Selection Criteria for PE Tubes versus PE Tubes Plus Adenoidectomy (2005)

Source: Nguyen LHP, Manoukian JJ, Yoskovitch A, et al. Adenoidectomy: selection criteria for surgical cases of otitis media. Laryngoscope. 2004;114:863–866.Placement of pressure equalizing tubes (PET) is undoubtedly the most frequent surgical option used for persistent otitis media with effusion (OME) and refractory recurrent acute otitis media (AOM). Researchers from Canada’s McGill University and the University of Kuwait evaluated the efficacy of concomitant adenoidectomy in decreasing the failure rate of PET placement. They evaluated 63 patients, aged 18 months to 18 years and with a history of either: 1) recurrent AOM, defined as more than 3 episodes in the previous 6 months or more than 4 episodes in the preceding 12 months; 2) persistent OME, defined as effusion persisting for more than 3 months or producing a hearing deficit of 30 dB or greater; or 3) both. Study patients were randomly assigned to either PET placement alone or PET with adenoidectomy. In all patients, the adenoids were evaluated during surgery to assess whether they abutted the eustachian tube orifice (ETO). Failure was defined as: 1) 2 episodes of AOM within 6 months or 3 episodes in 1 year not related to water exposure (ie, swimming); 2) OME for greater than 3 months or causing a greater than 30 dB hearing loss; or 3) reinsertion of PET. Of 63 patients, 40 (63%) underwent PET placement alone and 23 (37%) underwent PET placement with adenoidectomy. Thirty-four (54%) of the 63 patients had adenoids abutting the ETO, of which 16 were in the PET group and 18 in the PET plus adenoidectomy group.Failure rates in the adenoidectomy and non-adenoidectomy groups were 21.7% and 42.5%, respectively (P=.096). After stratifying patients by whether or not they had adenoidal abutment, statistically significant differences were found. Adenoidectomy did not decrease failure rates in patients without adenoidal abutment of the ETO (P=.92). However, among patients with adenoidal abutment of the ETO, those who underwent PET placement and adenoidectomy were less likely to have a failure of treatment compared to those who underwent PET placement alone (P<.05).Financial Disclosure: Dr. Willner has disclosed that he has no relationships relevant to this commentary.Financial Disclosure: Dr. Wohl has disclosed that he has no relationships relevant to this commentary.If the results of this small study are replicated by other clinicians in other populations, it may, at long last, provide the basis for a rational approach to the decision about adenoidectomy at the time of PET placement. A previous study found that in patients aged 4 to 8 years, PET placement, with or without adenoidectomy, led to an increased time until recurrence of effusion, and that adenoidectomy was associated with a reduced need for subsequent medical and surgical intervention.1 It was theorized that adenoidectomy provided a long-term benefit by removing persistent nasopharyngeal bacterial carriage. The authors of that study recommended adenoidectomy and bilateral myringotomy in patients of this age with 60 days of effusion refractory to multiple antibiotic courses and with bilateral associated hearing loss. Other investigators have commented that adenoidectomy is associated with more morbidity than PET placement alone.1 A consensus panel recommended that the treatment of each child should be individualized based on the duration of OME, the child’s response to medication and the time of year.2The above study suggested that relieving adenoid abutment at the ETO had a positive effect on PET placement success. Unlike previous studies, the current study included patients with both recurrent AOM and persistent OME as criteria for surgical intervention. Nevertheless, the results suggest that specifically evaluating the adenoids for abutment of the ETO is helpful in determining whether it is reasonable to proceed with adenoidectomy at the time of PET placement, and allows for further individualization of each patient’s care.