The bulk of the data suggest that the adenoid does not act to obstruct the eustachian tube. It is postulated that the adenoid acts as a storehouse for bacteria that then reflux into the middle ear and initiate infection. The size of the adenoid has not been convincingly linked to its ability to cause disease.
The three randomized controlled trials which looked at this question all show a statistically significant improvement over the natural history of the disease. Paradise et. al. found that removal of the adenoid decreased the number of recurrences of OM in otitis-prone children. Gates et. al. and Maw and Bawden showed that adenoidectomy decreased time with effusion and improved hearing compared with a control group.
There is evidence from the studies by Maw and Gates that these two procedures are about equally effective for COME. Gates showed a significantly decreased time to recurrence and decrease in the number of surgical procedures required in the adenoidectomy alone group. However the difference in total time with effusion or improvement in hearing was not significant. The study of recurrent OM in otitis-prone children appears to favor PET's alone over adenoidectomy alone.
Gates showed that adenoid plus tubes resulted in less total time with effusion, better hearing (in the worse ear) and less need for additional surgery than tubes alone. When adenoidectomy alone is compared to BMT & A, the latter resulted in significantly decreased time to first effusion. In the study by Maw and Bawden, they conclude that adenoid plus tubes is better than either one alone, but the data that support this is not statistically significant. Other authors have not found that adenoidectomy has any significant advantages over tubes except for a tendency to decrease the number of subsequent tube re-insertions. It is likely that when the tubes are patent, adenoidectomy has no additional benefit. However if the tubes extrude in a child still at risk for OM, the adenoidectomy will have some protective role.
Gates felt in children above 4 years of age (he did not study children <4), the operation of choice for COME was adenoidectomy and bilateral myringotomy without tubes. However his data does not really support adenoidectomy over tubes and this recommendation has been questioned. Paradise recommended adenoidectomy for the otitis prone child who had failed one set of tubes, because of the apparent protective effect of adenoidectomy when the tubes extruded.
2. T & A is no more effective than A for COME.
3. Adenoidectomy appears to favorably affect the natural history of OM.
4. The addition of adenoidectomy in the face of patent tubes probably does not confer additional benefit.
5. Adenoidectomy in the face of extruded tubes in the patient still at risk for OM probably is protective.
2. Who should be given more permanent PET's as an initial treatment for OM?
3. Role of cost-effectiveness studies?
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