|Year : 2021 | Volume
| Issue : 1 | Page : 12-17
Impact of adenoidectomy/adenotonsillectomy on hearing threshold and middle ear pressure
K S Gangadhara Somayaji1, A Fathima2, S Saimanohar1
1 Department of ENT, Yenepoya Medical College, Mangalore, Karnataka, India
2 Department of Head Neck Surgery, Yenepoya Medical College, Mangalore, Karnataka, India
|Date of Submission||02-May-2020|
|Date of Acceptance||05-Feb-2021|
|Date of Web Publication||03-Jul-2021|
Dr. K S Gangadhara Somayaji
Department of ENT, Yenepoya Medical College, Mangalore - 575 018, Karnataka
Source of Support: None, Conflict of Interest: None
Introduction: Enlarged adenoids may cause obstruction of the nasopharynx and blockage of the Eustachian tube and thereby preventing ventilation of the middle ear – mastoid system. It can also act as a reservoir for bacteria causing frequent middle ear infections. This study was done to assess the middle ear pressure (MEP) and hearing threshold before and after adenoidectomy or adenotonsillectomy. Materials and Methods: Fifty-four children aged between 4 and 12 years undergoing adenoidectomy or adenotonsillectomy were included in the study. Pure tone audiometry (PTA) and impedance audiometry were done preoperatively and postoperatively twice, on the 2nd day and at 6th week to assess the changes in hearing threshold and MEP. Statistical analysis was done using paired t-test and Chi-square test to determine the changes in hearing threshold and MEP. P < 0.05 was found to be statistically significant. Results: Of the 54 patients (108 ears) studied, 26 ears (24%) showed air–fluid level and 19 ears (17.6%) had dull-retracted tympanic membrane. The mean preoperative PTA value was 15.95 ± 8.19 dB. The mean preoperative MEP value was −63.69 ± 88.9 mm H2O. Postoperatively on 2nd postday, both the values were higher and at 6th week, there was an improvement as compared to preoperative and immediate postoperative values. At 6th week postoperatively, it was also observed that 52 children had tympanogram as type A, confirming the improvement in MEP. All these changes were statistically significant (P < 0.005). Conclusion: Adenoidectomy or adenotonsillectomy alone does improve the Eustachian tube function, especially in otitis media with effusion. Myringotomy with grommet insertion may not be necessary in all the cases.
Keywords: Adenoidectomy, hearing, middle ear, otitis media with effusion, pure tone audiometry, tympanometry
|How to cite this article:|
Somayaji K S, Fathima A, Saimanohar S. Impact of adenoidectomy/adenotonsillectomy on hearing threshold and middle ear pressure. Ann Indian Acad Otorhinolaryngol Head Neck Surg 2021;5:12-7
|How to cite this URL:|
Somayaji K S, Fathima A, Saimanohar S. Impact of adenoidectomy/adenotonsillectomy on hearing threshold and middle ear pressure. Ann Indian Acad Otorhinolaryngol Head Neck Surg [serial online] 2021 [cited 2021 Jul 25];5:12-7. Available from: https://www.aiaohns.in/text.asp?2021/5/1/12/320577
| Introduction|| |
The Eustachian tube serves to connect the middle ear with the nasopharynx. It is shorter, wider, and more horizontal in infants and children and hence accounts for the high incidence of otitis media in them. Eustachian tube serves to regulate the pressure and ventilate, protect, and drain the middle ear. Of these three functions, pressure regulation is the most important.
Middle ear pressure (MEP) is equilibrated to atmospheric pressure through active intermittent openings of the Eustachian tube, caused by contraction of the tensor veli palatini muscle during swallowing, jaw movements, and yawning. Negative pressure develops in the middle ear as a result of improper tubal function. The otitis prone children have poorer active tubal function, suggesting that recurrent infections are secondary to functional obstruction of the Eustachian tube. When adenoids are enlarged, it may cause obstruction of the nasopharynx and blockage of the Eustachian tube, preventing ventilation of the middle ear – mastoid system. The adenoids are covered with biofilm, and this may act as a reservoir for bacteria causing middle ear disease. This may explain the clinical improvement obtained after mechanical debridement of the adenoids.
The present study is an attempt to signify the importance of adenoidectomy or adenotonsillectomy to improve the function of Eustachian tube and to understand what impact it has on the MEP and hearing threshold.
| Materials and Methods|| |
All children aged between 4 and 12 years attending ENT outpatient department of a tertiary care medical center with symptoms and signs of chronic adenoiditis and/or adenotonsillitis, with or without features of chronic OME and undergoing adenoidectomy or adenotonsillectomy were included for the study. A prospective, experimental study was done after obtaining institutional ethical committee clearance.
Relevant history was taken, and clinical examination was done to look for the presence of adenoid hypertrophy, tonsil hypertrophy, and also for the retraction or perforation of tympanic membrane (TM) and or presence of air–fluid level.
X-ray Nasopharynx soft-tissue lateral view was done in all the cases to confirm the presence of adenoids. Then, pure tone audiometry (PTA) using INTERACOUSTICS CLINICAL AUDIOMETER AC40 and Impedance Audiometry using INTERACOUSTICS TITAN SERIES MIDDLE EAR ANALYSER were done in all the cases 1 day before surgery to assess the hearing threshold and MEP. Other preoperative investigations were also done.
The patients then underwent either adenoidectomy or adenotonsillectomy. They were then followed up with PTA and impedance audiometry on 2nd postoperative day and also after 6 weeks to assess the changes in hearing threshold and MEP.
Children aged <4 years and more than 12 years, having preexisting craniofacial anomalies or neuromuscular disorders, previously treated with adenoidectomy, adenotonsillectomy, and/or ear surgery (including ventilation tube insertion for otitis media with effusion [OME]), refused postoperative examination or study enrollment, and those with hemorrhagic diathesis were excluded from the study.
Preoperative, 2nd postoperative, and 6th week hearing threshold values and tympanogram were compared using paired t-test and Mc Nemar's Chi-square test, respectively.
P < 0.05 was found to be statistically significant.
| Results|| |
A total of 54 patients with symptoms and/or signs of chronic adenoiditis and/or adenotonsillitis undergoing adenoidectomy or adenotonsillectomy and falling into the inclusion criteria were studied. The study was conducted over a period of 18 months. Age of the patients ranged from 4 to 12 years with mean age being 7.44 ± 2.26. The majority of children belonged to 4 and 6-year age group (40.7%), followed by 7–9-year age group (33.3%). The study included 28 boys and 26 girls. Of the 54 cases studied, only 12 children presented with a history of hearing impairment. Of the 108 ears examined, 63 ears (58.3%) were normal, 26 ears (24.1%) showed air–fluid level, and 19 ears (17.6%) had dull-retracted TM. Out of the 54 children examined, 10 children showed air–fluid level in both ears [Table 1]. All the 54 children showed marked adenoid hypertrophy in plain X-ray of the nasopharynx in the lateral view. Among 54 children, majority of the patients underwent adenotonsillectomy (37 patients– 68.5%). The rest of the patients underwent adenoidectomy.
PTA for evaluation of hearing loss was done preoperatively and postoperatively on the 2nd day and at 6th week to assess the level of hearing loss and hearing improvement. The mean preoperative PTA value was 15.95 dB ± 8.19 Db. The postoperative PTA value on 2nd day was 19.59 dB ± 6.33 dB, which was higher when compared to preoperative value and was statistically significant (P < 0.001). The 6th-week PTA value was 7.69 dB ± 4.15 dB, which showed a significant improvement when compared with both preoperative and 2nd day postoperative PTA values and was statistically significant (P < 0.005) [Table 2].
|Table 2: Comparison of preoperative and postoperative pure tone audiometry values|
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The mean preoperative MEP value was −63.69 ± 88.9 mm H2O. The mean MEP value at 2nd postoperative day was −146.15 ± 131.8 mm H2O which was significantly higher when compared to preoperative value (P < 0.001). The postoperative 6th-week mean MEP was 17.5 ± 45.9 mm H2O which was significantly lower when compared to both preoperative value and 2nd postoperative day and was statistically significant (P < 0.001) [Table 3].
|Table 3: Comparison of preoperative and postoperative middle ear pressure|
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Tympanogram was used to verify the changes in MEP. Of the 108 ears examined preoperatively, Type A tympanogram was seen in 63 ears (58.3%), Type B tympanogram was seen in 27 ears (25%), and Type C tympanogram was seen in 18 ears (16.7%).
On the 2nd postoperative day, it was observed that 69.1% (38 ears) of Type A tympanogram changed to Type C and 17.2% (5 ears) changed to Type B. Of the 27 ears (25%) with Type B tympanogram, 65.5% (19 ears) continued to have Type B tympanogram and 10.9% (6 ears) changed to Type C. Among 18 ears (16.7%) with Type C tympanogram, 17.2% (5 ears) changed to Type B and 20% (11ears) continued as Type C. Using Chi-square test, it was observed that P < 0.001 and was statistically significant [Table 4].
|Table 4: Comparison of preoperative and 2nd postoperative day tympanogram|
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At 6th-week following surgery, it was observed that only one ear with Type A tympanogram changed to Type C, with others continuing as type A. Of the 27 ears with preoperative Type B, 25 ears improved to Type A. In two ears, Type B tympanogram was persistent. All 18 ears with preoperative Type C improved to Type A. These changes were found to be statistically significant with P < 0.001 [Table 5].
|Table 5: Comparison of preoperative and 6th week postoperative tympanogram|
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It was observed that of 29 ears with Type B tympanogram, 27 ears improved to Type A tympanogram after 6 weeks following surgery. Out of 55 ears with Type C tympanogram, 54 ears improved to Type A. These changes were statistically significant with P < 0.005 [Table 6].
|Table 6: Comparison of 2nd postoperative day and 6th week postoperative tympanogram|
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Thus, after evaluating the MEP and tympanograms of 54 children (108 ears) at 6 weeks following surgery, it was observed that 52 children had improvement in MEP and their tympanogram was Type A. In one child with bilateral secretory otitis media, MEP remained the same as preoperative value and tympanogram persisted to be Type B. Another child had more negative MEP compared to preoperative value and tympanogram changed to Type C from Type A.
| Discussion|| |
Adenoid enlargement is an important cause for Eustachian tube dysfunction and recurrent otitis media in pediatric population. In the present study of 54 children in the age group of 4–12 years, incidence of adenoid hypertrophy was more in 4–6-year age group, followed by 7–9-year age group. This observation was similar to the study by Fujioka et al., which showed that the size of adenoid varies among children, but the maximum size was between 4 and 8 years age, which then regress gradually by 15 years of age. There was no significant difference in the gender distribution of incidence of adenoid hypertrophy.
Children with OME may remain asymptomatic. Some present with deafness or ear fullness. In the present study, 12 children (22.2%) had hearing impairment. This incidence varies depending on the study. In a similar study by Kindermann et al. to investigate whether the obstruction of the Eustachian tube orifice due to adenoid hyperplasia causes a change in the MEP showed that the incidence of hearing loss to be 16% (8 out of 50 children). Sarafoleanu et al. in his study to show the implications of adenoid tissue hypertrophy in the genesis of Eustachian tube dysfunction observed the incidence of hypoacusis to be 77.8%. In another study by Khayat and Dabbagh to identify the incidence of OME in children with adenoid hypertrophy, 22 (50%) out of 44 children with OME had deafness which was detected by statements of parents and teachers. Enache et al. in his study on 119 children with OME observed that all children presented with a history of deafness.
In the present study, otoscopy findings showed varied appearance of TM. 24% (26 ears) showed air–fluid level and 17.6% (19 ears) had dull and retracted TM. Tympanogram results revealed pathological curves in 45 ears (25% Type B curve and 16.7% Type C curve). Sarafoleanu et al. in his study observed that 28.57% had retracted TM and 49.2% had middle ear effusion. Furthemore, tympanogram results showed pathologic curves in 98 cases (40.47% Type B curve and 37.30% Type C curve). In a similar study by Khayat and Dabbagh also, the otoscopic findings were varied with distorted cone of light, retraction of TM, and air bubbles. A study by Ajayan et al. conducted to study the effect of adenoidectomy with tonsillectomy in paediatric patients with OME, showed dull and retracted TM in 78.5% cases and air–fluid was seen only in 11.42%.
In the present study, in the immediate postoperative period, there was a significant increase in the hearing threshold and also reduction in the MEP. The mean preoperative and 2nd postoperative day hearing threshold was 15.95 ± 8.2 dB HL and 19.59 ± 6.3 dB HL, respectively. The difference between the two was statistically significant (P < 0.001). The mean preoperative and 2nd postoperative day MEP was −63.69 ± 88.9 and −146.15 ± 131.85 mm H2O. The difference between the two was statistically significant (P < 0.001). Furthermore, 69.1% and 17.2% with Type A tympanogram changed to Type C and Type B, respectively, in the immediate postoperative period.
These observations were similar to the study by Choi et al. to evaluate the effect of adenotonsillectomy on immediate Eustachian tube function in children with adenotonsillar hypertrophy. He observed that majority had C Type of curve. On postoperative day 2, 76% (38/50) of cases were unresolved (CC and BB types), while 24% (12/50) were normal (AA type) or resolved (CA type). There was a statistically significant difference (P < 0.001) in bilateral MEPs between preoperative and postoperative days.
Similar results were observed in a study by Unlu et al. to analyze the changes in the MEP in the early period after adenoidectomy in children with adenoid hypertrophy without OME. He observed that there was pathological decrease in the MEP 24 h after the procedure in one ear in 48 patients (75%) and bilateral Eustachian dysfunction in 38 patients (59.3%). Furthermore, Type B tympanogram was not seen in any patients postoperatively. These changes in MEP returned to preoperative value by 7th postoperative day.
The increase in hearing threshold and reduction in MEP in the immediate period could be due to temporary dysfunction of Eustachian tube due to edema or blood clots at the surgical site, especially around Eustachian tube orifice. Moreover, due to pain in the postoperative period, swallowing is reduced and this also adds on to the cause for Eustachian tube dysfunction.
In the present study, there was a significant improvement in the MEP and hearing threshold at 6 weeks following surgery as seen with PTA and tympanometry. There was complete resolution of OME in 15 out of 16 children as suggested by postoperative Type A tympanogram. Similar results were observed in a study by Tuohimaa and Palva. A similar study by Zaman and Borah also showed that there was a significant improvement in the MEP following adenoidectomy.
Sandooja et al. in his study on effect of adenotonsillectomy on hearing threshold and MEP also has shown improvement in MEP and hearing threshold following surgery and hence concluded that adenoidectomy improves the Eustachian tube function and MEP by eliminating the mechanical obstruction, edema of Eustachian tube orifice due to repeated infection.
Similar results were observed in a retrospective study by Enache et al. At 1 month after surgery, a normal Eustachian tube function was seen in 43.70% of the children and at 3 months after surgery, when the second reassessment was made, 109 children (91.60%) presented a total recovery of the middle ear function with a normal Eustachian tube activity.
Ajayan et al. in his study observed that 6 weeks following surgery 55.71% of Type B tympanogram changed to Type A and 15.7% to Type C, while in 28.57%, Type B persisted. After 3 months, 65.71% of tympanogram were Type A and 8.57% were Type C. In 25.71% of subjects, Type B tympanogram persisted. It was also observed that, in all those subjects with persistent Type B tympanogram, preoperative hearing loss was higher, that is, between 40 and 50 dB.
In the present study, one case (2%) had persistent OME bilaterally as suggested by persistence of Type B tympanogram and reduced MEP. This could be due to persistence of Eustachian tube dysfunction.
| Conclusion|| |
It is concluded that adenoidectomy or adenotonsillectomy does improve the Eustachian tube function, especially in OME by eliminating the mechanical obstruction and also the foci of infection which causes edema of eustachain tube orifice and/or lymphatic obstruction of Eustachian tube.
Early intervention with adenoidectomy or adenotonsillectomy will help in the improvement of hearing threshold and MEP and restoration of Eustachian tube function and prevent the sequelae of OME. Myringotomy with grommet insertion may be considered as a last resort as it carries complications such as otorrhea, permanent perforation, scarring, and retraction.
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Conflicts of interest
There are no conflicts of interest.
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[Table 1], [Table 2], [Table 3], [Table 4], [Table 5], [Table 6]