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Should Recurrent Otitis Media Be Treated Surgically?

Am Fam Physician. 2000 Feb 15;61(4):1128-1130.

Adenoidectomy and adenotonsillectomy (T&A) are the most common surgical procedures performed on children. Most children who undergo one of these procedures have recurrent otitis media. The adenoidectomy component of the T&A is generally thought to be the more effective element in reducing recurrent otitis media. Standard references and current guidelines of the American Academy of Otolaryngology–Head and Neck Surgery recommend adenoidectomy alone for treatment of recurrent otitis media. Despite these recommendations, most physicians recommend T&A for persistent or recurrent otitis media. Paradise and associates compared the efficacy of adenoidectomy alone with that of T&A in preventing recurrent otitis media in children who had not previously had tympanostomy tube placement.

Two parallel, randomized trials were conducted with children between three and 15 years of age. Inclusion criteria consisted of the following: at least three episodes of otitis media in the past six months, four episodes in the past year or middle-ear effusion in at least one ear extending over 180 days during the past year. In trial 1 (the three-way trial), patients were randomized to a no-surgery (control) group, an adenoidectomy group or a T&A group. In trial 2 (the two-way trial), patients were randomized to a control group or a T&A group.

Patients were free of otitis media at baseline, and those assigned to a surgery group underwent the procedure as soon as possible after randomization. Follow-up procedures consisted of biweekly inquiries about the patient's clinical status, and a standardized examination every six weeks and whenever patients had an acute illness or otitis media. Patients were classified as having acute otitis media or otitis media with effusion. The primary outcome measure was the number of episodes of acute otitis media occurring during the follow-up period.

Data were analyzed on 410 children—266 children in the three-way trial and 144 in the two-way trial. More than one half of the patients were followed for three years. Differences in outcome were small among patients in the three-way trial. Patients in both surgery groups had less time with acute otitis media than did patients in the control group. Patients undergoing T&A received less antibiotic treatment than the control group in the first year of the follow-up period. In the two-way trial, patients undergoing T&A had fewer episodes of acute otitis media than the control group over the three-year follow-up period. However, the efficacy did not approach levels that would make surgical intervention justifiable in these children. Of those who had surgical interventions, 11.5 percent had postoperative complications; these were more common in the T&A group than in the adenoidectomy group. Overall, outcomes were generally less favorable in younger patients and in patients with bilateral effusions at baseline.

The authors conclude that surgical intervention for recurrent or persistent otitis media is only modestly successful. Therefore, nonsurgical treatment should be the initial choice, followed by tympanostomy tube placement if surgery is deemed necessary. Adenoidectomy or T&A should be reserved for use in children who have recurrent otitis media after tympanostomy tubes are extruded. Further studies are needed to determine relative indications for adenoidectomy versus T&A.

Paradise JL, et al. Adenoidectomy and adenotonsillectomy for recurrent acute otitis media. Parallel randomized clinical trials in children not previously treated with tympanostomy tubes. JAMA. September 8, 1999;282:945–53.


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