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ANORL-814; No. of Pages 4 ARTICLE IN PRESS

European Annals of Otorhinolaryngology, Head and Neck diseases xxx (2018) xxx–xxx

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Original article

Relation between adenoid size and otitis media with effusion

L. Skoloudik a , D. Kalfert b,∗ , T. Valenta a , V. Chrobok a
a
Department of Otorhinolaryngology and Head and Neck Surgery, University Hospital Hradec Kralove, Charles University, Faculty of Medicine in Hradec
Kralove, Hradec Kralove, Czech Republic
b
Department of Otorhinolaryngology and Head and Neck Surgery, University Hospital Motol, Charles University, First Faculty of Medicine, Prague, Czech
Republic

a r t i c l e i n f o a b s t r a c t

Keywords: Aims: This study compares the efficacy of adenoidectomy on otitis media with effusion (OME) in patients
Otitis media with effusion with different size of adenoids and the connection between differently sized adenoids and middle ear
Adenoid size effusion.
Adenoidectomy
Material and methods: Children with a history of at least 3 months’ OME underwent adenoidectomy
Myringotomy
and myringotomy without the insertion of a tympanostomy tube. Treatment assignment was strati-
fied by adenoids’ size causing choanal obstruction (grade I-III) and according to Eustachian tube ostium
obstruction (grade A–C). The subjects were followed for 12 months.
Results: Adenoidectomy was significantly more effective in children with adenoids in contact with torus
tubarius (grade B, C) compared to those with small adenoids without contact (P < 0.001). The volume of
the adenoids was irrelevant (P = 0.146). The size of adenoids did not affect the viscosity of the middle ear
secretion. The distribution of mucous and serous secretion was not dependent on the size of adenoids;
the efficacy of adenoidectomy was 82% in mucous as well as serous secretion.
Conclusion: The relation between adenoids and torus tubarius is more important than the volume of the
adenoids. The viscosity of middle ear fluids (serous or mucous) did not influence the rate of treatment
efficacy.
© 2018 Elsevier Masson SAS. All rights reserved.

1. Introduction
Otitis media with effusion (OME) is characterized by a non-
purulent secretion (serous or mucous) without signs or symptoms
of acute ear infection, potentially leading to hearing loss or long-
term sequelae and has a negative impact on speech development
and behaviour [1]. OME is a very common disease; approximately
90% of children (80% of individual ears) have OME at some point
before reaching school age, often between 6 months and 4 years
of age. Many episodes resolve spontaneously within 3 months,
but 30% to 40% of children have recurrent OME, and 5% to 10%
of the episodes last 1 year or longer [2,3]. An important factor
in the etiopathology of OME is a poor function of the Eustachian
tube. Although the influence of adenoids on the Eustachian tube
is well known, the guidelines for OME treatment generally prefer
myringostomy over adenoidectomy. In 1994, The American Agency
for Health Care Policy and Research published the guidelines for the
treatment of otitis media with effusion, which recommended the
insertion of tympanostomy tubes as a first choice surgery treat-
ment. Consequently, adenoidectomy (AT) was not recommended
for initial OME surgery unless a distinct indication exists, such as
adenoiditis, postnasal obstruction, or chronic sinusitis. However,
several studies reported the efficacy of adenoidectomy and dis-
cussed AT as a first-line therapy for OME. The question is whether
the efficacy of AT depends on the size of adenoids. The guidelines
for OME treatment recommend the same treatment strategy for
patients with mucous middle ear secretion as well as serous secre-
tion. Could the viscosity of middle ear secretion be an important
factor in AT efficacy on OME?
The main objective of the present study was to compare the
efficacy of AT on OME in patients with different size of adenoids. The
secondary objective was to assess the efficacy of adenoidectomy in
patients with different viscosity of middle ear effusion.

∗ Corresponding author. Department of Otorhinolaryngology and Head and Neck

2. Materials and methods
Surgery, University Hospital Motol, Charles University, First Faculty of Medicine,
V Uvalu 84, 150 06 Prague, Czech Republic. Children from 2 to 16 years old with a documented history of
E-mail address: david.kalfert@email.cz (D. Kalfert). OME of at least 3 months were considered eligible for the study. A

https://doi.org/10.1016/j.anorl.2017.11.011
1879-7296/© 2018 Elsevier Masson SAS. All rights reserved.

Please cite this article in press as: Skoloudik L, et al. Relation between adenoid size and otitis media with effusion. European Annals of
Otorhinolaryngology, Head and Neck diseases (2018), https://doi.org/10.1016/j.anorl.2017.11.011
G Model
ANORL-814; No. of Pages 4 ARTICLE IN PRESS
2 L. Skoloudik et al. / European Annals of Otorhinolaryngology, Head and Neck diseases xxx (2018) xxx–xxx
standardized history was obtained for each child, composed of an
ear, nose, and throat examination, including endoscopic examina-
tion of nasopharynx, tympanometry and pure tone audiometry in
the case of operated children. The history of ear disease, includ-
ing the duration of OME at entry, was obtained from medical
records and case histories. The children underwent adenoidec-
tomy under endoscopic view and myringotomy under microscopic
view at the ENT Department of the University Hospital in Hradec
Kralove, Czech Republic. All operations were performed under gen-
eral anesthesia. The classification of adenoids and type of middle
ear secretion were qualified during surgery. The children were
excluded if presenting any of the following conditions: recent
acute infection, previous ear surgery including ventilation tube
insertion, medical conditions with a predisposition for OME, such
as cleft palate, Down syndrome, congenital malformations of the
ear; cholesteatoma or chronic mastoiditis; acute or chronic dif-
fuse external otitis; perforation of the tympanic membrane; or if
they had incomplete records. The subjects were observed every
3 months, at which time an examination of the ears, nose and
throat including otoscopy, tympanometry and audiometry were
performed during 1 year or A/C1 tympanometry curves occurred.
OME was defined as the presence of fluid in the middle ear with-
out signs or symptoms of acute ear infection. The determination of
the presence or absence of effusion was based on otoscopy and
tympanometry and proved by myringotomy during surgery. Tym-
panometry testing was performed during the scheduled visits using
the Siemens SD 30 tympanometer (Danplex, Copenhagen, Den-
mark). The test included an estimation of the acoustic equivalent
volume of the external ear canal and a tympanogram from which
we estimated and determined the peak compensated static acoustic
admittance, tympanometric width, and tympanometric peak pres-
sure. Tympanometry results were categorized as follows: Curve A:
tympanometric width (TW) ≤ 100 daPa; Curve C1: TW > 100 daPa
and ≤ 200 daPa; Curve C2: TW > 200 daPa; Curve B: flat curve with-
out peak.
The OME entry diagnosis required a tympanometry curve C2
or B and an otoscopical observation corresponding with OME. The
diagnosis and type of fluids were confirmed by myringotomy dur-
ing surgery under general anesthesia. The disease was considered
as healed if the subject showed a tympanometric curve A or C1
(TW ≤ 200 daPa) and corresponding otoscopical observation (with-
out fluid levels or bubbles) during the first year after surgery.
The grading system used for adenoid hypertrophy was based on
the classification described by Boleslavska et al. [4]. This classifica-
tion considers the anatomical relationships between the adenoid
tissue, choanal obstruction and torus tubarius. In this regard and
according to choanal obstruction, adenoids are differentiated in
three grades:
• grade I: adenoid tissue filling less than one third of vertical por-
tion of the choanae;
• grade II: adenoid tissue filling from one third to two thirds of the
choanae;
• grade III: adenoid tissue filling more than two thirds of the
choanae.
The condition of the nasopharyngeal orifice of the Eustachian
tube was also described and differentiated into 3 types relat-
ing to the condition of adenoid tissue. The condition of the
nasopharyngeal orifice of the Eustachian tube was also described
and differentiated into 3 types relating to the condition of ade-
noid tissue. The condition of the nasopharyngeal orifice of the
Eustachian tube was also described and differentiated into 3 types
relating to the condition of adenoid tissue. The condition of the
Please cite this article in press as: Skoloudik L, et al. Relation between adenoid size and otitis media with effusion. European Annals of
Otorhinolaryngology, Head and Neck diseases (2018), https://doi.org/10.1016/j.anorl.2017.11.011
nasopharyngeal orifice of the Eustachian tube was also differenti-
ated into 3 grades relating to the condition of adenoid tissue:
• grade A: adenoid tissue not in contact with the torus tubarius;
• grade B: adenoid tissue in contact with the torus tubarius without
complete covering;
• grade C: adenoid tissue completely covering the torus tubarius.
The classification of the adenoids and type of fluids in the middle
ear were assessed during surgery.
The surgical procedures were performed under general anesthe-
sia on an inpatient basis. The adenoidectomy was performed under
endoscopic view using curette and, in the case of severe bleeding,
with electrocautery hemostasis. The myringotomy was performed
under microscopy in the inferior portion of the pars tensa, followed
by aspiration of the middle ear fluid. Unless otherwise strictly war-
ranted, the use of antibiotics was not routine.
The inclusion criteria for the study were as follows: children
from 2 to 16 years old, a documented history of OME of at
least 3 months, endoscopic examination of nasopharynx proving
adenoids, tympanometry with B/C2 tympanometric curve before
operation, serous or mucous secretion in tympanic cavity (proven
by myringotomy). The history of ear disease, including the dura-
tion of OME at entry, was obtained from medical records and case
histories. The children underwent adenoidectomy under endo-
scopic view and myringotomy under microscopic view at the ENT
Department of the University hospital in Hradec Kralove, Czech
Republic. All operations were performed under general anesthesia.
The classification of adenoids and type of middle ear secretion were
qualified during surgery. The children were excluded if presenting
any of the following conditions: recent acute infection, previous
ear surgery including ventilation tube insertion, medical condi-
tions with a predisposition for OME, such as cleft palate, Down
syndrome, congenital malformations of the ear; cholesteatoma or
chronic mastoiditis; acute or chronic diffuse external otitis; per-
foration of the tympanic membrane; or if they had incomplete
records. The subjects were observed every 3 months, at which time
an examination of the ears, nose and throat including otoscopy,
tympanometry and audiometry were performed during 1 year.
The present study was conducted between 2010 and 2014 (for
60 months). During this period, a total of 559 children (320 boys,
239 girls) with OME underwent adenoidectomy with myringo-
tomy. At the predetermined end of the study 423 children (275
boys, 148 girls) from 2 to 16 years old with complete follow-up
were included. The mean age of subjects was 5 years, median 5
years. Myringotomy showed middle ear fluid in 675 ears.
The spontaneous healing of the tympanic membrane was
observed 2 weeks after myringotomy in all patients. No serious
difficulty during general anesthesia was noted in the study group.
We observed postoperative bleeding in 2 children (0.4%). One child
had early postoperative bleeding treated by electrocautery under
general anesthesia; another child was admitted 6 days after surgery
for late bleeding requiring electrocautery treatment as well.
The statistical analyses were performed using the SAS 9.2 pro-
gram (Statistical Analysis Software release 9.2, SAS Institute Inc.,
Cary, North Carolina, USA). The results were statistically evaluated
by the Pearson’s Chi-Square Test and Fisher’s Exact Test. P-values
less than 0.05 were considered to be statistically significant. The
data are presented according to the number of ears with OME. The
present analysis is the result of a 1 year follow-up.
The main goal of the study was to compare the efficacy of ade-
noidectomy on OME in children with different size of adenoids. We
statistically evaluated the results of treatment in children with dif-
ferent volume of adenoids (grades I, II III) and different relation of
adenoids to the Eustachian tube orifice (grades A, B, C). In order to
eliminate other variables that may influence success of treatment
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Table 1
Adenoids size and effect of adenoidectomy; postoperative tympanogram.
Grade of adenoids I II + III
A/C1 tympanogram (success proportion) 82% 88%
Sample size 98 577
Sample odds ratio 0.62
P-value 0.146a
a a
Fisher’s Exact Test (statistical analysis according to number of ears).
Fig. 1. Proportion of adenoids grades and viscosity of middle ear fluid.
the age and gender were evaluated. The secondary objective was
to assess the efficacy of adenoidectomy in patients with different
viscosity of middle ear effusion. We statistically evaluated the effi-
cacy of AT in patients with mucous middle ear secretion compared
to serous secretion.
3. Results
Adenoidectomy was significantly more effective in children
with adenoids in contact with the torus tubarius (grade B, C) when
compared to small adenoids (grade A) without contact (P < 0.001).
The dependency of adenoids size and healed OME is given in Table 1.
Adenoidectomy efficacy was 89% in children with grade B or C ade-
noids whereas it was only 68% in children with grade A adenoids.
The adenoids’ volume was not as relevant as the contact with the
torus tubarius. Adenoidectomy efficacy was 82% in children with
grade I adenoids and 88% in grade II and III adenoids. The difference
was not statistically significant (P = 0.146).
Myringotomy proved predominantly mucous secretion in 425
ears (63%), whereas serous secretion was found in 250 ears (37%).
The distribution of serous and mucous secretion among different
adenoids’ size groups is shown in Fig. 1. No significant difference
was observed when comparing adenoids’ size and secretion viscos-
ity.
The treatment efficacy was evaluated according to the viscos-
ity of middle ear secretion (Table 2). Mucous secretion was more
frequent than serous and was observed in 63% of patients. Chil-
dren with mucous secretion improved to an A or C1 tympanometric
curve in 82% of cases; the same efficacy was observed in children
with serous secretion (P = 1).
The statistical evaluation of other values (age, gender) is given
in Table 3.
Please cite this article in press as: Skoloudik L, et al. Relation between adenoid size and otitis media with effusion. European Annals of
Otorhinolaryngology, Head and Neck diseases (2018), https://doi.org/10.1016/j.anorl.2017.11.011
3
Table 2
The effect of treatment according to the viscosity of the middle ear fluids; postop-
erative tympanogram.
A B+C
Mucous OME Serous OME
68% 89%
68 607 Number of ears 425 (63%) 250 (37%)
0.26 A/C1 tympanogram (success proportion) 349 (82%) 208 (82%)
< 0.001a P-value P = 1a
Fisher’s Exact Test (statistical analysis according to the number of ears).
4. Discussion
In 1994 the US government Agency for Health Care Policy
and Research published the guidelines for the treatment of OME
[1]. Adenoidectomy was not recommended as first-line surgical
treatment of OME. More recent guidelines [5,6] make a clear
distinction between different indications of adenoidectomy as a
function of age: in a child ≤ 4 years old, adenoidectomy should
not be recommended for OME unless a distinct indication exists
(nasal obstruction, chronic adenoiditis); in a child ≥ 4 years old,
tymnpanostomy tubes, adenoidectomy, or both can be performed
for OME. The lack of evidence for or against the efficacy of ade-
noidectomy, with “the risk of postoperative bleeding”, leads to the
preference of ventilation tubes over adenoidectomy [4–6]. How-
ever, the etiopathology of OME has been extensively studied in the
last 10 years. Bacterial colonization and biofilm formation, viral
infections, allergy and immunological factors could contribute to
the development of OME; however, the most important factors
are often mechanical or caused by Eustachian tube dysfunction
[4,6–11]. Recent studies, including systemic reviews, demonstrate
the high efficacy of adenoidectomy [12,13]. The rationale for the
use of adenoidectomy in the treatment of OME includes the poten-
tial improvement of the Eustachian tube function [14,15]. Adenoids
may compress or obstruct the Eustachian tube ostium, thereby
causing middle ear underpressure and subsequent effusion forma-
tion. This mechanism has been supported by a case report of OM
in which manometrically proven active and passive ET obstruction
was relieved by adenoidectomy [15]. In our study, the efficacy of
adenoidectomy with paracentesis without insertion of ventilation
tubes was 87%. This means that 87% of children with OME under-
going adenoidectomy had an unobstructed middle ear without
effusion in the first year after surgery. The quality of adenoidec-
tomy was rapidly improved using endoscopical control. Regmi
et al. reported a rigid endoscopic evaluation of the nasophar-
ynx after conventional adenoid curettage without endoscope and
endoscopy-assisted adenoidectomy. Incomplete removal of ade-
noid tissue along the Eustachian tube opening was observed in 63%
of patients compared to 11% cases after rigid endoscopy-assisted
adenoidectomy [16]. Bross-Soriano et al. found residual adenoid
tissue involved in the pharyngeal part of the Eustachian tubes in
45% of patients after conventional “blind” adenoid curettage [17]. In
our study, all adenoidectomies were performed under endoscopical
view. This could explain the very high efficacy of adenoidectomy in
the treatment of OME. Furthermore, endoscopy provides a precise
control over bleeding during surgery, reducing unnecessary trauma
and improving safety.
Table 3
The influence of age and gender on treatment success.
Grade of adenoids I II + III A B+C
Age (mean; years) 5.6 ± 2.3 5.0 ± 2.0 5.4 ± 2.1 5.1 ± 2.0
P-value 0.0217a 0.245a
Sex (boys/girls; %) 67/33 62/38 65/35 62/38
P-value 0.435a 0.765a
a
Pearson’s Chi2 test (statistical analysis according to the number of patients).
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4 L. Skoloudik et al. / European Annals of Otorhinolaryngology, Head and Neck diseases xxx (2018) xxx–xxx
The relationship between adenoids’ size and OME has been
reported only in a few studies comparing the volume of adenoids
and the benefits of adenoidectomy. Maw et al. reported a better res-
olution rate for OME after adenoidectomy in children with larger
adenoids compared to children with smaller adenoids [18]. How-
ever, others have shown no association between the volume of
the adenoids and surgical procedure outcome [19,20]. Wright et al.
reported the correlation between the adenoids’ position and OME.
An association was found between lateral adenoids encroaching
upon the ET orifice and OME [21]. Our study shows that the rela-
tion between adenoids and torus tubarius is more relevant than
the volume of adenoids. The effect of the adenoidectomy is sig-
nificantly higher in patients with adenoids in contact with torus
tubarius. The grading of adenoids’ volume (I-III) resulted irrelevant.
Based on our results, we hypothesize that the extent and loca-
tion of hypertrophic adenoid tissue plays a role in the causation
of OME, specifically when concerning the contact of adenoid tissue
to torus tubarius as more relevant than the volume of the adenoid
tissue.
The middle ear effusion has different viscosities, from serous
to mucous secretion. Mucous secretion is often considered more
serious for the patient. We observed mucous secretion in 65% of
children with OME. We did not observe any relationship between
middle ear viscosity and adenoids’ grade. The outcome of ade-
noidectomy did not depend on effusion viscosity and the treatment
efficacy rate was similar in children with mucous and serous secre-
tion.
5. Conclusion
Adenoidectomy is significantly more effective in children with
adenoids in contact with torus tubarius when compared to small
adenoids without contact. However, the adenoids’ volume is not
relevant. The viscosity of middle ear fluids (serous or mucous) did
not influence the efficacy rate of adenoidectomy.
Disclosure of interest
The authors declare that they have no competing interest.
Acknowledgements
This work was supported by MH CZ-DRO (UHHK, 00179906).
We thank Dr. Eva Cermakova for statistical analysis and Govin-
dan Dayanithi for English correction service. Thanks also to Dr.
Daniel Díaz, Ph.D. for his kind assistance in proofreading this
manuscript.
Please cite this article in press as: Skoloudik L, et al. Relation between adenoid size and otitis media with effusion. European Annals of
Otorhinolaryngology, Head and Neck diseases (2018), https://doi.org/10.1016/j.anorl.2017.11.011
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