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The effect of adenoid hypertrophy on hearing thresholds in children with otitis media with effusion
International Journal of Pediatric Otorhinolaryngology 124 (2019) 116–119
Contents lists available at ScienceDirect
International Journal of Pediatric Otorhinolaryngology journal homepage: www.elsevier.com/locate/ijporl
The effect of adenoid hypertrophy on hearing thresholds in children with otitis media with effusion
T
Osman Durgut∗, Oğuzhan Dikici Health Science University, Bursa Yuksek Ihtisas Training and Research Hospital, Turkey
A R T I C LE I N FO
A B S T R A C T
Keywords: Adenoid hypertrophy Otitis media effusion Hearing loss
Introduction: Otitis media with effusion is common middle ear mucosa disease that can cause hearing loss in children. Adenoid hypertrophy can cause recurrent acute otitis media in addition to otitis media with effusion as a result of eustachian tube dysfunction and primary infection focus. The aim of this study was to investigate the effect of adenoid hypertrophy on the hearing threshold in children suffering from otitis media with effusion. Methods: Children of school age with otitis media with effusion were included in the study. The size and location of the adenoid tissue were determined by examination with a flexible endoscope. Four adenoid size groups were determined according to the percentage of choanal closure. The coverage was 0–25% in the first group, 26–50% in the second group, 51–75% in the third group and 76–100% in the 4th group. The location of the adenoid tissue in the nasopharynx was divided into three groups. In group A, the adenoid tissue was not in contact with torus tubarius. In group B, the adenoid tissue was in contact with the torus tubarius but did not cover it. In group C, the adenoid tissue covered the torus tubarius completely. Bone and air conduction thresholds were determined using standard procedures. The statistical relationship between the size and location of adenoid tissue and the hearing thresholds was investigated. Results: The study was conducted with the 88 ears of 50 children aged 5–15 years. The median values of mean air conduction thresholds at 500 Hz, 1000 Hz, and 2000 Hz in the adenoid tissue size groups 1–4 were 22 dB HL, 20 dB HL, 15 dB HL, and 20 dB HL respectively. The median values of the mean air conduction thresholds were 20 dB HL, 20 dBHL and 18 dB HL in the adenoid location group A-C, respectively. No significant correlation was found between the groups (p:0.213) and the relevant hearing values (p:0.670). Type B tympanogram was identified in 46 ears and type C tympanogram in 42 ears. The mean hearing thresholds were significantly higher in the ears with a type B tympanogram in the otitis media with effusion cases. (P < 0.001).There was no significant correlation between the duration of effusion and the adenoid size (p:0.931), adenoid location (p:0.626) and hearing threshold (p:0.815). Conclusion: We concluded that adenoid tissue size and location have no effect on hearing thresholds and the duration of effusion in otitis media with effusion. We suggest caution before deciding on adenoidectomy in otitis media with effusion cases. Adenoidectomy should not be performed in children over 4 years of age unless there is a definite indication such as nasal obstruction or chronic adenitis.
1. Introduction
infection or acute otitis media or spontaneously due to weak eustachian function [4]. Although its etiopathogenesis has not been fully clarified, the eustachian tube and its relation to other mechanisms are most commonly held responsible. The adenoid tissue has been shown to cause otitis media as a source of infection or with a mass effect [5,6]. Hearing loss due to OME can lead to auditory problems, language delay, poor school performance, and behavioral problems in children [7]. The determination of hearing status in children with OME is therefore valuable for disease surveillance and management [7]. At the
Otitis media with effusion (OME) is a disease characterized by accumulation of fluid in the middle ear without symptoms of acute ear infection [1]. It is widely seen in childhood. It has been reported that about 90% of pre-school children have had OME [1]. It is the most common cause of hearing loss in children [2]. The overall prevalence rate varies between 4% and 20% [3]. The recurrence rate can be as high as 40% [1]. The disorder can develop after upper respiratory tract
∗ Corresponding author. Health Science University, Bursa Yuksek Ihtisas Training and Research Hospital, Department of Otorhinolaryngology, Mimarsinan Mahallesi, Emniyet Cd. No:35, 16310, Yıldırım, Bursa, Turkey. E-mail address: [email protected] (O. Durgut).
https://doi.org/10.1016/j.ijporl.2019.05.046 Received 14 February 2019; Received in revised form 24 May 2019; Accepted 30 May 2019 Available online 01 June 2019 0165-5876/ © 2019 Elsevier B.V. All rights reserved.
International Journal of Pediatric Otorhinolaryngology 124 (2019) 116–119
O. Durgut and O. Dikici
tympanogram was accepted as an indicator of OME [10]. Pure tone audiometry was performed with the GSI AudioStar Pro device. Air and bone conduction pure tone thresholds were tested at 500 Hz, 1000 Hz, 2000 Hz, and 4000 Hz. The average pure tone thresholds at 500 Hz, 1000 Hz and 2000 Hz were used to estimate the level of hearing impairment. All audiometric investigations were performed by the same audiologist. The statistical relationship between the size and location of adenoid tissue and the hearing thresholds was investigated. Statistical analysis was performed with the Statistical Package for the Social Sciences (SPSS) Statistics version 23. The distribution of the groups was investigated with the Kolmogorov-Smirnov test. The Kruskal-Wallis H test was used to evaluate the relationship between the adenoid groups and hearing values. P value < 0.05 was considered statistically significant.
same time, the type and severity of hearing loss is also taken into account when determining surgical candidates [7]. A hearing loss of more than 40 dB in children with OME is an absolute indication for ventilation tube insertion [8]. A hearing loss of 21–40 dB hearing is a relative indication [8]. Although the effect of adenoid hypertrophy on the eustachian tube is well known, not performing adenoidectomy unless there is a clear indication (such as nasal obstruction or chronic adenitis) is suggested when placing a tympanostomy tube for the treatment of children with EOM below 4 years of age [1]. However, some studies report effectiveness of adenoidectomy and it is discussed in terms of first-line treatment in OME [9]. Because of the importance of hearing thresholds in OME management and the effect of adenoid hypertrophy on the disorder, we wanted to evaluate the relationship of these data in our study. The aim of this study was therefore to investigate the effect of adenoid size on hearing thresholds in children with OME.
3. Results A total of 50 children diagnosed with OME between August 2018 and December 2018 were included in the study. The total number of ears affected by OME was 88. The mean age of the patients aged 5 to 14 was 8.32 ± 2.66. There were no significant differences between the mean hearing thresholds (p:0.428) and adenoid size (p:0.500) and location (p:0.697) between children in different age groups. The gender distribution was equal (25 males and 25 females). There was no significant difference in the distribution of mean air hearing threshold values between genders (p:0.757). There was also no significant difference for adenoid size (p:0.502) and location (p:0.483) between the genders. The duration of the effusion ranged from 3 to 12 months in the patients diagnosed for the first time in our clinic and those directed to us from other hospitals. There was no significant correlation between the duration of effusion and the adenoid size (p:0.931), adenoid location (p:0.626) and hearing threshold (p:0.815). The diagnosis was bilateral OME in 38 children. The tympanogram was type B in 46 ears, type C2 in 42 ears, and type A in 12 ears. The median value of the mean hearing thresholds between 500 Hz and 2000 Hz was 25.78 db HL in the ears with type B tympanogram and 15.57 dB HL in the ears with Type C tympanogram and the difference was statistically significant (P < 0.001). We had 13 children (21 ears) in Group 1, 16 children (29 ears) in group 2, 17 children (31 ears) in Group 3 and 4 children (7 ears) in Group 4 in addition to 18 children (30 ears) in group A, 18 children (33 ears) in group B and 14 children (25 ears) in group C. The adenoid size and location were the same in endoscopic examinations performed in the same subject at different times. The median values of mean air conduction thresholds at 500 Hz, 1000 Hz, and 2000 Hz in the adenoid size groups were 22 dB HL in group 1, 20 dB HL in group 2, 15 dB HL in group 3, and 20 dB HL in group 4. The median values of the mean air conduction thresholds were 20 dB HL in group A, 20 dB HL in group B and 18 dB HL in group C according to adenoid location. Table 1 shows the detailed hearing threshold values in the adenoid size and location groups. Bone conduction was generally not affected in our study. The mean bone conduction thresholds of the 88 ears ranged from −7 dB HL to 15 dB HL and the mean value was 2.57 dB HL.
2. Methods The study was performed at the ENT clinic of Bursa Yuksek Ihtisas Training and Research Hospital. The study was carried out in accordance with the requirements of the declaration of Helsinki and it was approved by the Ethics Committee of the same hospital (decision number 2011-KAEK-25 2018/10-01). Children aged 5–15 years with a diagnosis of OME were included in the study. They were suspected of suffering from hearing loss and had presented for a routine check after acute otitis media or had come to our clinic with other complaints such as sleeping with the mouth open, nasal obstuction, and snoring. Children with OME in at least one ear were included in the study. The minimum duration of middle ear effusion was three months. Children with a history of preterm birth, congenital anomaly, chronic disease, adenoidectomy, tonsillectomy and ear operation were excluded from the study. All patients underwent otoscopic examination, flexible nasopharyngoscopy, pure tone audiometry and tympanometry. Otoscopic examination was performed by two otorhinolaryngologists with the Riester Ri-former model otoscopy device. Tympanic membrane retraction, absence or abnormal placement of the light triangle, color change of the tympanic membrane, visible air-fluid levels and the presence of bubbles were evaluated in favor of OME. Flexible nasopharyngoscopy was performed with the Optim Entity XL device. Endoscopic examination was performed at least twice at different times with at least two months between the two endoscopic evaluations. Children who had acute upper respiratory tract infection, nasal polyp or allergic rhinitis were excluded from the study. Four adenoid size groups were determined as 0–25% in the first group (Group 1), 26–50% in the second group (Group 2), 51–75% in the third group (Group 3) and 76–100% in the 4th group (Group 4). The location of the adenoid tissue was divided into three groups as follows: There was adenoid tissue not in contact with torus tubarius in Group A, adenoid tissue that was in contact with the torus tubarius but did not cover it in Group B and adenoid tissue completely covering the torus tubarius in Group C. Tympanometry was performed by using the Maico MI34 device in a quiet room. According to the Jerger classification, a type B or type C2
Table 1 Detailed auditory thresholds values are shown in the adenoid size and location groups.
N (Number of ears) Mean (dB HL) Median (dB HL) Std Deviation Minimum (dB HL) Maximum (dB HL)
Group 1 (0–25%)
Group 2 (26–50%)
Group 3 (51–75%)
Group 4 (76–100%)
Group A
Group B
Group C
21 22.33 22 9.77 8 42
29 22.44 20 11.54 3 47
31 18.09 15 9.18 7 43
7 22.71 20 7.65 15 37
30 20 20 9.91 3 42
33 22.33 20 10.23 7 47
25 20.12 18 10.39 8 43
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International Journal of Pediatric Otorhinolaryngology 124 (2019) 116–119
O. Durgut and O. Dikici
No significant correlation was found between adenoid size groups and mean air conduction thresholds (p:0.213). Similarly, no significant correlation was found between adenoid location groups and mean air conduction thresholds (p:0,670).
Future studies in this direction will contribute to the clarification of the relationship between adenoid tissue size and location and OME.
4. Discussion
We concluded that adenoid tissue size and location have no effect on hearing thresholds and duration of effusion in OME. The role of adenoidectomy in the first-line treatment of OME is still controversial. We suggest caution before deciding on adenoidectomy in OME. Adenoidectomy should not be performed in children over 4 years of age unless there is a definite indication for adenoidectomy such as nasal obstruction or chronic adenitis. Similar studies in the future will contribute to the determination of the necessity of adenoidectomy in the first-line treatment of OME.
5. Conclusion
The etiopathology of OME has been extensively studied in recent years [9]. Viral infections, bacterial colonization and biofilm formation, allergy and immunological factors can contribute to the development of OME [9,11,12]. However, mechanical factors or eustachian dysfunction generally play the key role [9,11]. Adenoidectomy is often performed as part of OME treatment but it is unclear whether the procedure affects Eustachian tube function. Some studies report a beneficial effect of adenoidectomy while others report the opposite [13]. The mean AN (adenoidal-nasopharyngeal) ratio for children selected for adenoidectomy has been reported as 0.71 [14,15]. Adenoids can compress or block the ostium of the Eustachian tube, thereby causing increased middle ear pressure and subsequent effusion. In the case report presented by Buchman and et al. it was shown by manometric evaluation that active and passive eustachian tube obstruction was alleviated after adenoidectomy [16]. The reason for the use of adenoidectomy in the treatment of EOM involves the potential for improved Eustachian tube function [9]. Skoloudik et al. [9] found that the EOM recovery rate after paracentesis and endoscopyguided adenoidectomy without insertion of a ventilation tube was 87%. The relationship between the adenoids and the torus tubarius was more relevant for the result than the volume of adenoids [9]. Maw reported a better resolution rate for OME after adenoidectomy in children with larger adenoids [17]. However, there are also studies that have not determined any relationship between the volume of adenoids and the surgical procedure [18,19]. Wright et al. found a correlation between OME development and lateral adenoids extending to the ostium of the eustachian tube [20]. Maw et al. confirmed a significant improvement in fluid clearance and hearing thresholds as a result of adenoidectomy [21]. Large adenoid tissue partially or completely blocks the entry to the eustachian tube, thus interfering with the ventilation function. Type C2 and type B tympanograms were found in 74% of the patients where the eustachian tube ostium was completely closed with adenoid tissue [22]. Otitis media is actually a spectrum of related disorders. Wang et al. found no significant association between adenoid size and tympanogram results [13]. We also found no correlation between tympanogram results and adenoid size and location. Studies have found that middle ear pressures are significantly higher in patients with large adenoids than those with small ones [23–25]. However, Toros et al. [26] did not find a correlation between adenoid size and middle ear pressure. The effect of the enlarged adenoids on the eustachian tube and thus the development of effusion is more likely to be through regional inflammation or infection than direct compression [27]. Although adenoid tissue plays a role in effusion development, it does not seem to have an effect on hearing thresholds in OME. The relationship between adenoid size and location and middle ear effusion is still controversial today. There is no study investigating the relationship between the size and location of adenoid tissue and hearing thresholds in the literature. In this study, we determined that adenoid size and location were not associated with hearing thresholds in children with OME. Although adenoid tissue has a role in OME etiopathogenesis through the development of effusion, there is no direct relationship with hearing thresholds. Factors such as the structural features of the fluid formed in the middle ear (glue or serous), the changes in the tympanic membrane and ossicles, and the changes in middle ear pressure can have an impact on the hearing thresholds in OME. As a matter of fact, we found that hearing thresholds in the ears with Type B tympanograms were statistically significantly higher. Adenoid tissue can indirectly have an impact on hearing thresholds.
Conflicts of interest Osman Durgut, M.D. declares that he has no conflicts of interest. Oğuzhan Dikici, M.D. declares that he has no conflicts of interest. Funding There is no funding sources. References [1] R.M. Rosenfeld, J.J. Shin, S.R. Schwartz, R. Coggins, L. Gagnon, J.M. Hackell, et al., Clinical practice guideline: otitis media with effusion (update), Otolaryngol. Head Neck Surg. 154 (2016) 1–41. [2] M.M. Rovers, G.A. Zielhuis, H. Straatman, K. Ingels, G.J. van der Wilt, M. Kauffmande Boer, Comparison of the CAPAS and Ewing tests for screening of hearing in infants, J. Med. Screen 6 (1999) 188–192. [3] T. Cai, B. McPherson, Hearing loss in children with otitis media with effusion: a systematic review, Int. J. Audiol. 56 (2017) 65–76. [4] J.L. Paradise, H.E. Rockette, D.K. Colborn, B.S. Bernard, C.G. Smith, M. Kurs-Lasky, et al., Otitis media in 2253 Pittsburgh-area infants: prevalence and risk factors during the first two years of life, Pediatrics 99 (1997) 318–333. [5] C.D. Bluestone, E.I. Cantekin, Q.C. Beery, Certain effects of adenoidectomy of Eustachian tube ventilatory function, The Laryngoscope 85 (1975) 113–127. [6] C.D. Bluestone, E.I. Cantekin, Q.C. Beery, Effect of inflammation of the ventilatory function of the eustachian tube, The Laryngoscope 87 (1977) 493–507. [7] T. Cai, B. McPherson, C. Li, F. Yang, Pure tone hearing profiles in children with otitis media with effusion, Disabil. Rehabil. 40 (2018) 1166–1175. [8] Z. Sezgin, Otitis media with effusion: overview of diagnosis and treatment approaches, Pediatric Practice and Research 4 (2016) 1–11. [9] L. Skoloudik, D. Kalfert, T. Valenta, V. Chrobok, Relation between adenoid size and otitis media with effusion, Eur Ann Otorhinolaryngol Head Neck Dis 135 (2018) 399–402. [10] R. Perera, P.P. Glasziou, C.J. Heneghan, J. McLellan, I. Williamson, Autoinflation for hearing loss associated with otitis media with effusion, Cochrane Database Syst. Rev. 31 (2013) 1–41. [11] G.P. Buzatto, E. Tamashiro, J.L. Proenca-Modena, T.H. Saturno, M.C. Prates, T.B. Gagliardi, et al., The pathogens profile in children with otitis media with effusion and adenoid hypertrophy, PLoS One 23 (2017) 1–12. [12] G. Saylam, E.C. Tatar, I. Tatar, A. Ozdek, H. Korkmaz, Association of adenoid surface biofilm formation and chronic otitis media with effusion, Arch. Otolaryngol. Head Neck Surg. 136 (2010) 550–555. [13] D.Y. Wang, N. Bernheim, L. Kaufman, P. Clement, Assessment of adenoid size in children by fibreoptic examination, Clin. Otolaryngol. Allied Sci. 22 (1997) 172–177. [14] S. Elwany, The adenoidal-nasopharyngeal ratio (AN ratio):its validity in selecting children for adenoidectomy, J. Laryngol. Otol. 101 (1987) 569–573. [15] S. Mahboubi, R.R. Marsh, W.P. Potsic, P.S. Pasquariello, The lateral neck radiograph in adenotonsillar hyperplasia, Int. J. Pediatr. Otorhinolaryngol. 10 (1985) 67–73. [16] C.A. Buchman, S.E. Stool, Functional-anatomic correlation of eustachian tubeobstruction related to the adenoid in a patient with otitis media with effusion: a case report, Ear Nose Throat J. 73 (1994) 835–838. [17] A.R. Maw, Chronic otitis media with effusion (glue ear) and adenotonsillectomy: prospective randomised controlled study, Br. Med. J. 287 (1983) 1586–1588. [18] J.L. Paradise, C.D. Bluestone, K.D. Rogers, F.H. Taylor, D.K. Colborn, R.Z. Bachman, et al., Efficacy of adenoidectomy for recurrent otitis media in children previously treated with tympanostomy-tube placement. Results of parallel randomized and nonrandomized trials, J. Am. Med. Assoc. 263 (1990) 2066–2073. [19] G.A. Gates, Sizing up the adenoid, Arch. Otolaryngol. Head Neck Surg. 122 (1996) 239–240. [20] E.D. Wright, A.J. Pearl, J.J. Manoukian, Laterally hypertrophic adenoids as a contributing factor in otitis media, Int. J. Pediatr. Otorhinolaryngol. 45 (1998)
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tympanic pressure, J. Laryngol. Otol. 101 (1987) 892–896. [25] E. Egeli, F. Oghan, O. Ozturk, U. Harputluoglu, B. Yazici, Measuring the correlation between adenoidal-nasopharyngeal ratio (AN ratio) and tympanogram in children, Int. J. Pediatr. Otorhinolaryngol. 69 (2005) 229–233. [26] S.Z. Toros, G. Kiliçoğlu, H. Noşeri, B. Naiboğlu, C. Kalaycik, S. Külekçi, et al., Does adenoid hypertrophy really have effect on tympanometry? Int. J. Pediatr. Otorhinolaryngol. 74 (2010) 365–368. [27] C.D. Bluestone, J.O. Klein, Otitis Media in Infants and Children, second ed., WB Saunders, Philadelphia, 1995, pp. 215–223.
207–214. [21] R. Maw, R. Bawden, Spontaneous Resolution of Severe Chronic Glue Ear in Children and the Effect of Adenoidectomy, Tonsillectomy, and Insertion of Ventilation Tubes (Grommets) vol. 306, (1993), pp. 756–760. [22] D. Wang, P. Clement, L. KaufmanL, M.P. Derde, Fiberoptic examination of the nasal cavity and nasopharynx in children, Int. J. Pediatr. Otorhinolaryngol. 24 (1992) 35–44. [23] R.A. Alhady, M.E. Sharnoubi, Tympanometric findings in patients with adenoid hyperplasia, chronic sinusitis and tonsillitis, J. Laryngol. Otol. 98 (1984) 671–676. [24] P. Tuohimaa, T. Palva, The effect of tonsillectomy and adenoidectomy on the intra-
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Contents lists available at ScienceDirect
International Journal of Pediatric Otorhinolaryngology journal homepage: www.elsevier.com/locate/ijporl
The effect of adenoid hypertrophy on hearing thresholds in children with otitis media with effusion
T
Osman Durgut∗, Oğuzhan Dikici Health Science University, Bursa Yuksek Ihtisas Training and Research Hospital, Turkey
A R T I C LE I N FO
A B S T R A C T
Keywords: Adenoid hypertrophy Otitis media effusion Hearing loss
Introduction: Otitis media with effusion is common middle ear mucosa disease that can cause hearing loss in children. Adenoid hypertrophy can cause recurrent acute otitis media in addition to otitis media with effusion as a result of eustachian tube dysfunction and primary infection focus. The aim of this study was to investigate the effect of adenoid hypertrophy on the hearing threshold in children suffering from otitis media with effusion. Methods: Children of school age with otitis media with effusion were included in the study. The size and location of the adenoid tissue were determined by examination with a flexible endoscope. Four adenoid size groups were determined according to the percentage of choanal closure. The coverage was 0–25% in the first group, 26–50% in the second group, 51–75% in the third group and 76–100% in the 4th group. The location of the adenoid tissue in the nasopharynx was divided into three groups. In group A, the adenoid tissue was not in contact with torus tubarius. In group B, the adenoid tissue was in contact with the torus tubarius but did not cover it. In group C, the adenoid tissue covered the torus tubarius completely. Bone and air conduction thresholds were determined using standard procedures. The statistical relationship between the size and location of adenoid tissue and the hearing thresholds was investigated. Results: The study was conducted with the 88 ears of 50 children aged 5–15 years. The median values of mean air conduction thresholds at 500 Hz, 1000 Hz, and 2000 Hz in the adenoid tissue size groups 1–4 were 22 dB HL, 20 dB HL, 15 dB HL, and 20 dB HL respectively. The median values of the mean air conduction thresholds were 20 dB HL, 20 dBHL and 18 dB HL in the adenoid location group A-C, respectively. No significant correlation was found between the groups (p:0.213) and the relevant hearing values (p:0.670). Type B tympanogram was identified in 46 ears and type C tympanogram in 42 ears. The mean hearing thresholds were significantly higher in the ears with a type B tympanogram in the otitis media with effusion cases. (P < 0.001).There was no significant correlation between the duration of effusion and the adenoid size (p:0.931), adenoid location (p:0.626) and hearing threshold (p:0.815). Conclusion: We concluded that adenoid tissue size and location have no effect on hearing thresholds and the duration of effusion in otitis media with effusion. We suggest caution before deciding on adenoidectomy in otitis media with effusion cases. Adenoidectomy should not be performed in children over 4 years of age unless there is a definite indication such as nasal obstruction or chronic adenitis.
1. Introduction
infection or acute otitis media or spontaneously due to weak eustachian function [4]. Although its etiopathogenesis has not been fully clarified, the eustachian tube and its relation to other mechanisms are most commonly held responsible. The adenoid tissue has been shown to cause otitis media as a source of infection or with a mass effect [5,6]. Hearing loss due to OME can lead to auditory problems, language delay, poor school performance, and behavioral problems in children [7]. The determination of hearing status in children with OME is therefore valuable for disease surveillance and management [7]. At the
Otitis media with effusion (OME) is a disease characterized by accumulation of fluid in the middle ear without symptoms of acute ear infection [1]. It is widely seen in childhood. It has been reported that about 90% of pre-school children have had OME [1]. It is the most common cause of hearing loss in children [2]. The overall prevalence rate varies between 4% and 20% [3]. The recurrence rate can be as high as 40% [1]. The disorder can develop after upper respiratory tract
∗ Corresponding author. Health Science University, Bursa Yuksek Ihtisas Training and Research Hospital, Department of Otorhinolaryngology, Mimarsinan Mahallesi, Emniyet Cd. No:35, 16310, Yıldırım, Bursa, Turkey. E-mail address: [email protected] (O. Durgut).
https://doi.org/10.1016/j.ijporl.2019.05.046 Received 14 February 2019; Received in revised form 24 May 2019; Accepted 30 May 2019 Available online 01 June 2019 0165-5876/ © 2019 Elsevier B.V. All rights reserved.
International Journal of Pediatric Otorhinolaryngology 124 (2019) 116–119
O. Durgut and O. Dikici
tympanogram was accepted as an indicator of OME [10]. Pure tone audiometry was performed with the GSI AudioStar Pro device. Air and bone conduction pure tone thresholds were tested at 500 Hz, 1000 Hz, 2000 Hz, and 4000 Hz. The average pure tone thresholds at 500 Hz, 1000 Hz and 2000 Hz were used to estimate the level of hearing impairment. All audiometric investigations were performed by the same audiologist. The statistical relationship between the size and location of adenoid tissue and the hearing thresholds was investigated. Statistical analysis was performed with the Statistical Package for the Social Sciences (SPSS) Statistics version 23. The distribution of the groups was investigated with the Kolmogorov-Smirnov test. The Kruskal-Wallis H test was used to evaluate the relationship between the adenoid groups and hearing values. P value < 0.05 was considered statistically significant.
same time, the type and severity of hearing loss is also taken into account when determining surgical candidates [7]. A hearing loss of more than 40 dB in children with OME is an absolute indication for ventilation tube insertion [8]. A hearing loss of 21–40 dB hearing is a relative indication [8]. Although the effect of adenoid hypertrophy on the eustachian tube is well known, not performing adenoidectomy unless there is a clear indication (such as nasal obstruction or chronic adenitis) is suggested when placing a tympanostomy tube for the treatment of children with EOM below 4 years of age [1]. However, some studies report effectiveness of adenoidectomy and it is discussed in terms of first-line treatment in OME [9]. Because of the importance of hearing thresholds in OME management and the effect of adenoid hypertrophy on the disorder, we wanted to evaluate the relationship of these data in our study. The aim of this study was therefore to investigate the effect of adenoid size on hearing thresholds in children with OME.
3. Results A total of 50 children diagnosed with OME between August 2018 and December 2018 were included in the study. The total number of ears affected by OME was 88. The mean age of the patients aged 5 to 14 was 8.32 ± 2.66. There were no significant differences between the mean hearing thresholds (p:0.428) and adenoid size (p:0.500) and location (p:0.697) between children in different age groups. The gender distribution was equal (25 males and 25 females). There was no significant difference in the distribution of mean air hearing threshold values between genders (p:0.757). There was also no significant difference for adenoid size (p:0.502) and location (p:0.483) between the genders. The duration of the effusion ranged from 3 to 12 months in the patients diagnosed for the first time in our clinic and those directed to us from other hospitals. There was no significant correlation between the duration of effusion and the adenoid size (p:0.931), adenoid location (p:0.626) and hearing threshold (p:0.815). The diagnosis was bilateral OME in 38 children. The tympanogram was type B in 46 ears, type C2 in 42 ears, and type A in 12 ears. The median value of the mean hearing thresholds between 500 Hz and 2000 Hz was 25.78 db HL in the ears with type B tympanogram and 15.57 dB HL in the ears with Type C tympanogram and the difference was statistically significant (P < 0.001). We had 13 children (21 ears) in Group 1, 16 children (29 ears) in group 2, 17 children (31 ears) in Group 3 and 4 children (7 ears) in Group 4 in addition to 18 children (30 ears) in group A, 18 children (33 ears) in group B and 14 children (25 ears) in group C. The adenoid size and location were the same in endoscopic examinations performed in the same subject at different times. The median values of mean air conduction thresholds at 500 Hz, 1000 Hz, and 2000 Hz in the adenoid size groups were 22 dB HL in group 1, 20 dB HL in group 2, 15 dB HL in group 3, and 20 dB HL in group 4. The median values of the mean air conduction thresholds were 20 dB HL in group A, 20 dB HL in group B and 18 dB HL in group C according to adenoid location. Table 1 shows the detailed hearing threshold values in the adenoid size and location groups. Bone conduction was generally not affected in our study. The mean bone conduction thresholds of the 88 ears ranged from −7 dB HL to 15 dB HL and the mean value was 2.57 dB HL.
2. Methods The study was performed at the ENT clinic of Bursa Yuksek Ihtisas Training and Research Hospital. The study was carried out in accordance with the requirements of the declaration of Helsinki and it was approved by the Ethics Committee of the same hospital (decision number 2011-KAEK-25 2018/10-01). Children aged 5–15 years with a diagnosis of OME were included in the study. They were suspected of suffering from hearing loss and had presented for a routine check after acute otitis media or had come to our clinic with other complaints such as sleeping with the mouth open, nasal obstuction, and snoring. Children with OME in at least one ear were included in the study. The minimum duration of middle ear effusion was three months. Children with a history of preterm birth, congenital anomaly, chronic disease, adenoidectomy, tonsillectomy and ear operation were excluded from the study. All patients underwent otoscopic examination, flexible nasopharyngoscopy, pure tone audiometry and tympanometry. Otoscopic examination was performed by two otorhinolaryngologists with the Riester Ri-former model otoscopy device. Tympanic membrane retraction, absence or abnormal placement of the light triangle, color change of the tympanic membrane, visible air-fluid levels and the presence of bubbles were evaluated in favor of OME. Flexible nasopharyngoscopy was performed with the Optim Entity XL device. Endoscopic examination was performed at least twice at different times with at least two months between the two endoscopic evaluations. Children who had acute upper respiratory tract infection, nasal polyp or allergic rhinitis were excluded from the study. Four adenoid size groups were determined as 0–25% in the first group (Group 1), 26–50% in the second group (Group 2), 51–75% in the third group (Group 3) and 76–100% in the 4th group (Group 4). The location of the adenoid tissue was divided into three groups as follows: There was adenoid tissue not in contact with torus tubarius in Group A, adenoid tissue that was in contact with the torus tubarius but did not cover it in Group B and adenoid tissue completely covering the torus tubarius in Group C. Tympanometry was performed by using the Maico MI34 device in a quiet room. According to the Jerger classification, a type B or type C2
Table 1 Detailed auditory thresholds values are shown in the adenoid size and location groups.
N (Number of ears) Mean (dB HL) Median (dB HL) Std Deviation Minimum (dB HL) Maximum (dB HL)
Group 1 (0–25%)
Group 2 (26–50%)
Group 3 (51–75%)
Group 4 (76–100%)
Group A
Group B
Group C
21 22.33 22 9.77 8 42
29 22.44 20 11.54 3 47
31 18.09 15 9.18 7 43
7 22.71 20 7.65 15 37
30 20 20 9.91 3 42
33 22.33 20 10.23 7 47
25 20.12 18 10.39 8 43
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No significant correlation was found between adenoid size groups and mean air conduction thresholds (p:0.213). Similarly, no significant correlation was found between adenoid location groups and mean air conduction thresholds (p:0,670).
Future studies in this direction will contribute to the clarification of the relationship between adenoid tissue size and location and OME.
4. Discussion
We concluded that adenoid tissue size and location have no effect on hearing thresholds and duration of effusion in OME. The role of adenoidectomy in the first-line treatment of OME is still controversial. We suggest caution before deciding on adenoidectomy in OME. Adenoidectomy should not be performed in children over 4 years of age unless there is a definite indication for adenoidectomy such as nasal obstruction or chronic adenitis. Similar studies in the future will contribute to the determination of the necessity of adenoidectomy in the first-line treatment of OME.
5. Conclusion
The etiopathology of OME has been extensively studied in recent years [9]. Viral infections, bacterial colonization and biofilm formation, allergy and immunological factors can contribute to the development of OME [9,11,12]. However, mechanical factors or eustachian dysfunction generally play the key role [9,11]. Adenoidectomy is often performed as part of OME treatment but it is unclear whether the procedure affects Eustachian tube function. Some studies report a beneficial effect of adenoidectomy while others report the opposite [13]. The mean AN (adenoidal-nasopharyngeal) ratio for children selected for adenoidectomy has been reported as 0.71 [14,15]. Adenoids can compress or block the ostium of the Eustachian tube, thereby causing increased middle ear pressure and subsequent effusion. In the case report presented by Buchman and et al. it was shown by manometric evaluation that active and passive eustachian tube obstruction was alleviated after adenoidectomy [16]. The reason for the use of adenoidectomy in the treatment of EOM involves the potential for improved Eustachian tube function [9]. Skoloudik et al. [9] found that the EOM recovery rate after paracentesis and endoscopyguided adenoidectomy without insertion of a ventilation tube was 87%. The relationship between the adenoids and the torus tubarius was more relevant for the result than the volume of adenoids [9]. Maw reported a better resolution rate for OME after adenoidectomy in children with larger adenoids [17]. However, there are also studies that have not determined any relationship between the volume of adenoids and the surgical procedure [18,19]. Wright et al. found a correlation between OME development and lateral adenoids extending to the ostium of the eustachian tube [20]. Maw et al. confirmed a significant improvement in fluid clearance and hearing thresholds as a result of adenoidectomy [21]. Large adenoid tissue partially or completely blocks the entry to the eustachian tube, thus interfering with the ventilation function. Type C2 and type B tympanograms were found in 74% of the patients where the eustachian tube ostium was completely closed with adenoid tissue [22]. Otitis media is actually a spectrum of related disorders. Wang et al. found no significant association between adenoid size and tympanogram results [13]. We also found no correlation between tympanogram results and adenoid size and location. Studies have found that middle ear pressures are significantly higher in patients with large adenoids than those with small ones [23–25]. However, Toros et al. [26] did not find a correlation between adenoid size and middle ear pressure. The effect of the enlarged adenoids on the eustachian tube and thus the development of effusion is more likely to be through regional inflammation or infection than direct compression [27]. Although adenoid tissue plays a role in effusion development, it does not seem to have an effect on hearing thresholds in OME. The relationship between adenoid size and location and middle ear effusion is still controversial today. There is no study investigating the relationship between the size and location of adenoid tissue and hearing thresholds in the literature. In this study, we determined that adenoid size and location were not associated with hearing thresholds in children with OME. Although adenoid tissue has a role in OME etiopathogenesis through the development of effusion, there is no direct relationship with hearing thresholds. Factors such as the structural features of the fluid formed in the middle ear (glue or serous), the changes in the tympanic membrane and ossicles, and the changes in middle ear pressure can have an impact on the hearing thresholds in OME. As a matter of fact, we found that hearing thresholds in the ears with Type B tympanograms were statistically significantly higher. Adenoid tissue can indirectly have an impact on hearing thresholds.
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