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Table of Contents
ORIGINAL ARTICLE
Year : 2018  |  Volume : 20  |  Issue : 2  |  Page : 62-67

Recurrent Tympanostomy Tube Insertion for Chronic Otitis Media with Effusion in Children and the Effect of Concurrent Adenoidectomy on the Outcome.


1 ENT Consultant, Otology and Cochlear Implant Surgeon. Former Head of Cochlear Implant Programme, King Fahad Hospital, Jeddah, Saudi Arabia
2 Otolaryngology Senior Resident, King Abulaziz University Hospital, Jeddah, Saudi Arabia
3 Otolaryngology Resident, Ministry of Health, Jeddah, Saudi Arabia

Date of Web Publication23-Dec-2019

Correspondence Address:
MD Abdulmonem Al-Shaikh
P.O.Box 10462, Jeddah
Saudi Arabia
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/1319-8491.273923

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  Abstract 


Purpose: To determine the incidence of recurrent tube insertion in our region and to study the effect of adenoidectomy in concurrent with 1st tube insertion surgery on the outcome in our target population.
Methods: Retrospective medical chart review was performedfor all children between the age of 6 mo-12 years, who underwent tympanostomy tube insertion due to otitis media 2014 at a referral hospital; Otolaryngology specialized center at King Fahad Hospital, Jeddah, Saudi Arabia. Information regarding initial and repeated tympanostomy tube placement from the medical records. Because of incomplete records for at risk children (children at risk for otitis media with effusion due to presence of bronchial asthma, Down’s syndrome, cleft palate, craniofacial malformation), all at risk children were excluded from our analysis. To study the effect of age and gender on the need for repeated sets of tube insertion, our population was divided in two groups as follow: Group A (children from 6mo to 4years; n= 131) and Group B (children form 4 years and 12 years; n= 232). To study the effect of adenoidectomy in concurrence with first set of tube insertion; our population was divided further into two groups: group I (tube insertion + adenoidectomy) and group II (tube insertion alone).
Results: Three hundred and sixty three children were included in this study. Forty six (12.7%) of the 363 children who underwent initial tympanostomy tube insertion subsequently required another set of tubes insertion as follows: thirty one (8.5%) children required two sets of tube insertion, fourteen (3.9%) required three sets, one child (0.3%) required four sets. Age and gender showed a non significant difference between the two groups, group A and group B(Chi-square =0.73, P = 0.24; Chi-square = 0.28, P= 0.35 respectively). A total of 208 out of 363 patients underwent adenoidectomy in concurrent with the first set of tube insertion. One eighty seven (89.9%) of them required only one set; 21(10.1%) required more than one set. The remaining 155 patients underwent tubes insertion alone, without adenoidectomy. One thirty (83.9%) of them required only one set; 25(16.1%) required more than one set. There were no significant difference between the two groups, group I and group II, in regard to both the need for repeated use and the frequency of tube usage (chi-square = 2.91, 4.71, P = 0.087, 0.195 respectively)
Conclusions: In our region, repeated use of tympanostomy tube insertion for otitis media with effusion carry a considerable incidence. Adenoidectomy performed at the fist set of tube insertion does not show a significant effect on the risk of repeated tube insertion. In as well as potential risk factors for otitis media were extracted addition, age (at the first tube insertion) and gender have no clear role on the need for repeated tube usage.

Keywords: Tympanostomy tube, chronic otitis media with effusion, adenoidectomy, myringotomy


How to cite this article:
Al-Shaikh A, Mandura R, Bafail O. Recurrent Tympanostomy Tube Insertion for Chronic Otitis Media with Effusion in Children and the Effect of Concurrent Adenoidectomy on the Outcome. Saudi J Otorhinolaryngol Head Neck Surg 2018;20:62-7

How to cite this URL:
Al-Shaikh A, Mandura R, Bafail O. Recurrent Tympanostomy Tube Insertion for Chronic Otitis Media with Effusion in Children and the Effect of Concurrent Adenoidectomy on the Outcome. Saudi J Otorhinolaryngol Head Neck Surg [serial online] 2018 [cited 2021 Jun 25];20:62-7. Available from: https://www.sjohns.org/text.asp?2018/20/2/62/273923




  Introduction Top


Otitis media with effusion (OME) is defined as the presence of fluid in the middle ear without signs or symptoms of acute ear infection [1],[2]. It is considered to be a common pediatric disease. Worldwide, the condition carries a health burden as a 90% of children have OME before school age [3] and they tend to develop, on average, 4 episode of OME every year [4)]. Myringotomy with tympanostomy tube insertion as s surgical option for OME treatment is also a common procedure in that particular age group. It is the most common ambulatory surgery performed on children in the United States. By the age of 3 years, nearly 1 of every 15 children (6.8%) will have tympanostomy tubes, increasing by more than 2-fold with day care attendance [5].

Adenoid hypertrophy with resultant  Eustachian tube More Details dysfunction and OME subsequently, is known to be a factor. The primary benefits of adenoidectomy are to reduce failure rate, reduce time with OME, and decrease the need for repeat surgery (e.g. future tubes). These benefits are independent of adenoid volume and may relate to improve microflora of the nasopharynx when adenoid tissue and associated pathologic bacteria (planktonic and in biofilms) are removed. Additionally, contact of adenoid with torus tubarius may be predictive of increase benefit of adenoidectomy [6].

The repeated need for tympanostomy tubes insertion for children with recurrent OME is widely used in our practice. There is no statistically determined incidence of repeated tube use in our region. Furthermore, the affect of adenoidectomy, in concurrence with first set of tube insertion surgery, on the need for repeated tube usage is controversial. Our objectives were 1) To determine the incidence of recurrent tube insertion in our region and 2) To study the effect of adenoidectomy in concurrence with 1st tube insertion surgery on the outcome in our target population.


  Materials and Methods Top


With the approval of our institutional review board, we performed a retrospective, cross sectional analysis of all children between 6 months and 12 years of age who underwent tympanostomy tube insertion for otitis media with effusion; with or without adjuvant procedures by members of our institution between January 2012 and January 2014. Information regarding initial and repeated tympanostomy tube placement as well as potential risk factors for otitis media were extracted from the medical records. Because of incomplete records for at risk children (children at risk for otitis media with effusion due to presence of bronchial asthma, Down’s syndrome, cleft palate, craniofacial malformation), all at risk children were excluded from our analysis. Patients who had undergone adenoidectomy, adenotonsillectomy, or tonsillectomy prior to their first set of tympanostomy tube were also excluded. In addition, children who were lost for follow up visits or had incomplete follow up records were excluded.

The data collected from each record included the patient’s age, sex, date of procedure performed. The data were entered into a Microsoft excel spreadsheet created specifically for this study.

This yielded 363 medical records for review. Of these, forty-six (12.7%) children who underwent initial tympanostomy tube insertion with or without adenoidectomy subsequently required another set of tubes insertion. To study the effect of age and gender on the need for repeated sets of tube insertion, our population was divided in two groups as follow: Group A (children from 6mo to 4years; n= 131) and Group B (children form 4 years and 12 years; n= 232). The procedures performed were classified into two categories: tympanostomy tube insertion alone, and adenoidectomy concurrent with first set of tube insertion. Consequently, to find the effect of adenoidectomy in concurrent with first set of tube insertion on the need for repeated tube insertion, our population (n= 363) divided further into two groups, group I (tube insertion + adenoidectomy n=208) and group II (tube insertion alone n= 155).

Statistical Analysis

Qualitative data were expressed as numbers and percentages. Chi-square test was used as a test of significance for qualitative data. Quantitative data were expressed as mean and standard deviation. Statistical analysis was done by using SPSS(statistical package for social science) version 22.Significance was considered when P value was less than 0.05.


  Results Top


A total of 363 medical records, which met our inclusion and exclusion criteria, were reviewed.

[Table 1] displays age and gender distribution in our population. The age group most likely to undergo tympanostomy tube placement with or without adenoidectomy was > 4 years old. Male gender was reported to be higher incidence than female gender.
Table 1: Age and gender of the studied cases (n=363).

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[Figure 1],further illustrates the age distribution pattern in our population.
Figure 1: Age Distribution Pattern.

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[Figure 2], displays the incidence of recurrent tympanostomy tube insertion in our population. The tube usage reported as either one time usage only or more than one time. It also detailed the number of tube set inserted; one, two, three, and four sets. Forty six children (12.7%) required multiple sets of tube reinsertion for otitis media with effusion. [Table 2]-i shows the results of analysis made to find the effect of child’s age at first tympanostomy tube insertion on the need of repeated tube usage. When Group A (children from 6months to 4years; n= 131) compared to Group B (children form 4 years and 12 years; n= 232), no statically significant difference was identified. In addition, gender effect showed no statically significant difference between the two groups as illustrated in [Table 2]-ii.
Table 2:

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Figure 2: Incidence of Recurrent Tympanostomy Tube Insertion

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[Table 3], displays that the majority (n=187, 89.9 %) of children who underwent adenoidectomy concurrent with first set of tube insertion (group I, n= 208) required only one set of tube insertion; and only 10% (n=21) required multiple tube reinsertion.
Table 3: Incidence of (Group I ) Adenoidectomy in Concurrent with Tympanostomy Tube Insertion (N=208).

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[Table 4], displays the effect of age at initial set of tube insertion performed in concurrent with adenoidectomy(group I) on the outcome, reduction in the need of multiple sets of tube insertion. No statistical significant difference between group A (children from 6mo to 4years; n= 131) and B (children form 4 years and 12 years; n= 232).
Table 4: Incidence of ( Group I) Adenoidectomy in Concurrent with Tympanotomy Tube Insertion and the Effect of Age. (N=208).

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[Table 5], displays the statistical difference between group I (adenoidectomy in concurrent with first set of tube insertion) and group II (tube insertion alone) on overall reduction in need for tube reinsertion. No statically significant difference between the two groups was evident.
Table 5: Incidence of Adenoidectomy in Concurrent with Tympanostomy Tube Insertion ( Group I) Versus Tympanostomy Tube Alone (Groupii).

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  Discussion Top


Although there is much information available worldwide concerning the incidence of recurrent tympanostomy tubes usage, no data at our region could be found.

Regarding the effect of age at initial set of tube insertion performed concurrent with adenoidectomy (group I in our study), there is a wide variability between the studies in regard to the age factor. In one study for instance, universal adenoidectomy concurrent with tympanostomy tube insertion is not recommended as first line surgical treatment in children 2-4 years of age for chronic OME [7]. In contrast, there is a study that showed that adenoidectomy has protective effect in preventing tube re-insertions compared to tympanostomy tubes alone especially for children older than 4 years and who needed tubes for the first time [8]. This finding was supported by another study which showed that tympanostomy tube insertion plus adenoidectomy in children between 4-8 years significantly lowered the overall post-treatment morbidity and number of repeat tympanostomy tube procedures when compared to tube placement alone [9]. In our study, the age at first tube insertion with and without adenoidectomy did not play a role in the outcome.

Multiple studies have shown that the addition of an adenoidectomy to a child’s first tympanostomy tube insertion decreases the need to tube reinsertion up to 50% [1],[2],[3],[4]. Our study showed no statistical difference of concurrent adenoidectomy on overall reduction for tube reinsertion.

There are a number of limitations in our study. First: being a retrospective in nature with all the limitations of retrospective analysis. Second: other factors that might increase the risk for tympanostomy tubes reinsertion were excluded from our study because of incomplete medical records. These include children with bronchial asthma, Down’s syndrome, cleft palate, craniofacial malformation, environmental factors, and day care attendance. Further studies that address these limitations are highly recommended.[13]


  Conclusion Top


In our region, repeated use of tympanostomy tube insertion for otitis media with effusion carries a considerable incidence. Adenoidectomy performed at the first set of tube insertion does not show a significant effect on the risk of repeated tube insertion. In addition, age (at the first tube insertion) and gender have no clear role on the need for repeated tube usage.

Disclaimers: not declared

Source of support: none

Conflicts of interest: none



 
  References Top

1.
Stool SE, Berg AO, Berman S, et al. Otitis Media with Effusion in Young Children: Clinical Practice Guideline No. 12. Rockville, MD: Agency for Healthcare Research and Quality; 1994. AHCPR Publication 94-0622.  Back to cited text no. 1
    
2.
Berkman ND, Wallace IF, Steiner MJ, et al. Otitis Media with Effusion: Comparative Effectiveness of Treatments. Comparative Effectiveness Review No. 101. Rockville, MD: Agency for Healthcare Research and Quality; 2013. AHRQ Publication 13- EHC091-EF.  Back to cited text no. 2
    
3.
Tos M. Epidemiology and natural history of secretory otitis. Am J Otol. 1984;5:459-462.  Back to cited text no. 3
    
4.
Mandel EM, Doyle WJ, Winther B, Alper CM. The incidence, prevalence and burden of OM in unselected children aged 1-8 years followed by weekly otoscopy through the “common cold’' season. Int J Pediatr Otorhinolaryngol. 2008;72:491-499.  Back to cited text no. 4
    
5.
Kogan MD, Overpeck MD, Hoffman HJ, Casselbrant ML. Factors associated with tympanostomy tube insertion among pre- school-aged children in the United States. Am J Public Health. 2000;90(2):245-250.  Back to cited text no. 5
    
6.
Nguyen LHP, Manoukian JJ, Yoskovitch A, Al-Sebeih KH. Adenoidectomy: selection criteria for surgical cases of otitis media. Laryngoscope. 2004;114:863-866.  Back to cited text no. 6
    
7.
M. Casselbrantetal. Adenoidectomy for otitis media with effusion in 2 to 3 year old children. Int J Pediatr Otorhinolaryngol. 2009 Dec;73(12): 1718-1724.  Back to cited text no. 7
    
8.
M. Wang et al. The protective effect of adenoidectomy on pediatric tympanostomy tube reinsertions: A population-based birth cohort study. https://doi.org/10.1371/journal.pone.0101175.  Back to cited text no. 8
    
9.
G Gates et al. Effectiveness of adenoidectomy and tympanostomy tubes in the treatment of chronic otitis media with effusion. N Engl J Med.1987;317 :1444-1451.  Back to cited text no. 9
    
10.
D Gleinser, H Kriel, S Mukerji, The relationship between repeat tympanostomy tube insertion and adenoidectomy. Int J Pediat Otolaryngol. 2011;75:1247-1251.  Back to cited text no. 10
    
11.
M Boston, J McCook, B Burke et al,.incidence of and risk factors for additional tympanostomy tube insertion in children. Arch Otolaryngol Head Neck Surg. 2003;129 (3) : 293-296.  Back to cited text no. 11
    
12.
P C Coyte, R Crocford, W Mclsaac, et al., The role of adjuvant adenoidectomy and tonsillectomy in the outcome of the insertion of tympanostomy tubes. N Engl J Med. 2001;344 : 1188-1195.  Back to cited text no. 12
    
13.
A L Kadhim, K Spilsbury, J B Semmens, et al., Adenoidectomy for middle ear effusion: a study of 50,000 children over 24 years, Laryngoscope.2007; 117 (3) :27-433.  Back to cited text no. 13
    


    Figures

  [Figure 1], [Figure 2]
 
 
    Tables

  [Table 1], [Table 2], [Table 3], [Table 4], [Table 5]



 

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