Am J Otolqngol

1020km3,1989

Effect of Adenoidectomy on
Otitis Media With Effusion,
Tubal Function, and Sinusitis
HARUOTAKAHASHI, MD,* AKIHIKO FUJITA,MD,t ANDIWAOHONJO,MD

Three clinical studies were performed to investigate the effects of adenoidectomy on otitis
media with effusion (OME), especially with regard to eustachian tube (ET) disfunction and
sinusitis, which often accompanies OME. In the first study, the audiograms, tympano-
grams, and ET ventilatory functions of 78 adenoidectomized patients (121 ears) and 54
non-adenoidectomized patients (63 ears) were compared over 6 months. The audiograms
and tympanograms of the adenoidectomized group showed significant improvement;
however, no difference in passive tubal opening pressure was noted despite an improve-
ment in positive pressure equalizing function observed in the adenoidectomized group at
6 months after the operation. In the second study, tubal passive resistance (PR) and the
ratio of passive resistance to active resistance (PfUAR) were compared before and 1
month after adenoidectomy using the forced response test (12 subjects, 12 ears). Neither
PR nor PFUAR had significantly improved after the operation. In the third study, sinusitis
improvement in 45 adenoidectomized patients 6 months after the operation was evaluated
in comparison with 33 non-adenoidectomized patients. This condition was found to have
improved significantly in the adenoidectomized group. Overall, adenoidectomy appeared
effective in reducing the incidence of OME and sinusitis, and in improving the active
ventilatory function of the ET without causing changes in the tubal passage. It is conceiv-
able that tubal active ventilatory function was improved due to a reduction of inflamma-
tion and pollution around the nasopharynx by adenoidectomy, and that the effect of
adenoid mass on the ET is minimal. AM J OTOLARYNGOL10:208-213. 0 1989 by W.B.
Saunders Company.
Key words: adenoid, otitis media with effusion, tubal function, sinusitis.

In 1870, Meyer’ detailed the pathophysiologic nasopharynx and ET function pathophysiologi-

effects of adenoidectomy on otitis media with
effusion (OME). Although many authors’-7 have
investigated this issue since Meyer, it still re-
mains controversial whether the adenoids have
an important effect on OME, and whether ade-
noidectomy is effective in treating OME or im-
proving eustachian tube [ET) function.
The disagreement seems to be due to the fol-
lowing: (1) it is difficult to adequately study the
Received September 11,1988, from the Department of Oto-
laryngology, Kyoto University, Japan. Accepted for publica-
tion November 27, 1988.
* Present address: Department of Otolaryngology, Univer-
sity of Pittsburgh School of Medicine, Eye & Ear Institute of
Pittsburgh, Pittsburgh, PA 15213.
t Present address: Department of Otolaryngology, Kurash-
iki Central Hospital, Miwa, Kurashiki, 710 Japan.
Address correspondence and reprint requests to Haruo Ta-
kahashi, MD, Department of Otolaryngology, Faculty of Med-
icine, Kyoto University, Sakyo-ku, Kyoto 606, Japan.
Q 1989 by W.B. Saunders Company.
0196-0709/8911003-0007$5.oo/o
tally in young children, who comprise the ma-
jority of individuals with adenoid vegetation; (2)
the actual effects of adenoidectomy on OME are
difficult to assess because OME frequently re-
solves without intervention; (3) in most studies,
sinusitis, which is often accompanied by OME
and adenoid vegetation, was not taken into con-
sideration; and (4) indications and procedures
for adenoidectomy vary among investigators.
To clarify the relationship between the ade-
noids and OME, especially with regard to ET
function and sinusitis, we undertook three clin-
ical studies.
MATERIALS AND METHODS
Study No. 1
The participants in this study were 132 chil-
dren aged 4 to 7, with 184 ears with chronic
OME. All were found to have adenoid vegetation

208
TAKAHASHI ET AL
by endoscopy or x-ray, and to have hearing
losses of 20 dB or more. Ventilation tubes were
inserted in all 184 ears, and, concurrently,
randomly selected subjects (121 OME ears) also
underwent adenoidectomy under general anes-
thesia.
All children, in both the adenoidectomized
group (78 children, 121 ears) and non-
adenoidectomized group (54 children, 63 ears),
were followed by audiograms, tympanograms,
and tests of ET ventilatory function (including
measurements of tubal opening pressure [OP]
and positive pressure [PP] equalizing function)
for 6 months after the operation. The normal
range of OP and the criteria for good or poor PP
equalizing function were defined using data
from 33 ears with traumatic perforations of the
eardrum.* Audiograms and tympanograms were
compared for ears in both groups from which the
ventilation tubes had extruded within 6 months.
ET ventilatory function was compared for ears in
which the ventilation tubes were still in position
6 months after the operation. The natural extru-
sion rate for ventilation tubes at 6 months after
the operation was 45.5% (55 of 121 ears) in the
adenoidectomized group and 52.4% (33 of 63
ears) in the non-adenoidectomized group.
Study No. 2
The subjects for this study were 12 children,
aged 4 to 9 years, with adenoid vegetation. One
ear with chronic OME was studied in each child.
Passive resistance (PR) of the eustachian tube
n Pre. lwk
Figure 1. Average hearing 20
levels of the adenoidecto-
mized group. Dashed lines
indicate the hearing levels af-
ter the ventilation tubes had
extruded. 30
50
dB
and the ratio of passive tubal resistance to active
tubal resistance (PIUAR) were determined using
78 the forced response test (FRT)“” both before
and 1 month after adenoidectomy, and the re-
sults were compared.
Study No. 3
In 78 children with chronic OME, adenoid
vegetation, and sinusitis diagnosed by x-ray
(Water’s view), the severity of the cloudiness of
the maxillary sinus was graded as follows: grade
0, normal; grade 1, marginal cloudiness (mu-
cosal hypertrophy) of the sinus; grade 2, air
space only around the sinus ostium; and grade 3,
diffuse cloudiness of the sinus.
The total score for both maxillary sinuses was
recorded both before and 6 months after the op-
eration for 45 adenoidectomized subjects, and
simultaneously for 33 the non-adenoidecto-
mized subjects. An improvement of two or more
grades was regarded as a substantial improve-
ment in the sinusitis.
RESULTS
Study No. 7
Figure 1 shows the average hearing level at
500 Hz, 1,000 Hz, and 2,000 Hz for adenoidec-
tomized children whose ventilation tubes had
extruded within 6 months. Good hearing levels
were maintained even after the ventilation tubes
had extruded (indicated by dashed lines). Figure
2M 4M 6M
17.3dB
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Number 3
May 1989
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 EFFECT OF ADENOIDECTOMY ON OME

Figure 2. Average hearing

levels of the non-adenoidec-
tomized group. Dashed lines
indicate the hearing levels af-
27.5dB ter the ventilation tubes had
extruded.

50L
dB

2 shows the results of the non-adenoidectomized
group. It is evident that hearing levels gradually
deteriorated within 4 and 6 months as the tubes
extruded. The average hearing gain for the two
groups are juxtaposed in Fig 3. In the adenoidec-
tomized group, the average hearing gain was
17.6 dB, while in the non-adenoidectomized
group the average gain at the end of 6 months
was only 3.8 dB.
Tympanograms were compared for the 55 ears
in the adenoidectomized group and 33 ears in
the non-adenoidectomized group 6 months after
the operation. All of these ears had type B tym-
panograms before the operation. After 6 months,
the proportion of ears with type B tympano-
grams in the adenoidectomized group decreased
to 28%, while 52% of the ears in the non-
adenoidectomized group still had type B tym-
panograms. The difference was statistically sig-
nificant (x2 test; P < .05; Fig 4).
In most of the ears in both groups, OPs were
within the normal range at 2 and 6 months after
the operation (Fig 5); there was no statistically
significant difference.
However, with regard to PP equalizing func-
tion, ears in the adenoidectomized group
showed significantly better results at 1 week and
6 months after the operation than did those in
the non-adenoidectomized group (x2 test; P <
.05 and P < .Ol; Fig 6).
Study No. 2
Neither PR nor PIUAR improved significantly
1 month after adenoidectomy in the 12 ears
tested (paired t test; Figs 7 and 8).
Study No. 3

010 Adenoidectomized (31 ears) In the adenoidectomized group, sinusitis im-

dS XmuI)( Non-Adenoidectomized (24 ears) proved in 25 of the 45 patients examined (56%)
3o t
Adenoidectomized
(55 ears)

160%
American P<O.O5
Journal Pre. lwk 2M 4M 6M Figure 4. Tympanograms of the adenoidectomized and
of Figure 3. The average hearing gains for both the adenoidec- non-adenoidectomized groups 6 months after the operation.
tomized and non-adenoidectomized group. A, B, and C indicate the type of tympanogram.
Otolaryngology

210
TAKAHASHI ET AL

Gmonths postop.
&u
.

. .
600-

500- m
Figure 5. Passive OPs of ET
in the adenoidectomized and
the non-adenoidectomized
groups at 2 and 6 months af-
ter the operation. Percents are
those in the normal range at
each time for each group.

0'
Adenoid- Non- Adenoid- Non-
ectomized Adenoid- ectomized Adenoid-
ectomized ectomized
(61 ears) (42 ears) (58 ears) (25 ears)

6 months after adenoidectomy, while only eight

of 33 patients (24%) in the non-adenoidecto-
mized group experienced improvement in sinus-
itis. This difference was statistically significant
(x2 test; P < .Ol;Fig 9).

DISCUSSION

In most of the studies investigating the effect

of adenoidectomy on OME, the follow-up peri-
ods were 1 or 2 years or more.2-5 In this study, it
was limited to 6 months to eliminate the effect of
the natural resolution of OME and to clarify the
effects of adenoidectomy. Furthermore, adenoid-
lwk 2M 4M 6M
, ectomy was performed under general anesthesia
O-
by two surgeons in an effort to eliminate varia-
v 32% 36% 39% 30% tion in the operative procedure.
E
In study no. 1, audiograms and tympanograms
were compared for the ears in the two groups
from which the ventilation tubes had extruded
naturally within 6 months. Eustachian tube
functions were examined through the ventila-
tion tubes in those ears in both groups in which
ventilation tubes were still in position 6 months
._” after the operation. Because natural extrusion
% (50) ( 42 > ( 36 > ( 30 > rates were similar in the two groups (45.5% and
52.4%),the distribution of adenoidectomy can
P< 0.05 P< 0.01 be considered random with respect to ventila-
Figure 6. Positive pressure equalizing function of the ET for tion tube patency. From the results of the audio-
the adenoidectomized and non-adenoidectomized groups at Volume 10
I week, z months, 4 months, and 6 months after the opera- grams and tympanograms, it is clear that ade- Number 3
tion. noidectomy is effective in treating OME. May 1989
211
 EFFECT OF ADENOIDECTOMY ON OME

(mmHnOlcclmin)
N.S.

l! j- 2

l(I-

ci-
CI

N.S.
0
r3 I 1 Pre op. Post op.
Pre op. Postop. Figure 8. Passive tubal resistance/active tubal resistance be-
fore and 1 month after adenoidectomy.
Figure 7. Passive tubal resistance before and 1 month after
adenoidectomy.

Positive pressure equalizing function was sig- the PP equalizing function did not improve sig-
nificantly improved in the adenoidectomized nificantly until 6 months after adenoidectomy.
group both 1 week and 6 months after the oper- Our clinical observation showed that 99 of 126
ation. These results are similar to those of Blue- OME children (78.6%) had sinusitis. Moreover,
stone et al.‘l Although postoperative administra- most of these children’s ET pharyngeal orifices
tion of antibiotics might have contributed to the were found to be obstructed by mucus or puru-
improvement in ET function 1 week after the lent nasal discharge, which prevented transtubal
operation, the improvement observed 6 months ventilation of the middle ear. The results of
after the operation is considered to be substan- study no. 3, in which the effect of adenoidecto-
tially due to the effects of adenoidectomy. If this my on sinusitis were studied, showed that ade-
improvement had been due simply to relief of ET noidectomy significantly improves sinusitis
compression by adenoid tissue, it would have
been observed sooner after adenoidectomy.
In study no. 2, more detailed and direct anal-
yses of changes in tubal function were per-
formed using FRT, by which substantial tubal
passive and tubal active opening ability can be
detected by eliminating the influence of mucus
and surface tension of the ET. That PR did not
decrease after adenoidectomy agreed well with
measurements of OP; this indicates that there
was no obvious compression of the ET by the Adenoidectomized Non-adenoidectomized
adenoid tissue. That PR/AR, which indicates
American (45 cases) (33 cases)
Journal
substantial active tubal opening ability, did not
Figure 9. Improvement of sinusitis in adenoidectomized
of
show significant improvement 1 month after ad- and non-adenoidectomized groups 6 months after the oper-
Otolaryngology
enoidectomy does not contradict the finding that ation.

212
TAKAHASHI ET AL
within 6 months, by which time active ventila-
tory function of the ET was found to be improved
as well.
In conclusion, we found that adenoidectomy
is effective in the treatment of OME and sinus-
itis, and also improves the active ventilatory
function of the ET; and that the pathologic influ-
ence of the adenoids on middle ear diseases, es-
pecially OME, is not considered to be due to the
effect of tissue mass on the ET, but rather as a
source of inflammation and pollution in the na-
sopharynx.
References
1. Meyer W: On adenoid vegetation in the nasopharyngeal
cavity. Med Surg Trans (London) 1870;53:191-215
2. Mackee WJE: A controlled study of the effects of tonsil-
lectomy and adenoidectomy in children. Br J Prev Sot
Med 1963; 17:49-46
3. Rynnel-Dagoo B: Effects of adenoidectomy: A controlled
two-year follow-up. Ann Otol Rhino1 Laryngol 1978;
87~272-278
4. Roydhouse N: Adenoidectomy for otitis media with ef-
fusion. Ann Otol Rhino1 Laryngol 1980; 89:312-315
(suppl68)
5. Fiellau-Nikolajsen M: Tympanometry and secretory oti-
tis media. Acta Otolaryngol 1983; 394:1-73 (suppl)
6. Maw AR: Chronic otitis media with effusion (glue ear)
and adenotonsillectomy: Prospective randomized
controlled study. Br Med J 1983; 287:1586-1588
7. Bulman CH, et al: A prospective randomized controlled
trial of adenoidectomy vs grommet insertion in the
treatment of glue ear. Clin Otolaryngol 1984; 9:87-75
8. Takahashi H, et al: Fundamental deficits in eustachian
tube function in patients with otitis media with effu-
sion. Arch Otolaryngol [submitted)
9. Cantekin EI, et al: Normal and abnormal middle ear ven-
tilation. Ann Otol Rhino1 Laryngol 1977; 86:1-15
(suppl411
10. Cantekin EI, et al: Airflow through the eustachian tube.
Ann Otol Rhino1 Laryngol 1979; 88:603-612
11. Bluestone CD, et al: Certain effects of adenoidectomy on
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