OBSTRUCTIVE ADENOIDS IN RELATION TO OTITIS MEDIA CHARLES D. BLUESTONE, M.D. PnTSBURGH, PENNSYLVANIA
Recurrent acute otitis media and by to visualize the middle ear and prochronic middle ear effusions are com- tympanic portion of the Eustachian tube. mon problems in childhood, and ade- If not, and if a tympanostomy tube had noidectomy is frequently undertaken in previously been inserted, contrast median effort to ameliorate them. However, um was instilled transtympanically into the efficacy of the operation has yet to the middle ear. Using these techniques, be shown. In 1930 Kaiser" reported a it was possible to evaluate not only struclower incidence of purulent otorrhea in ture but function, as manifested by the a large group of children who had re- flow of contrast medium, at both ends of ceived adenotonsiIIectomy as compared the Eustachian tube. Adenoid size was with a control group. In 1963 McKee2 , 3 also estimated roentgenographically. reported two controlled studies of tonsil- Three types of abnormal Eustachian lectomy and adenoidectomy. Entry into tube function were found: retrograde obthe study was based on a history of three struction, retrograde reflux, and prograde or more sore throats during the previous obstruction. An additional abnormality, year. He concluded that tonsillectomy manifested by the positive roentgenodid not seem to alter the course of otitis graphic Toynbee test was described. Normedia but found a reduction in ear dis- mal retrograde function and prograde ease following adenoidectomy. In two clearance were both present in 5 of 44 similar studies, Boydhouse- also found a children ( 11%) before adenoidectomy decreased incidence of otitis media but and in 23 of 33 children (70%) following adenoidectomy (Table I). Thirteen Mawson" did not. of the 33 children (39%) developed otitis Unfortunately, in all of these studies media within a period of nine months or the methods for assessing the presence less following adenoidectomy, and the or severity of otitis media were not de- results were considered failures. Eight scribed and secretory otitis media, my- of these children developed more severe ringotomy, tympanostomy tube insertion ear disease than had been present before or hearing evaluations were not men- adenoidectomy. Favorable otologic retioned. Prospective controlled studies of sults were maintained following adenoidadenoidectomy for otitis media have not ectomy in 20 of the 33 children (61%) been reported. (Table II). Eight of these had normal prograde clearance, normal retrograde CURRENT STUDIES function, and a negative roentgenographIn an attempt to improve preoperative ic Toynbee test following adenoidecselection of patients for adenoidectomy, tomy. The remaining 12 (and also two Bluestone et al" studied the Eustachian "failures") had normal prograde cleartube roentgenographically before and ance and retrograde function, but their after adenoidectomy in a group of chil- roentgenographic Toynbee test was posidren who had recurrent or chronic otitis tive. The effectiveness of adenoidectomy media. The nasopharynx and the naso- in preventing otitis media appeared to pharyngeal portion of the Eustachian be correlated, to a considerable degree, tube were visualized after the instilla- with the preadenoidectomy roentgenotion of radiopaque material into the na- graphic findings: In 19 of the 27 chilsopharynx through a nasal catheter. In dren (70%) who had retrograde obstruc. some instances it was also possible there- tion the results were successful, whereas
44
45
ADENOIDS AND OTITIS MEDIA
Fig. 1. Postadenoidectomy roentgenogram of a child who demonstrated retrograde reflux. (By permission of the Laryngoscope 82:1654-1670, 1972.)
in two of the three (67%) with normal' nique. Nasal pressures during swallowretrograde function and in all three with ing were also determined in some. The reflux the results were failures (Fig. 1). study group consisted of 23 children Allergic rhinitis was associated with a with otitis media in whom tyrnranoshigh failure rate; in only two of ten al- tomy tubes had been inserted. Al were lergic children (20%), as compared with judged clinically and roentgenograph18 of 23 nonallergic children (80%), the ically to have prominent adenoids. Inresults were considered successful. Ade- flation-deflation Eustachian tube ventinoid size was not necessarily predictive lation studies were obtained in 36 ears of Eustachian tube function, although that remained intubated, aerated, and most children with large adenoids had dry both before and eight weeks after retrograde obstruction. adenoidectomy. Fifteen of the 36 (42%) In an effort to develop a more simple ears had improvement in Eustachian and accurate method to identify chil- tube ventilatory function postadenoidecdren in whom adenoidectomy migbt pre- tomy which was attributed to relief of vent otitis media, Bluestone, et a17 as- extrinsic mechanical obstruction of the sessed the ventilatory function of the tube. In the remaining 21 (58%) ears in Eustachian tube by a manometric tech- whom Eustachian tube function was not improved, mechanical obstruction was TABLE I not apparent preoperatively. The effect PRE- AND POSTADENOIDECTOMY of nasopharyngeal pressures on a pliant ROENTGENOGRAPHIC ASSESSMENT OF Eustachian tube (Toynbee phenomenon) RETROGRADE EUSTACHIAN TUBE due to obstruction of the posterior nasal FUNCTION IN 33 CHILDREN WITH choanae by the adenoid mass was sugPREVIOUS CHRONIC OR RECURRENT OTITIS MEDIA
Before Obstructed Normal Reflux
Adenoidectomy (No. of Children) After ObNorN structed mal Reflux 27 3 3
3
1
21 2
o
o
3
3
o
TABLE II OTITIS MEDIA BEFORE AND AFTER ADENOIDECTOMY IN 33 CHILDREN
Otitis Media Present Absent
Adenoidectomy (No. of Children) Before After
33 (100%)
o
13 (39%) 20 (61%)
46
CHARLES D. BLUESTONE
OBSTRUCTIVE ADENOIDS
+/- PRESSURES
CHOANAL OBSTRUCTION
MIDDLE EAR
Fig. 2. Author's conception of mechanical and functional obstruction of the Eustachian tube caused by obstructive adenoids.
gested as a possible cause of functional Eustachian tube obstruction (Fig. 2). In several instances in which preadenoidectomy mechanical obstruction of the Eustachian tube was not demonstrated, the tube appeared to have been made more pliant by the operation. This increase in compliance of the Eustachian tube was attributed to loss of adenoid support of the tube in the fossa of Rosenmiiller (Fig. 3).
PATHOGENESIS AND PATHOPHYSIOLOGY,
Do the adenoids mechanically obstruct the Eustachian tube? If so, where? In the fossa of Rosenmuller? At the nasopharyngeal orifice? To what degree?
How does this obstruction affect the protective, clearance, and ventilation functions of the tube? What effect does inflammation (allergy or infection) of the adenoids have on tubal function?
UNANSWERED RESEARCH QUESTIONS
Unfortunately, many basic questions remain unanswered. The following is a list of some of these questions.
Does intrinsic inflammation of the tube playa role? Is the compliance of the tube a factor? The geometry of the nose and nasopharynx?
EPIDEMIOLOGY.
What are the population characteristics of otitis media in relation to adenoids?
Do the adenoids obstruct the posterior nasal choanae?
ADENOIDECTOMY AND COMPLIANCE OF THE EUSTACHIAN TUBE
It
NASAL CAVITIES COMPLIANT EUSTACHIAN" ,', TUBE '/
,,
I ADENOIDECTOMY
Fig. 3. Author's conception of increased compliance of Eustachian tube following adenoidectomy.
ADENOIDS AND OTITIS MEDIA
If so, how, when, where, and to what degree? What role does inflammation play? Is the geometry of the nose and nasopharynx (craniofacial morphology) a factor? Is age a factor? What effect does nasal obstruction have on the function of the Eustachian tube? What are the nasopharyngeal pressures during tubal opening? When does the tube open? Can functional Eustachian tube obstruction result? Is the compliance of the tube a factor? Is velopharyngeal function important? What factors contribute to the compliance of the Eustachian tube? Amount and consistency of the cartilage support? Muscle tension or vector? Craniofacial morphology? Does the mucus blanket of the Eustachian tube playa role? Which technique is best for evaluation of the adenoids in relation to the nasal airway and Eustachian tube, e.g., roentgenographic, manometric, tympanometric? When should the test be performed, e.g., during periods of inflammation or between episodes, or both? MEDICAL MANAGEMENT OF OBSTRUCTIVE ADENOIDS.
What is the effect of medical treatment of the adenoids in relation to otitis media? What are the effects of nasal decongestants, antihistamines, and antibiotics on adenoids that are obstructive to the posterior nasal choanae or Eustachian tube, or both? SURGICAL MANAGEMENT OF ADENOIDS.
Does adenoidectomy alter the course of acute otitis media or chronic middle ear effusions?
47
What is the effect of adenoidectomy on the function of the Eustachian tube? Does the compliance of the Eustachian tube change? Which method of evaluation of the nasopharynx and Eustachian tube is best? Which technique of adenoidectomy is best? When should the adenoids be removed from the fossa of Rosenmuller? At what age is adenoidectomy indicated? Should a myringotomy be performed or tympanostomy tubes inserted into the tympanic membrane when effusion is present in the middle ear? When should the tympanostomy tubes be removed? METHODS OF FINDING THE ANSWERS TO THE RESEARCH QUESTIONS EPIDEMIOLOGY.
Determine the population characteristics of otitis media (suppurative and nonsuppurative) in relation to adenoids. PATHOGENESIS AND PATHOLOGY.
Define the normal physiology of the nose-nasopharynx-palate-Eustachian tube-middle ear-mastoid system. Study the effect of adenoids on the "system" in relation to otitis media. Study the effect of inflammation on the system. Study the effect of surgical and nonsurgical management on the system. Develop techniques to evaluate the system including the following: Roentgenography. Static-lateral and basalar cephlometrics; dynamic-video and cine basalar and lateral projections, contrast media. Manometry. Tympanometry.
48
CHARLES D. BLUESTONE
Audiometry.
adenoids to the nose or Eustachian tube or both by manometry or roentgenographic techniques.
Electromyography. Studies of craniofacial morphology as related to the adenoids within the system.
Complete work-up including immunologic status.
Special studies of the Eustachian tube as related to structure and function.
Determine the pathop,hysiologic changes in the "system' prior to management.
Studies of the histopathology, biochemistry, rheology of the system. Studies of middle ear effusions. Develop an animal model to study the system. Studies of normal physiology and induced pathophysiologic states. MANAGEMENT.
Design a prospective controlled study to determine the best surgical and nonsurgical methods of management of otitis media when associated with obstructive adenoids. The following should be included in the design: Entry into the study should be based on objective criteria. Objective evidence of otitis media by tympanometry, audiometry, and objective otoscopy. Objective evidence of obstructive
Accurate documentation of the technique employed when surgery is selected. Follow-up should include evaluation of the system by objective methods, Le., tympanometry, audiometry, and objective otoscopy. Documentation of all other surgical procedures performed both before and after management, i.e., myringotomy, tympanostomy tube insertion. CONCLUSION
A prospective, controlled study of the best surgical vs the best nonsurgical management of adenoids in relation to otitis media appears indicated. Studies leading to better understanding of the population characteristics, pathogenesis and pathophysiology of otitis media in relation to adenoids will also be necessary.
REFERENCES 1. Kaiser AD: Results of tonsillectomy: A comparative study of 2,200 tonsillectomized children with an equal number of controls three and ten years after operation. JAMA 95:837, 1930 2. McKee WJE: A controlled study of the effects of tonsillectomy and adenoidectomy in children. Br J Prev Soc Med 17:49, 1963 3. McKee WJE: The part played by adenoidectomy in the combined operation of tonsillectomy with adenoidectomy; Second part of a controlled study in children. Br J Prev Soc Med 17: 133, 1963 4. Roydhouse N: A controlled study of ade-
notonsillectomy. 1970
Arch
Otolaryngol
92:611,
5. Mawson SR, Adlington P, Evans M: A controlled study evaluation of adeno-tonsillectomy in children. J Laryngol Otol 81:777, 1967 6. Bluestone CD, Wittel RA, Paradise JL, et al: Eustachian tube function as related to adenoidectomy for otitis media. Trans Am. Acad Ophthalmol Otolaryngol 76:1325-1339, 1972 7. Bluestone CD, Cantekin EI, Beery QC: Certain effects of adenoidectomy on Eustachian tube ventilatory function. Laryngoscope 85:113-127, 1975
Recurrent acute otitis media and by to visualize the middle ear and prochronic middle ear effusions are com- tympanic portion of the Eustachian tube. mon problems in childhood, and ade- If not, and if a tympanostomy tube had noidectomy is frequently undertaken in previously been inserted, contrast median effort to ameliorate them. However, um was instilled transtympanically into the efficacy of the operation has yet to the middle ear. Using these techniques, be shown. In 1930 Kaiser" reported a it was possible to evaluate not only struclower incidence of purulent otorrhea in ture but function, as manifested by the a large group of children who had re- flow of contrast medium, at both ends of ceived adenotonsiIIectomy as compared the Eustachian tube. Adenoid size was with a control group. In 1963 McKee2 , 3 also estimated roentgenographically. reported two controlled studies of tonsil- Three types of abnormal Eustachian lectomy and adenoidectomy. Entry into tube function were found: retrograde obthe study was based on a history of three struction, retrograde reflux, and prograde or more sore throats during the previous obstruction. An additional abnormality, year. He concluded that tonsillectomy manifested by the positive roentgenodid not seem to alter the course of otitis graphic Toynbee test was described. Normedia but found a reduction in ear dis- mal retrograde function and prograde ease following adenoidectomy. In two clearance were both present in 5 of 44 similar studies, Boydhouse- also found a children ( 11%) before adenoidectomy decreased incidence of otitis media but and in 23 of 33 children (70%) following adenoidectomy (Table I). Thirteen Mawson" did not. of the 33 children (39%) developed otitis Unfortunately, in all of these studies media within a period of nine months or the methods for assessing the presence less following adenoidectomy, and the or severity of otitis media were not de- results were considered failures. Eight scribed and secretory otitis media, my- of these children developed more severe ringotomy, tympanostomy tube insertion ear disease than had been present before or hearing evaluations were not men- adenoidectomy. Favorable otologic retioned. Prospective controlled studies of sults were maintained following adenoidadenoidectomy for otitis media have not ectomy in 20 of the 33 children (61%) been reported. (Table II). Eight of these had normal prograde clearance, normal retrograde CURRENT STUDIES function, and a negative roentgenographIn an attempt to improve preoperative ic Toynbee test following adenoidecselection of patients for adenoidectomy, tomy. The remaining 12 (and also two Bluestone et al" studied the Eustachian "failures") had normal prograde cleartube roentgenographically before and ance and retrograde function, but their after adenoidectomy in a group of chil- roentgenographic Toynbee test was posidren who had recurrent or chronic otitis tive. The effectiveness of adenoidectomy media. The nasopharynx and the naso- in preventing otitis media appeared to pharyngeal portion of the Eustachian be correlated, to a considerable degree, tube were visualized after the instilla- with the preadenoidectomy roentgenotion of radiopaque material into the na- graphic findings: In 19 of the 27 chilsopharynx through a nasal catheter. In dren (70%) who had retrograde obstruc. some instances it was also possible there- tion the results were successful, whereas
44
45
ADENOIDS AND OTITIS MEDIA
Fig. 1. Postadenoidectomy roentgenogram of a child who demonstrated retrograde reflux. (By permission of the Laryngoscope 82:1654-1670, 1972.)
in two of the three (67%) with normal' nique. Nasal pressures during swallowretrograde function and in all three with ing were also determined in some. The reflux the results were failures (Fig. 1). study group consisted of 23 children Allergic rhinitis was associated with a with otitis media in whom tyrnranoshigh failure rate; in only two of ten al- tomy tubes had been inserted. Al were lergic children (20%), as compared with judged clinically and roentgenograph18 of 23 nonallergic children (80%), the ically to have prominent adenoids. Inresults were considered successful. Ade- flation-deflation Eustachian tube ventinoid size was not necessarily predictive lation studies were obtained in 36 ears of Eustachian tube function, although that remained intubated, aerated, and most children with large adenoids had dry both before and eight weeks after retrograde obstruction. adenoidectomy. Fifteen of the 36 (42%) In an effort to develop a more simple ears had improvement in Eustachian and accurate method to identify chil- tube ventilatory function postadenoidecdren in whom adenoidectomy migbt pre- tomy which was attributed to relief of vent otitis media, Bluestone, et a17 as- extrinsic mechanical obstruction of the sessed the ventilatory function of the tube. In the remaining 21 (58%) ears in Eustachian tube by a manometric tech- whom Eustachian tube function was not improved, mechanical obstruction was TABLE I not apparent preoperatively. The effect PRE- AND POSTADENOIDECTOMY of nasopharyngeal pressures on a pliant ROENTGENOGRAPHIC ASSESSMENT OF Eustachian tube (Toynbee phenomenon) RETROGRADE EUSTACHIAN TUBE due to obstruction of the posterior nasal FUNCTION IN 33 CHILDREN WITH choanae by the adenoid mass was sugPREVIOUS CHRONIC OR RECURRENT OTITIS MEDIA
Before Obstructed Normal Reflux
Adenoidectomy (No. of Children) After ObNorN structed mal Reflux 27 3 3
3
1
21 2
o
o
3
3
o
TABLE II OTITIS MEDIA BEFORE AND AFTER ADENOIDECTOMY IN 33 CHILDREN
Otitis Media Present Absent
Adenoidectomy (No. of Children) Before After
33 (100%)
o
13 (39%) 20 (61%)
46
CHARLES D. BLUESTONE
OBSTRUCTIVE ADENOIDS
+/- PRESSURES
CHOANAL OBSTRUCTION
MIDDLE EAR
Fig. 2. Author's conception of mechanical and functional obstruction of the Eustachian tube caused by obstructive adenoids.
gested as a possible cause of functional Eustachian tube obstruction (Fig. 2). In several instances in which preadenoidectomy mechanical obstruction of the Eustachian tube was not demonstrated, the tube appeared to have been made more pliant by the operation. This increase in compliance of the Eustachian tube was attributed to loss of adenoid support of the tube in the fossa of Rosenmiiller (Fig. 3).
PATHOGENESIS AND PATHOPHYSIOLOGY,
Do the adenoids mechanically obstruct the Eustachian tube? If so, where? In the fossa of Rosenmuller? At the nasopharyngeal orifice? To what degree?
How does this obstruction affect the protective, clearance, and ventilation functions of the tube? What effect does inflammation (allergy or infection) of the adenoids have on tubal function?
UNANSWERED RESEARCH QUESTIONS
Unfortunately, many basic questions remain unanswered. The following is a list of some of these questions.
Does intrinsic inflammation of the tube playa role? Is the compliance of the tube a factor? The geometry of the nose and nasopharynx?
EPIDEMIOLOGY.
What are the population characteristics of otitis media in relation to adenoids?
Do the adenoids obstruct the posterior nasal choanae?
ADENOIDECTOMY AND COMPLIANCE OF THE EUSTACHIAN TUBE
It
NASAL CAVITIES COMPLIANT EUSTACHIAN" ,', TUBE '/
,,
I ADENOIDECTOMY
Fig. 3. Author's conception of increased compliance of Eustachian tube following adenoidectomy.
ADENOIDS AND OTITIS MEDIA
If so, how, when, where, and to what degree? What role does inflammation play? Is the geometry of the nose and nasopharynx (craniofacial morphology) a factor? Is age a factor? What effect does nasal obstruction have on the function of the Eustachian tube? What are the nasopharyngeal pressures during tubal opening? When does the tube open? Can functional Eustachian tube obstruction result? Is the compliance of the tube a factor? Is velopharyngeal function important? What factors contribute to the compliance of the Eustachian tube? Amount and consistency of the cartilage support? Muscle tension or vector? Craniofacial morphology? Does the mucus blanket of the Eustachian tube playa role? Which technique is best for evaluation of the adenoids in relation to the nasal airway and Eustachian tube, e.g., roentgenographic, manometric, tympanometric? When should the test be performed, e.g., during periods of inflammation or between episodes, or both? MEDICAL MANAGEMENT OF OBSTRUCTIVE ADENOIDS.
What is the effect of medical treatment of the adenoids in relation to otitis media? What are the effects of nasal decongestants, antihistamines, and antibiotics on adenoids that are obstructive to the posterior nasal choanae or Eustachian tube, or both? SURGICAL MANAGEMENT OF ADENOIDS.
Does adenoidectomy alter the course of acute otitis media or chronic middle ear effusions?
47
What is the effect of adenoidectomy on the function of the Eustachian tube? Does the compliance of the Eustachian tube change? Which method of evaluation of the nasopharynx and Eustachian tube is best? Which technique of adenoidectomy is best? When should the adenoids be removed from the fossa of Rosenmuller? At what age is adenoidectomy indicated? Should a myringotomy be performed or tympanostomy tubes inserted into the tympanic membrane when effusion is present in the middle ear? When should the tympanostomy tubes be removed? METHODS OF FINDING THE ANSWERS TO THE RESEARCH QUESTIONS EPIDEMIOLOGY.
Determine the population characteristics of otitis media (suppurative and nonsuppurative) in relation to adenoids. PATHOGENESIS AND PATHOLOGY.
Define the normal physiology of the nose-nasopharynx-palate-Eustachian tube-middle ear-mastoid system. Study the effect of adenoids on the "system" in relation to otitis media. Study the effect of inflammation on the system. Study the effect of surgical and nonsurgical management on the system. Develop techniques to evaluate the system including the following: Roentgenography. Static-lateral and basalar cephlometrics; dynamic-video and cine basalar and lateral projections, contrast media. Manometry. Tympanometry.
48
CHARLES D. BLUESTONE
Audiometry.
adenoids to the nose or Eustachian tube or both by manometry or roentgenographic techniques.
Electromyography. Studies of craniofacial morphology as related to the adenoids within the system.
Complete work-up including immunologic status.
Special studies of the Eustachian tube as related to structure and function.
Determine the pathop,hysiologic changes in the "system' prior to management.
Studies of the histopathology, biochemistry, rheology of the system. Studies of middle ear effusions. Develop an animal model to study the system. Studies of normal physiology and induced pathophysiologic states. MANAGEMENT.
Design a prospective controlled study to determine the best surgical and nonsurgical methods of management of otitis media when associated with obstructive adenoids. The following should be included in the design: Entry into the study should be based on objective criteria. Objective evidence of otitis media by tympanometry, audiometry, and objective otoscopy. Objective evidence of obstructive
Accurate documentation of the technique employed when surgery is selected. Follow-up should include evaluation of the system by objective methods, Le., tympanometry, audiometry, and objective otoscopy. Documentation of all other surgical procedures performed both before and after management, i.e., myringotomy, tympanostomy tube insertion. CONCLUSION
A prospective, controlled study of the best surgical vs the best nonsurgical management of adenoids in relation to otitis media appears indicated. Studies leading to better understanding of the population characteristics, pathogenesis and pathophysiology of otitis media in relation to adenoids will also be necessary.
REFERENCES 1. Kaiser AD: Results of tonsillectomy: A comparative study of 2,200 tonsillectomized children with an equal number of controls three and ten years after operation. JAMA 95:837, 1930 2. McKee WJE: A controlled study of the effects of tonsillectomy and adenoidectomy in children. Br J Prev Soc Med 17:49, 1963 3. McKee WJE: The part played by adenoidectomy in the combined operation of tonsillectomy with adenoidectomy; Second part of a controlled study in children. Br J Prev Soc Med 17: 133, 1963 4. Roydhouse N: A controlled study of ade-
notonsillectomy. 1970
Arch
Otolaryngol
92:611,
5. Mawson SR, Adlington P, Evans M: A controlled study evaluation of adeno-tonsillectomy in children. J Laryngol Otol 81:777, 1967 6. Bluestone CD, Wittel RA, Paradise JL, et al: Eustachian tube function as related to adenoidectomy for otitis media. Trans Am. Acad Ophthalmol Otolaryngol 76:1325-1339, 1972 7. Bluestone CD, Cantekin EI, Beery QC: Certain effects of adenoidectomy on Eustachian tube ventilatory function. Laryngoscope 85:113-127, 1975
