Prophylactic or Therapeutic Adenoidectomy?: In Reply

Abstract

In Reply.—We thank Dr Carron for his comments on our study.1 His main concern was the accuracy of the diagnosis of otitis media. Although it was not explicitly stated in our report, all the children had tympanostomy tubes, which made the diagnosis straightforward because it invariably involved discharge from the tympanostomy tube. Some children had lost their tympanostomy tubes during the follow-up period, but adenoidectomy did not prevent the need for reinsertion of tympanostomy tubes.Dr Carron suggested that children who have had adenoidectomy because of obstructive symptoms should have been included in our study. Such children, however, benefit from adenoidectomy irrespective of middle ear disease, because adenoidectomy will enable normal nasal breathing. Therefore, these children were excluded from our study. Comparisons of such children with our study children with recurrent otitis media would have been difficult, because they have different diseases.In some children, adenoids may be infected chronically and serve as a source of pathogenic bacteria, presumably predisposing to otitis media. This may explain why adenoidectomy was beneficial in earlier studies of children who were mainly older than 4 years and who had previously received tympanostomy tubes2 and in children who suffered from persistent middle ear disease.3,4 It may be presumed that these children had had infections starting from their infancy, which allowed a chronic infection to develop in their adenoids. However, this is entirely hypothetical, and it is quite vague to call adenoidectomy “therapeutic” without gross adenoid enlargement.Dr Carron also questioned what would happen to the child when the tympanostomy tubes fall out and the child is reliant on his or her own ventilation system again. The focus of such a study should involve only those children who have middle ear disease after the initial or even secondary insertion of tympanostomy tubes, as has been evaluated in an earlier study.2 He stated that “tympanostomy tubes are great for preventing ear infections.” This certainly is not an evidence-based fact at all, because the effect of tympanostomy tubes for preventing otitis media is at its best quite modest5 and is not “preventing most ear infections anyway.”Because children who are younger than 4 years and who do not suffer from gross adenoid enlargement comprise the vast majority of children with middle ear infections, it is especially important to evaluate the effect of adenoidectomy in this very population. As our study showed, adenoidectomy failed to produce any additional benefit in preventing otitis media.