Sari Hammarén-Malmi

Adenoidectomy Does Not Significantly Reduce the Incidence of Otitis Media in Conjunction With the Insertion of Tympanostomy Tubes in Children Who Are Younger Than 4 Years: A Randomized Trial

Objective. To evaluate the efficacy of adenoidectomy in reducing the incidence of otitis media among children who are younger than 4 years and receive tympanostomy tubes. Methods. A randomized trial was conducted at a tertiary center clinic. A total of 217 children who were aged 12 to 48 months and had recurrent acute otitis media (>3 episodes during the past 6 months) or chronic otitis media with effusion, no obstructive symptoms as a result of adenoid enlargement, and no previous surgical intervention were enrolled in the study. Adenoidectomy in conjunction with the insertion of tympanostomy tubes or insertion of tympanostomy tubes without adenoidectomy was studied. The number of otitis media episodes during the follow-up period of 12 months was measured. Results. During the follow-up, the mean number of otitis media episodes was 1.7 among children who underwent adenoidectomy with concurrent insertion of tympanostomy tubes and 1.4 among children who received tympanostomy tubes only. The risk for recurrent otitis media (≥3 episodes) could not be reduced by adenoidectomy (odds ratio: 1.66; 95% confidence interval: 0.80–3.46). Conclusion. Adenoidectomy does not significantly reduce the incidence of acute otitis media in otitis prone children who are younger than 4 years and receive tympanostomy tubes.

Exercise‐induced changes in respiratory impedance in young wheezy children and nonatopic controls

Exercise‐induced bronchoconstriction (EIB) is a specific sign of active asthma, but its assessment in young children may be difficult with lung function techniques requiring active cooperation. The aim of the study was to assess the normal pattern of exercise‐induced responses of respiratory impedance by using impulse oscillometry (IOS), and to investigate how these responses discriminate wheezy children from control subjects. IOS measurements were performed in a consecutive sample of wheezy children aged 3–7 years (n = 130) and in an aged matched control group of nonatopic children without respiratory symptoms (n = 79) before and after a free running test. After exercise, wheezy children showed significantly larger responses in respiratory resistance (Rrs5), reactance (Xrs5), and the resonance frequency (Fr) than the control subjects. In the control group, the upper 95% confidence limit of the maximal change was 32.5% for Rrs5, 85.7% for Xrs5, and 53.1% for Fr. By using analysis of receiver operating characteristics, the change in Rrs5 distinguished the wheezy children from the control subjects more effectively than change in Xrs5 or Fr. In wheezy children, the response was significantly effected by the outdoor temperature and exercise intensity in terms of maximum heart rate. In conclusion, an increase of 35% in Rrs5 after a free running test can be regarded as an abnormal response. Wheezy children show an enhanced airway response, which is clearly distinguishable from the control subjects. IOS is a feasible method to detect EIB in young children. Pediatr Pulmonol. 2008; 43:538–544.

Analysis of risk factors for childhood persistent middle ear effusion.

Conclusions Although exposure to infectious agents and parental smoking are known to influence the overall risk of otitis media, these risk factors do not appear to be linked with the tendency to develop chronic otitis media with effusion (COME) instead of recurrent acute otitis media (RAOM). The genetic inflammatory response type of the child appears to influence the risk of persistent middle ear effusion in COME. Objective Two different clinical presentations of childhood otitis media are encountered: RAOM; and COME, which is associated with persistent effusion in the middle ear. The objective of this study was to assess putative factors that may regulate the development of persistent middle ear effusion in COME. Material and methods In total, 159 children with RAOM and their parents (n=304), and 55 children with COME and their parents (n=110) were evaluated. All the children with COME or RAOM were aged <4 years. Results There was no difference in the frequency of attendance at day care outside the home, number of siblings or parental smoking between children with RAOM and those with COME. The frequency of parental allergy and asthma was lower among children with COME than those with RAOM.

Endoscopic sinus surgery might reduce exacerbations and symptoms more than balloon sinuplasty.

Background Endoscopic sinus surgery (ESS) is considered after medical therapy failure of chronic rhinosinusitis (CRS). The balloon sinuplasty dilates the natural ostium without moving mucosa or bone. It still lacks evidence from randomized controlled trials. The aim of this retrospective controlled study was to compare the symptom outcomes after maxillary sinus surgery with either the ESS or the balloon sinuplasty technique. No previous or additional sinonasal operations were accepted. Methods Two hundred eight patients with CRS without nasal polyps underwent either balloon sinuplasty or ESS. The patients who met with the inclusion criteria (n = 45 in ESS group and n = 40 in balloon group) replied to a questionnaire of history factors, exacerbations, and a visual analog scale (VAS) scoring of the change in symptoms, on average 28 ± 6 (mean ± SD) months postoperatively. Results The groups were identical in the response rate (64%), patient characteristics, and the improvement in all of the asked symptoms. Patients with CRS-related comorbidity and/or present occupational exposure had a statistically significantly better symptom reduction after ESS than after balloon sinusotomy. Moreover, the balloon sinusotomy group reported a statistically significant higher number of maxillary sinus punctures and antibiotic courses during the last 12 months. Conclusion ESS might be superior to balloon sinuplasty, especially in patients with risk factors. There is a need to perform more controlled studies on the treatment choices of CRS.

Effect of adenoidectomy on respiratory function: a randomised prospective study

Objective: Risk of childhood asthma is increased in children with recurrent otitis media. This may be associated with recurrent respiratory tract infections in these children, but the role of adenoidectomy, a frequent operation during childhood, is unknown. Therefore, the role of adenoidectomy in the development of atopy and respiratory function changes characteristic of asthma was evaluated. Design: Randomised controlled study. Setting: Tertiary care centre. Patients: 166 children aged 12–48 months who had recurrent or persistent otitis media and who were followed-up for 3 years after randomisation. Intervention: Randomisation to undergo insertion of tympanostomy tubes with or without adenoidectomy. Main outcome measures: The primary outcome measure was exercise-induced bronchoconstriction as evaluated by impulse oscillometry. The secondary outcome measures were bronchial inflammation as evaluated by exhaled nitric oxide and atopy as evaluated by skin prick tests. During the 3-year follow-up period otitis media episodes were documented in patient diaries. Results: Adenoidectomy did not significantly influence baseline lung function, exercise-induced bronchoconstriction, exhaled nitric oxide concentration, the development of positive skin prick tests, or doctor-diagnosed asthma. Adenoidectomy did not significantly prevent otitis media. Recurrent otitis media (⩾4 episodes) during the first follow-up year was associated with an abnormal exercise-induced bronchoconstriction (OR 6.62, 95% CI 1.27 to 34) and an elevated exhaled nitric oxide concentration (OR 3.26, 95% CI 0.98 to 10.8) regardless of adenoidectomy. Conclusions: Adenoidectomy did not promote asthma or allergy. Recurrent respiratory tract infections during early childhood are associated with the risk of bronchial hyper-reactivity.

Adenoidectomy during early life and the risk of asthma

The objective of the study was to evaluate the risk of asthma in children who had undergone an adenoidectomy, an operation frequently performed on children with glue ear or recurrent otitis media. Two surveys were carried out, a nation‐wide questionnaire returned by 483 individuals (survey A) and a survey of hospital discharge records involving 1616 children who had undergone an adenoidectomy and 161 control children who had undergone probing of the nasolacrimal duct due to congenital obstruction (survey B). The questionnaire (survey A) showed that an adenoidectomy before the age of 4 years was associated with asthma (OR 3.19, 95% CI 1.25; 8.13) and with allergy to animal dust (OR 2.50, 95% CI 1.27; 4.95). In survey B, asthma diagnosis was retrieved from the national asthma register. It showed also that adenoidectomy at an early age was associated with an increased risk of asthma (OR 6.74, 95% CI 2.99; 15.2). There was an association between asthma and adenoidectomy, even before adenoidectomy had actually been performed. The risk of asthma was highest among children who had had adenoidectomy because of recurrent otitis media. The observed association between an adenoidectomy and asthma may be explained by an underlying factor predisposing to both recurrent otitis media and asthma.

Predisposition to Childhood Otitis Media and Genetic Polymorphisms within the Toll-Like Receptor 4 (TLR4) Locus

Background Predisposition to childhood otitis media (OM) has a strong genetic component, with polymorphisms in innate immunity genes suspected to contribute to risk. Studies on several genes have been conducted, but most associations have failed to replicate in independent cohorts. Methods We investigated 53 gene polymorphisms in a Finnish cohort of 624 cases and 778 controls. A positive association signal was followed up in a tagging approach and tested in an independent Finnish cohort of 205 cases, in a British cohort of 1269 trios, as well as in two cohorts from the United States (US); one with 403 families and the other with 100 cases and 104 controls. Results In the initial Finnish cohort, the SNP rs5030717 in the TLR4 gene region showed significant association (OR 1.33, P = .003) to OM. Tagging SNP analysis of the gene found rs1329060 (OR 1.33, P = .002) and rs1329057 (OR 1.29, P = .003) also to be associated. In the more severe phenotype the association was stronger. This finding was supported by an independent Finnish case cohort, but the associations failed to replicate in the British and US cohorts. In studies on TLR4 signaling in 20 study subjects, the three-marker risk haplotype correlated with a decreased TNFα secretion in myeloid dendritic cells. Conclusions The TLR4 gene locus, regulating the innate immune response, influences the genetic predisposition to childhood OM in a subpopulation of patients. Environmental factors likely modulate the genetic components contributing to the risk of OM.

Adenoidectomy and nasopharyngeal carriage of Streptococcus pneumoniae in young children

Objective The effect of adenoidectomy on nasopharyngeal colonisation of pathogens has not previously been evaluated. The authors studied the effect of adenoidectomy on nasopharyngeal colonisation by bacteria causing otitis media and the effect of adenoidectomy on the development of pneumococcal capsular polysaccharide antibodies. Design Randomised controlled study. Setting Tertiary care centre. Patients 217 children aged 12–48 months who had recurrent or persistent otitis media were randomised. 166 children were followed up for 3 years. Intervention Random allocation to undergo adenoidectomy or not to undergo adenoidectomy. All the children underwent insertion of tympanostomy tubes. Main outcome measures Nasopharyngeal colonisation by pneumococci, Haemophilus influenzae and Moraxella catarrhalis 1, 2 and 3 years after randomisation. Serum IgG antibodies against pneumococcal capsular polysaccharide serotypes 6B, 14, 19F and 23F 3 years after randomisation. Results After the first year of randomisation adenoidectomy increased nasopharyngeal carriage of pneumococci (RR, 1.47; 95% CI 1.04 to 2.07) but it did not influence the carriage of H influenzae or M catarrhalis. Among carriers of serotype 6B pneumococci, adenoidectomy resulted in lower concentrations of pneumococcal serotype 6B polysaccharide antibodies (ratio of geometric means of antibody concentrations, 0.37; 95% CI 0.16 to 0.85). Concentrations of serotype 14, 19F and 23F antibodies seemed not to be influenced by adenoidectomy. Despite this, adenoidectomy resulted in a significant increase in nasopharyngeal carriage of serotype 19F pneumococci. Conclusions Adenoidectomy increases the risk of nasopharyngeal carriage of pneumococci in children younger than 4 years of age. This may be independent of the development of serum IgG capsular polysaccharide antibodies.

Adenoidectomy in young children and serum IgG antibodies to pneumococcal surface protein A and choline binding protein A

OBJECTIVE We have previously reported that surgical removal of the nasopharyngeal adenoid in young children resulted in increased risk of nasopharyngeal colonization by pneumococci. We now investigated whether adenoidectomy influences the development of serum IgG antibodies to pneumococcal choline-binding protein A (CbpA) and pneumococcal surface protein A (PspA). METHODS Altogether 217 children aged 12-48 months who had recurrent or persistent otitis media were randomized to undergo or not to undergo adenoidectomy. All the children underwent insertion of tympanostomy tubes. 166 children were followed-up for 3 years. The main outcome measures were concentrations of serum IgG antibodies to CbpA and PspA three years after randomization. Nasopharyngeal colonization by pneumococci was assessed 1, 2, and 3 years after randomization. RESULTS Adenoidectomy decreased concentrations of CbpA antibodies by ca. 25% independently of the observed increase in pneumococcal carriage (OR of log(10) transformed concentrations 0.74, 95% CI 0.58-0.94, P=0.016). Concentrations of PspA antibodies were lower and they seemed not to be influenced by adenoidectomy. CONCLUSIONS Adenoidectomy in young children causes a small but detectable impairment in the development of serum IgG antibodies to pneumococcal CbpA. The adenoid seems to have a role in augmenting systemic immunity against pneumococci.