A. Richard Maw

OTOSCOPIC, IMPEDANCE, AND AUDIOMETRIC FINDINGS IN GLUE EAR TREATED BY ADENOIDECTOMY AND TONSILLECTOMY: A Prospective Randomised Study

150 children aged between 2 and 9 years (mean 5.25 years) with chronic bilateral otitis media with effusion were randomly allocated to three groups who, in addition to unilateral myringotomy and grommet insertion, would have an adenotonsillectomy, an adenoidectomy, or neither. The contralateral ear was assessed. Otoscopic, impedance, and audiometric findings were recorded preoperatively and at six and twelve months postoperatively. Subtraction of the no-surgery results indicates that at twelve months adenoidectomy produces otoscopic resolution of OME in 41.7% and no-peak/peak conversion of impedance in 29.8%. The hearing gain from adenoidectomy alone was similar to that resulting from insertion of a grommet alone, but the children having adenoidectomy required fewer reinsertions to maintain adequate subjective hearing thresholds in the treated ear (26% versus 54%). Tonsillectomy conferred no additional benefit. Without treatment there was a small but significant improvement in all indices at twelve months but not at six months postoperatively.

Tympanic membrane atrophy, scarring, atelectasis and attic retraction in persistent, untreated otitis media with effusion and following ventilation tube insertion

Two hundred and twenty two children with persistent bilateral otitis media with effusion (OME) were treated with unilateral ventilation tube insertion and no treatment to the contralateral ear. The tympanic membrane changes in the operated and unoperated ears were compared during a 12 year follow-up. Segmental atrophy resulted from tube insertion whereas minor scarring and thickening of the pars tensa was related to the middle ear condition. Eight three percent of untreated ears and 85% of those treated with tubes did not develop atelectasis. Sixty percent of untreated ears and 64% of treated ears did not develop attic retraction. Very few cases (1.5 and 2%) in untreated and treated ears, respectively developed severe atelectasis. The overall duration of OME was assessed from the pre-operative history of hearing loss, the 3 month period of pre-operative observation and the post-operative time with effusion. There is a relationship between duration of the disease and development of both atelectasis and attic retraction.

Prospective study of tympanosclerosis developing after grommet insertion

Grommets have been used as a treatment for middle-ear effusions since their introduction by Armstrong in 1954. However, it is now accepted that the presence of a grommet in a tympanic membrane is associated with the development of tympanosclerosis in that membrane. Furthermore, it has been shown that this is a progressive phenomenon and that the incidence increases with time to as much as 65 per cent at 3 to 4 years after grommet insertion (Mawson and Fagan, 1972; Tos and Poulsen, 1976). Initially it was suggested that the development of tympanosclerosis might be due to the middle ear disease rather than to the grommet (McKinnon, 1971). However, most recent studies have found that, in bilateral cases of effusion, tympanosclerosis develops more frequently in ears with a grommet than in those without (Brown, Richards and Ambegaokar, 1978; Lildholt, 1979). This prospective study was designed to show the development of tympanosclerosis in the tympanic membrane of children treated for bilateral middle-ear effusions and to elicit any factors from the clinical history and operative technique which might be associated with the pathogenesis of the complication.

Chronic otitis media with effusion and adeno-tonsillectomy--a prospective randomized controlled study.

Otitis media with effusion (OME) is one of the commonest, chronic otological conditions of early childhood. There is considerable variation in management in different centres throughout the world. Surgical treatment of the ears, adenoids, tonsils and sinuses is frequently employed and the condition constitutes one of the main indications for adenoidectomy and to a lesser extent for tonsillectomy. To date no randomized prospective, adequately controlled study has demonstrated the effect of these operations on established OME. The present work reports the results at 6 weeks, 3 months, 6 months, 9 months and one year following adenoidectomy and adenotonsillectomy performed randomly and prospectively with a controlled no-surgery group on a cohort of 103 children with established OME, unresponsive to medical treatment. Following adenoidectomy the rate of resolution of OME increases from 39% at 6 weeks, to 72% at one year; and following adeno-tonsillectomy the rate increases from 59% at 6 weeks to 62% at one year. In the no-surgery group the rate increases from 16% at 6 weeks to 26% at one year. Compared with the no-surgery group the effect of adenoidectomy alone at one year is highly significant (P less than or equal to 0.001) and similarly the effect of adenotonsillectomy is significant (P less than or equal to 0.01). However, there is no increased benefit from the addition of tonsillectomy compared with adenoidectomy alone. Thus adenoidectomy resolves established OME in 36-46% of cases for up to 12 months.

Rhinomanometry in the selection for adenoidectomy and its relation to preoperative radiology

Recent work has shown that resolution of otitis media with effusion (OME) following adenoidectomy may be related to certain preoperative radiographic parameters. This study was performed to investigate the relationship between the total nasal resistance (TNR), adenoid volume and the radiographic palatal airway and adenoid depth in children with OME. Fifty-six children underwent anterior active rhinomanometry and 40 completed the investigation. There was a significant association between the Palatal Airway and the TNR, and in the 27 who subsequently underwent adenoidectomy this was nearly so with respect to adenoid volume and TNR. The relationship demonstrated was not strong enough for TNR to be of use in selection of children for adenoidectomy based on radiographic parameters. Rhinomanometry can be difficult and time-consuming to perform in children. In its present form it is unlikely to be of routine clinical use in this context.

The Long Term Effect of Adenoidectomy on Established Otitis Media with Effusion in Children

Adenoidectomy is a recommended treatment for otitis media with effusion (OME). This work up-dates a previous report and includes a larger number of 155 cases. Surgery has been allocated at random with a control non-adenoidectomy group. The study is prospective and allows for a wide variety of variables. These include age, sex, adenoid size, seasonal variation, observer accuracy, and spontaneous resolution. Adenoidectomy results in clearance of OME even one year following operation in 31-45% of cases. Clearance is related to the duration of history of hearing loss though this may reflect on age effect. Tonsillectomy provides no additional benefit.