Abstract
Objective
Our aim was to analyze the changes in middle ear pressure in the early period after adenoidectomy in children with adenoid hypertrophy without otitis media with effusion.
Methods
This prospective, descriptive study was performed on 64 patients (with normal tympanic membranes and tympanograms) undergoing adenoidectomy or adenotonsillectomy. All patients were operated by single experienced team using curettage technique. First tympanometry was done on the day before surgery. Tympanometry was repeated on the first-, third-, and seventh-day after the operation. Patients are separated into two groups according to age as patients younger than 6 years (Group A) and patients older than 6 years (Group B). All data were separately evaluated for each ear using Jerger Classification.
Results
Of the 64 patients included in the study, 35 were male and 29 were female, and the average age was 91.01 ± 37.4 (35–178) months. Pathological decreases in the middle ear pressures of at least one ear were determined in 48 (75%) patients on the first postoperative day and in 10 (15.6%) patients on the third postoperative day. Middle ear pressures returned to preoperative values by the seventh postoperative day except in two patients. There were statistically significant differences (p < 0.0001) among preoperative and first, third, and seventh postoperative day mean middle ear pressure. There were no statistically significant differences between Groups A and B in terms of tympanometry values of both ears obtained preoperatively and on the first, third, and seventh postoperative day.
Conclusion
In our study, temporary eustachian dysfunction and aural fullness occur in the early period after adenoidectomy and/or adenotonsillectomy. This situation may be due to post-surgery clots and edema in nasopharynx. We consider that tubal orifice can be exposed to surgical trauma as adenoidectomy surgeries are done by curettage technique. There is a need for comparative studies using microdebrider or laser adenoidectomy accompanied by an endoscope.
1
Introduction
The adenoid is a lymphoepithelial organ sat in the roof of the nasopharyngeal cavity. Enlargement of adenoid is one of the common reasons of upper airway obstruction . Diagnosis of adenoid enlargement is mainly based on patient’s history and this is the most common diagnostic modality . Fiberoptic examination and cephalometric graph are other diagnostic modalities .
Adenoidectomy is a commonly applied surgical procedure. The most common indications are obstructive sleep apnea, nasal obstruction, chronic rhinosinusitis, otitis media with effusion and recurrent otitis media. Wilhelm Meyer described adenoidectomy first in 1885 and advised curettage through the nose assisted with digital palpation in the nasopharyngeal cavity . Afterwards, many alternative techniques have been suggested, including suction electrocautery ablation, laser adenoidectomy and microdebrider assisted adenoidectomy . Curettage technique that is widely used currently, remains quite popular. However it has various complications, such as incomplete removal, trauma to underlying tissues and hemorrhage .
Eustachian tube dysfunction is most commonly caused by mechanical obstruction of the tubal orifice, insufficient swallowing and inflammation in the nasopharyngeal mucosa .
Eustachian dysfunction can develop due to surgical trauma, edema in surrounding tissues and clots in the early period following adenoidectomy surgery performed with curettage technique. The literature contains no detailed study on how middle ear pressure is affected in the early period after adenoidectomy in adenoid hypertrophy patients with normal middle ear pressure.
Our study aims to analyze the changes in middle ear pressure in the early period after adenoidectomy in children with adenoid hypertrophy without otitis media with effusion.
2
Method
A prospective study was performed on 64 patients undergoing adenoidectomy or adenotonsillectomy for upper airway obstruction in the period of December 2013–June 2014 at Duzce Univercity Medical School. Patients undergoing adenoidectomy or adenotonsillectomy because of recurrent adenotonsillar infection are not included in this study. All patients were evaluated preoperatively by transnasal fiber optic flexible endoscopy or lateral nasopharyngeal X-ray. Only patients with normal tympanic membranes and type A preoperative tympanograms were included in this study. Patients are separated into two groups according to age as patients younger than 6 years (Group A) and patients older than 6 years (Group B).
Patients were asked whether they had complaints such as otalgia, aural fullness and hearing loss after 24 h postoperatively.
The study was carried out in accordance with the principles of Helsinki Declaration. Informed consent was obtained from the patients and local ethics committee approval was obtained from Duzce University prior to the study.
2.1
Surgical technique
All patients were operated by single experienced team using curettage technique. Crowe–Davis surgical retractor was used as a mouth gag. The palate and uvula were visually and digitally inspected to eliminate a palate cleft. Nelaton Catheter (10 Ch) was passed through nasal cavity and then pushed forward from nasopharynx to oropharynx and catheter was taken out from mouth by the help of clamp in order to retract the soft palate. Adenoid tissue was removed with adenoid curette without visualization then surgical place was controlled by palpation and curettage was repeated until the surgeon was satisfied with completeness of the removal. Sponge was placed in nasopharyngeal cavity for a few minutes for hemostasis. Bipolar cautery was used for ongoing bleeding after removal of the sponge. Patients requiring tonsillectomy concomitantly with adenoidectomy were operated by the method of dissection.
2.2
Tympanometry
The middle ear pressure levels of patients were measured preoperatively and postoperatively using tympanometry (Interacoustics AZ-26 impedance audiometer, Interacoustics A/S, Assens, Denmark). Both ears were examined before the test, and ear cerumen was removed in the external ear canal.
First tympanometry was done on the day before the surgery. It was repeated on the first, third and seventh day following surgery.
One hundred and twenty eight ears of 64 patients were examined. Right and left ears of the patients were evaluated separately. Jerger Classification was used to classify tympanograms ( Table 1 ).
| Tympanogram | Middle ear pressure peak |
|---|---|
| Type A | <+50 daPa |
| > − 100 daPa | |
| Type B | < − 100 daPa |
| Type C | ≤ 0.3 mL (admittance) |
2.3
Statistical analyses
Data analysis was done using SPSS (Statistical Package for Social Sciences) for Windows 15.0 (SPSS Inc., Chicago, IL) program. A chi-square test was used to compare the categorical variables. All continuous variables were normally distributed according to the Kolmogorov–Smirnov normality test. The Student t test was used to compare the continuous variables. Repeated measures analysis of variance test was used to compare the preoperative and postoperative first-, third-, and seventh-day postoperative tympanometric pressures. Continuous variables were presented as mean and standard deviation. A P value < 0.05 was considered statistically significant.
2
Method
A prospective study was performed on 64 patients undergoing adenoidectomy or adenotonsillectomy for upper airway obstruction in the period of December 2013–June 2014 at Duzce Univercity Medical School. Patients undergoing adenoidectomy or adenotonsillectomy because of recurrent adenotonsillar infection are not included in this study. All patients were evaluated preoperatively by transnasal fiber optic flexible endoscopy or lateral nasopharyngeal X-ray. Only patients with normal tympanic membranes and type A preoperative tympanograms were included in this study. Patients are separated into two groups according to age as patients younger than 6 years (Group A) and patients older than 6 years (Group B).
Patients were asked whether they had complaints such as otalgia, aural fullness and hearing loss after 24 h postoperatively.
The study was carried out in accordance with the principles of Helsinki Declaration. Informed consent was obtained from the patients and local ethics committee approval was obtained from Duzce University prior to the study.
2.1
Surgical technique
All patients were operated by single experienced team using curettage technique. Crowe–Davis surgical retractor was used as a mouth gag. The palate and uvula were visually and digitally inspected to eliminate a palate cleft. Nelaton Catheter (10 Ch) was passed through nasal cavity and then pushed forward from nasopharynx to oropharynx and catheter was taken out from mouth by the help of clamp in order to retract the soft palate. Adenoid tissue was removed with adenoid curette without visualization then surgical place was controlled by palpation and curettage was repeated until the surgeon was satisfied with completeness of the removal. Sponge was placed in nasopharyngeal cavity for a few minutes for hemostasis. Bipolar cautery was used for ongoing bleeding after removal of the sponge. Patients requiring tonsillectomy concomitantly with adenoidectomy were operated by the method of dissection.
2.2
Tympanometry
The middle ear pressure levels of patients were measured preoperatively and postoperatively using tympanometry (Interacoustics AZ-26 impedance audiometer, Interacoustics A/S, Assens, Denmark). Both ears were examined before the test, and ear cerumen was removed in the external ear canal.
First tympanometry was done on the day before the surgery. It was repeated on the first, third and seventh day following surgery.
One hundred and twenty eight ears of 64 patients were examined. Right and left ears of the patients were evaluated separately. Jerger Classification was used to classify tympanograms ( Table 1 ).
