ADENOIDECTOMY IN RELATION TO OTITIS MEDIA CHARLES
QUINTER C. BEERY,
SUMMARY - Past studies of the efficacy of adenoidectomy in the management of children with otitis media have been inconclusive due to significant limitations in experimental design. At the Children's Hospital of Pittsburgh, the effect of adenoidectomy on the outcome of otitis media is currently being studied in a prospective manner. An attempt is being made to document and to control those factors cited as lacking in the previous studies. This report describes the techniques for assessment of nasal and Eustachian tube function and for the completeness of adenoidectomy.
The efficacy of adenoidectomy in the management of children with middle ear effusions and recurrent acute otitis media has yet to be shown. Unfortunately, the prospective controlled studies!" that have addressed this problem in the past had the following limitations in experimental design: 1) entry was based on the occurrence of sore throat and not the presence of middle ear disease; 2) objective evidence of otitis media was not documented by tympanometry or audiometry; 3) documentation of all other surgical procedures, e.g., myringotomy, tympanostomy tube insertions, was not presented; 4) the technique of adenoidectomy was not described and evidence of complete removal was not documented; and 5) nasal and Eustachian tube function was not objectively assessed. At the Children's Hospital of Pittsburgh we are currently studying the effect of adenoidectomy on the outcome of otitis media in a prospective manner and are attempting to document and control those factors cited as lacking in the previous studies. The techniques for assessment of nasal and Eustachian tube function and for completeness of adenoidectomy have been derived from our previous studies of the effect of adenoidectomy on the ventilatory, protective, and clearance functions of the Eustachian tube.t-" This report describes the techniques currently em-
ployed and presents some of the findings of our past and current studies. Protective and Clearance Functions of the Eustachian Tube. The protective and clearance functions of the Eustachian tube have been studied roentgenographically before and after adenoidectomy in a group of children who had recurrent acute otitis media or persistent middle ear effusions or both." The nasopharynx and the nasopharyngeal portion of the Eustachian tube were visualized after the instillation of radiopaque media into the nasopharynx through a nasal catheter. In some instances it was possible thereby to visualize the aural portion of the Eustachian tube and the middle ear. If not, and if a tympanostomy tube had previously been inserted, contrast material was instilled through the tympanostomy tube into the middle
Fig. 1. Postadenoidectomy roentgenogram of a child who demonstrated retrograde reflux.
From the Department of Otolaryngology, Children's. Hospital of Pittsburgh, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvama.
Fig. 2. Postadenoidectomy roentgenogram of a child who insufflated nasopharyngeal radiopaque material into the middle ear during closed-nose swallowing but not when the nose remained open (positive roentgenographic Toynbee test).
ear. Assessment of adenoid size and the degree of obstruction of the posterior nasal choanae and Eustachian tube could also be evaluated by this roentgenographic technique. Many of the children in this investigation appeared to have Eustachian tubes that failed to
protect the middle ear from contrast material instilled into the nasopharynx. Several Eustachian tubes demonstrated reflux of the radiopaque material into the middle ear and mastoid air cells during open-nose swallowing, especially following adenoidectomy (Fig. 1) . In the
Fig. 3. Lateral roentgenograms of the soft tissues of the head and neck of a child with chronic secretory otitis media. Prior to adenoidectomy the adenoids were considered to be of only moderate size (left). Postadenoidectomy they appeared slightly smaller (right).
Fig. 5. Submental-vertex roentgenogram of a child with adenoids obstructing the posterior nasal choanae.
Fig. 4. In the same child as in Figure 3, preadenoidectomy submental-vertex reentgenogram (top) demonstrated bilateral mechanical compression of the Eustachian tubes and medium sized adenoids. Following adenoidectomy (bottom), function of the Eustachian tube at the nasopharyngeal end was judged normal.
others, contrast media was insufflated into the middle ear during closed-nose swallowing but not when the nose remained open (positive roentgenographic Toynbee test) (Fig. 2). The findings appeared to indicate excessive distensibility of the Eustachian tube in these children which might have predisposed them to otitis media. The assessment of the clearance Iunc-
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tion of the Eustachian tube in this study was not very informative, but, in general, those few subjects who demonstrated obstruction to the flow of radiopaque media from the middle ear into the nasopharynx ( prograde obstruction), also showed obstruction at the nasopharyngeal end of the Eustachian tube (retrograde obstruction). These roentgenographic studies employing contrast media are technically difficult and are uncomfortable for the child, therefore, they are reserved for selected patients in our current investigations. Ventilatory Function of the Eustachian Tube. The ventilatory function of the Eustachian tube has been studied using a manometric technique before and after adenoidectomy in a group of children with otitis media in whom tympanostomy tubes had been inserted." Infla-
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Fig. 6. Recordings of nasal pressures during open- and closed-nose swallowing in a child with adenoids obstructing the posterior nasal choanae. Intranasal positive pressures were recorded during both open- and closed-nose swallowing.
Fig. 7. Preadenoidectomy (left) and postadenoidectomy (right) lateral roentgenograms of the soft tissues of the head and neck of a child with otitis media who received an incomplete adenoidectomy.
tion-deflation studies of the Eustachian tube were obtained in ears that remained intubated, aerated and dry both before and eight weeks after adenoidectomy. Nasal pressures during swallowing were also determined in some. The results of this study indicated that following adenoidectomy Eustachian tube ventilatory function improved in some, remained the same in others, and in a few children the function appeared to have been made worse. Improvement was related to a reduction of mechanical obstruction of the Eustachian tube while in those in whom the function was adjudged worse, the tube was considered to be more pliant after the adenoidectomy than before. This increase in compliance was attributed to loss of adenoid support of the Eustachian tube in the fossa of Rosenmiiller, A comparable situation was described in the roentgenographic study in which several of the children demonstrated reflux of radiopaque liquid media from the nasopharynx into the middle ear after the adenoidectomy but not
before (Fig. 1). This type of manometric assessment of nasal and Eustachian tube function is included in our current studies of adenoidectomy. Adenoid Size in Relation to the Nasal Airway and Eustachian Tube. Adenoid size in relation to the posterior nasal choanae and Eustachian tube can be evaluated by lateral roentgenograms of the soft tissues of the head and neck. Figure 3 shows an example of a lateral roentgenographic study of a child with chronic secretory otitis media who received an adenoidectomy. Before surgery the adenoids were adjudged to be of only moderate size. Eight weeks following the adenoidectomy the adenoid size appeared only somewhat smaller. However, when the pre- and postadenoidectomy submental-vertex views were compared in the same child, the function of the Eustachian tube at the nasopharyngeal end appeared obstructed before the operation and normal following
Fig. 8. Postadenoidectomy submentalvertex roentgenogram in which contrast media outlined the residual adenoid tissue following an incomplete operation.
the operation (Fig. 4). This example demonstrates that lateral roentgenographic views alone may not be sufficient to assess the effect of the adenoids on the nasopharyngeal end of the Eustachian tube. The manometric assessment of nasal pressure as well as simultaneous studies of Eustachian tube function may also be required. The effect of nasopharyngeal pressures on the Eustachian tube due f h to obstruction 0 t e posterior nasal choanae by the adenoid mass may be a cause of functional Eustachian tube obstruction. During open-nose swallowing, the pressure within the nasopharynx is ambient, however, when the nose is obstructed, the nose and nasopharyngeal cavity represents a closed compartment during swallowing activity. The pressure within the closed cavity usually is biphasic, a positive pressure followed by a negative. The possible effect of these pressures on the Eustachian tube has been termed the "Toynbee phenome-
non.?" The degree of nasal obstruction created by the adenoid mass can be assessed by the submental roentgenogram (Fig. 5), but the manometric technique is more precise. An example of a pressure recording indicating obstructive adenoids to the posterior nasal choanae is shown in Figure 6. Positive intranasal pressures were recorded during both open- and closed-nose swallowing, which indicated complete obstruction of the posterior nasal choanae. Manometric assessment of nasal and Eustachian tube function following adenoidectomy is also helpful in determining if mechanical obstruction to the nose or the Eustachian tube has been relieved. These lateral roentgenographic and manometric studies are now performed on all subjects who are randomized for adenoidectomy in the current investigation. Completeness of Adenoidectomy. The completeness of the adenoidectomy can be assessed by the roentgenographic technique. Figure 7 shows the pre- and postadenoidectomy lateral roentgenograms of a child in whom the adenoids were not completely removed. Figure 8 shows an example of an incomplete adenoidectomy in another child, as demonstrated by a postadenoidectomy submental-vertex roentgenogram. Neither of these children were involved in our current study of adenoidectomy. CONCLUSION
Objective assessment of nasal and Eustachian tube function in relation to adenoidectomy is a necessary component of any study of the efficacy of the procedure in the prevention of otitis media in children.
REFERENCES 1. McKee WJE: A controlled study of the 4. Roydhouse N: A controlled study of adeeffects of tonsillectomy and adenoidectomy in notonsillectomy. Arch Otolaryngol 92:611, children. Br J Prev Soc Med 17:49, 1963 1970 5. Bluestone CD, Wittel RA, Paradise JL, 2. McKee WJE: The part played by adeet al: Eustachian tube function as related to noidectomy in the combined operation of tonsillectomy with adenoidectomy; second part adenoidectomy for otitis media. Trans Am of a controlled study in children. Br J Prey Acad Ophthalmol Otolaryngol 76:1325-1339, Soc Med 17: 133 1963 1972 3. Mawson SR, Adlington P, Evans M: A 6. Bluestone CD, Cantekin EI, Beery QC: controlled study evaluation of adeno-tonsil- Certain effects of adenoidectomy on Eustalectomy in children. J Laryngol Otol 81 :777, chian tube ventilatory function. Laryngoscope 85:113-127,1975 1967 REPRINTS - Charles D. Bluestone, M.D., Children's Hospital of Pittsburgh, 125 DeSoto St., Pittsburgh, PA 15213.