PEDIATRICS Vol. 116 No. 5 November 2005, pp. 1257 (doi:10.1542/peds.2005-1695)
Prophylactic or Therapeutic Adenoidectomy?
Jeffrey D. Carron, MD, FAAPOtolaryngology and Communicative Sciences
University of Mississippi Medical Center
Jackson, MS 39216
To the Editor.—
As a practicing pediatric otolaryngologist, I read with interest the article about adenoidectomy and tympanostomy tube insertion by Hammarén-Malmi et al.1 As usual, the problems start with the title, which states that adenoidectomy performed at the time of tympanostomy tube insertion does not significantly reduce the incidence of acute otitis media (AOM). This sounds like a great conclusion until one reads that they excluded patients with adenoid enlargement (precisely the ones we would expect to benefit from adenoidectomy) by theoretically removing a larger bacterial reservoir and possibly a mechanical obstruction of the eustachian-tube orifice. Even if these excluded patients could not be randomly assigned in the study, they could have represented an important parallel arm to compare to controls.
The second problem I had was with the duration of follow-up, which was 1 year—approximately the average amount of time that a standard grommet-style tympanostomy tube stays in the tympanic membrane. Because we already know that tympanostomy tubes are great for preventing ear infections (which is why the children were referred in the first place), following them only while the tubes are in place and effectively bypassing the eustachian-tube mechanism will give very little information about what happens when the tubes are out and the child is reliant on his own ventilation system again. Furthermore, nowhere does it say whether the tubes remained patent during the follow-up period or became nonfunctional, which is essential information.
This leads us to the biggest problem, one that is more fundamental. The authors relied on the diagnosis of AOM from a doctor at a primary care center who was not involved in the study, and the diagnosis was based on "acute symptoms and middle ear inflammation." One would have hoped that they had used more objective measures such as otorrhea through the tube (which is what happens in AOM with a patent tympanostomy tube) or used pneumatic otoscopy or middle ear impedance when the tube became nonfunctional. The use of vague terms such as "middle ear inflammation" or "redness" has led to countless erroneous diagnoses of AOM in children with tubes, as otolaryngologists everywhere can attest.
Without an objective way to diagnose the AOM in a child with tympanostomy tubes, little can be gained from this study looking at prophylactic, not therapeutic, adenoidectomy in children in the period of time that their tympanostomy tubes are supposed to be preventing most ear infections anyway.
REFERENCE
- Hammarén-Malmi S, Saxen H, Tarkkanen J, Mattila PS. 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.
Pediatrics. 2005;116
:185
–189
[Abstract/Free Full Text]
PEDIATRICS (ISSN 1098-4275). ©2005 by the American Academy of Pediatrics
CiteULike 
Connotea 
Del.icio.us 
Digg 
Facebook 
Reddit 
Technorati 
Twitter What's this?
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
