. Takahashi). 0531-5131/ D 2003 Elsevier B.V. All rights reserved. doi:10.1016/S0531-5131(03)01174-9
208
H. Takahashi et al. / International Congress Series 1257 (2003) 207–211
Fig. 1. Comparison of passive opening pressure of the Eustachian tube between positive and negative compression of tubal orifice by adenoid through endoscopic observation (76 ears).
In this paper, the mechanism was discussed from the viewpoints of ETF and sinusitis by reviewing our clinical studies carried out over 15 years. 2. Relationship between the adenoid and ETF [6] We examined ETF of children with OME in two groups: one group was with hypertrophic adenoids that endoscopically appeared to compress the ET, and the other group was with those that did not appear to compress the ET. There was no difference
Fig. 2. Comparison of positive middle-ear pressure equalizing function of the Eustachian tube between positive and negative compression of tubal orifice by adenoid through endoscopic observation (73 ears).
H. Takahashi et al. / International Congress Series 1257 (2003) 207–211
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either in the passive opening pressure (POP) or in the active ventilatory function during swallowing between these two groups (Figs. 1 and 2). 3. Effect of adenoidectomy on ETF After tympanostomy tube insertion, we compared POP before and immediately after adenoidectomy in children with OME and adenoid hypertrophy in the operating theater. We found no difference in the pressure, indicating no difference in the passage of the tube [4,6]. The next trial was to compare the ETFs chronologically after two kinds of surgeries: one was tympanostomy tube insertion and adenoidectomy, and the other was tympanostomy tube insertion only [4,5]. There was no difference in POP either at 2 or 6 months after the surgeries. But in the active ventilatory function represented by positive middle-ear pressure equalizing function, adenoidectomized group showed significantly better results at 1 week and 6 months after surgery. 4. Effect of adenoidectomy on sinusitis [4,5,7] We compared the rate of improvement in sinusitis between adenoidectomized and nonadenoidectomized groups 6 months after surgery. All of the participants had both sinusitis and OME before surgery. The adenoidectomized group showed better improvement of sinusitis than the non-adenoidectomized group. We also endoscopically followed up the conditions of the nasopharynx after adenoidectomy in OME children [7]. Within a month after adenoidectomy, inflammatory findings such as edema or nasal discharge were still frequently observed, but they eventually subsided and a normal finding as well as probably reactive hypertrophy of the peritubal tonsils had gradually increased up to 6 months after adenoidectomy. 5. Relationship between improvement of sinusitis and improvement of ETF after adenoidectomy [4] Improvement ratio of an ETF (positive middle-ear pressure equalizing function) was compared between two groups: one consisted of children with OME and sinusitis whose sinusitis improved after adenoidectomy, the other consisted of those whose sinusitis had not improved. Improvement of the ETF was significantly better in the group with improved sinusitis than in the group without improvement. These results may indicate that children whose sinusitis is improved by adenoidectomy are more likely to have improvement in their ETFs. 6. Discussion The present results, that the size of the adenoid did not make any difference in the ETFs and that adenoidectomy did not immediately lower the POP, suggested that the adenoid did not appear to influence the passage of the ET as a mass; in other words, the adenoid did not compress the ET at the pharyngeal orifice of the ET. However, an active ETF (positive middle-ear pressure equalizing function) was significantly improved by
210
H. Takahashi et al. / International Congress Series 1257 (2003) 207–211
Fig. 3. Incidence of adenoid hypertrophy and sinusitis in children with OME (100 children).
adenoidectomy. The better result at 1 week after surgery may have been influenced by postoperative antibiotics treatment, because the treatment is usually longer after adenoidectomy than after tympanostomy tube insertion only. In contrast, the better result at 6 months after surgery cannot be explained by such an artifact, and it was considered a substantial improvement by adenoidectomy. Consequently, the result that the ETF showed improvement as late as 6 months after adenoidectomy allowed us to speculate that the improvement may have resulted from some indirect factors caused by adenoidectomy rather than from a direct effect such as relief of compression on the ET by a mass of adenoid. To obtain some clue to clarify this, we turned our attention to the condition in the nose, because in our observations, as many as 70% of children with OME had both adenoid hypertrophy and sinusitis (Fig. 3). Sinusitis was found to be significantly improved by adenoidectomy, and inflammatory conditions in the nasopharynx were also found to subside around 6 months after adenoidectomy. Furthermore, improvement of the ETF was found to correlate well with the improvement of sinusitis after adenoidectomy. It is, therefore, very likely that adenoidectomy improves the ETF by diminishing inflammatory conditions in the nasopharynx, including sinusitis, and that OME may be improved through the improvement in the ETF and sinusitis. We would like to further confirm these results from other aspects such as a bacteriological one. References [1] A.R. Maw, Chronic otitis media with effusion (glue ear) and adenotonsillectomy: prospective randomized controlled study, Brit. Med. J. 287 (1983) 1586 – 1588. [2] G.A. Gates, C.A. Avery, T.J. Prihoda, Effect of adenoidectomy upon children with chronic otitis media with effusion, Laryngoscope 98 (1988) 58 – 63. [3] J.L. Paradise, C.D. Bluestone, K.D. Rogers, F.H. Tailor, D.K. Colborn, R.Z. Bachman, B.S. Bernard, R.H. Schwarzbach, Efficacy of adenoidectomy for recurrent otitis media in children previously treated with tympanostomy-tube placement, JAMA 263 (1990) 2066 – 2073. [4] A. Fujita, H. Takahashi, I. Honjo, Etiological role of adenoids upon otitis media with effusion, Acta Otolaryngol. (Stockh.) (Suppl. 454) (1988) 210 – 213.
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[5] H. Takahashi, A. Fujita, I. Honjo, Effect of adenoidectomy on otitis media with effusion, tubal function, and sinusitis, Am. J. Otolaryngol. 10 (1989) 208 – 213. [6] H. Takahashi, M. Hayashi, I. Honjo, Adenoid and Eustachian tube function, Oto-rhino-laryngol. Tokyo 30 (1987) 43 – 46 (in Japanese). [7] H. Takahashi, I. Honjo, A. Fujita, K. Kurata, Effects of adenoidectomy on sinusitis, Acta Oto-rhino-laryngol. Belg. 51 (1997) 85 – 87.