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Assessment of middle ear function after conventional or endoscopic microdebrider assisted adenoidectomy
Abstract
Objectives. To compare pre- and post-operative pure tone audiometric and impedance audiometric analysis following conventional and endoscopic microdebrider assisted adenoidectomy and compare the outcomes.
Methods. Patients diagnosed with chronic adenoiditis were divided in groups of 25 each. Patients in the first group underwent conventional curettage adenoidectomy, while those in second group underwent endoscopic microdebrider assisted adenoidectomy. Preand post-operative pure tone and impedance audiometry were performed for all patients and outcomes were compared.
Results. The endoscopic microdebrider assisted method resulted in significantly better outcomes compared to conventional curettage. Criteria such as hearing threshold (p value 0.004 at second follow-up), peak pressure (p value 0.045 at first follow-up) and tympanogram (p value 0.016) showed that the endoscopic method was better, while peak compliance (p value 0.340 at first follow-up) did not show any significant difference between groups.
Conclusions. The endoscopic microdebrider assisted method for adenoidectomy has a definite advantage of better visualisation resulting in better clearance of tissue, leading to enhanced middle ear function compared to conventional curettage.
Introduction
Enlarged adenoids are an important cause for conditions such as serous otitis media, obstructive sleep apnoea, Eustachian tube dysfunction and nasal obstruction. Traditionally the technique of adenoidectomy has been a transoral approach with an adenoid curette or adenotome. As this is a blind procedure, there is always a chance of leaving behind some adenoid tissue. Hence, attention has been drawn towards an endoscopic microdebrider assisted technique that involves direct transnasal visualisation and removal of adenoid tissue by a rigid 0° nasal endoscope. This technique offers the advantage of direct visualisation of the nasopharynx which results in more complete removal of adenoid tissue as well as less chance of injury to surrounding structures. Various studies have been conducted to compare the conventional curettage technique for adenoidectomy with the endoscopic microdebrider technique in terms of parameters such as completeness of removal of adenoid tissue, time required for procedure, amount of blood loss during the procedure, damage to the surrounding structures, post-operative pain, recovery time and symptomatic improvement following the procedure 1-5. However, there are no conclusive studies on whether the type of technique bears a relationship with the improvement in middle ear function after the surgery 6,7. Although coblator assisted adenoidectomy is currently popular, considering its creditability and cost factor, the endoscopic microdebrider is still used widely in surgical treatment of adenoids. Our study aims to compare the conventional curettage method of adenoidectomy with the endoscopic microdebrider assisted technique in terms of post-operative improvement in middle ear function.
Materials and methods
This was a prospective observational study conducted among 50 patients aged 5 to 14 years over a 2-year period (Tab. I). Subjects diagnosed with adenoid hypertrophy were divided in two study groups of 25 each, a sample size that was attained taking into consideration the proportions mentioned in various references and clinically meaningful difference in proportions of the outcome. Children whose guardian/parents did not give consent for myringotomy were included in the study and those not willing microdebrider assisted adenoidectomy due to financial constraints underwent conventional adenoidectomy. All the cases of adenoid hypertrophy which were diagnosed clinically and confirmed by x-ray examination were included in the study. Conditions mimicking adenoid hypertrophy clinically like angiofibroma, nasal polyposis, nasopharyngeal carcinoma and gross nasal septum deviation were excluded from the study. In each group, pre-operative assessment of middle ear function was done using pure tone audiometry and tympanometry for all patients. Group 1 patients were treated using a transoral approach with conventional curettage adenoidectomy using St. Clair Thomson’s adenoid curette as they refused microdebrider assisted surgery because of increased costs. Group 2 patients were treated with an endoscopic microdebrider assisted approach and both nasal cavities were packed with cotton pledgets soaked with 2% lignocaine and adrenaline for 15 minutes. Following removal of the pledgets, a 4 mm 0° Storz rigid nasal endoscope was passed through the nasal cavities to visualise the nasopharynx and the adenoid tissue was removed transnasally under direct vision using microdebrider. Thinning of torus tubaris was done for microdebrider assisted patients. Post-operatively, patients were called for two follow-up visits, the first after 1 month and the second after 2 months. Pre- and post-operative pure tone and impedance audiometric parameters were compared. Pure tone average threshold was calculated taking into consideration the average of 500, 1000, 2000, 4000 Hz frequencies. Statistical analysis of the data was done by using ANOVA (Fischer F test) and student’s unpaired T test. A statistical package, SPSS 17 was used for analysis. A p value of less than 0.05 was considered significant.
Results
Conventional adenoidectomy was performed in 25 patients and endoscopic microdebrider assisted adenoidectomy was performed in 25 patients. Both groups were compared in terms of various audiological parameters.
Hearing threshold
42 ears (84%) in the conventional adenoidectomy group had hearing thresholds higher than 15 dB compared to 40 ears (80%) in the endoscopic microdebrider assisted group. The p value for pre-operative comparison between groups was 0.604, which is not statistically significant. After 1st follow-up, 30 (60%) patients in the conventional curettage group had abnormal hearing thresholds vs 20 (40%) in the endoscopic approach group. The p value for comparison between groups was 0.047, indicating that the difference is statistically significant. At second follow-up, 12 ears (24%) in the conventional curettage group had abnormal hearing thresholds, while in the endoscopic microdebrider group only 2 ears (4%) had hearing thresholds above 15 dB. The p value for comparison was 0.004 (Tab. II).
Peak compliance
At presentation, 21 ears (42%) in the conventional curettage group had abnormal peak compliance compared to 24 ears (48%) in the endoscopic microdebrider assisted group. Comparison between groups yielded a p value of 0.549. At first follow-up, 7 ears (14%) in the conventional group and 4 ears (8%) in the endoscopic microdebrider assisted group had abnormal peak compliance (p value 0.340). At second follow-up, 4 ears (8%) in the conventional curettage group and 3 ears (6%) in the endoscopic microdebrider assisted group had abnormal compliance (p value 0.697) (Tab. III).
Peak middle ear pressure
Out of 50 ears in the conventional curettage group, 38 (76%) had impaired peak middle ear pressure at presentation vs 36 ears (72%) in the endoscopic microdebrider assisted group (p = 0.650). At first follow-up, 15 ears (30%) in conventional curettage group and 7 ears (14%) in the endoscopic microdebrider assisted group had abnormal peak middle ear pressure (p value 0.045). After 2nd follow-up, 6 ears (12%) in conventional curettage group and 4 ears (8%) in the endoscopic microdebrider assisted group had abnormal peak pressures (p value 0.507) (Tab. IV).
Tympanogram
In the conventional curettage group, 38 ears (76%) had a type B or C curve at presentation compared to 39 ears (78%) in the endoscopic microdebrider assisted group (p value 0.813). After the first post-operative follow-up, 20 ears (40%) in the conventional group and 9 ears in the endoscopic microdebrider assisted group had a type B or C curve (p value 0.016). At 2nd follow-up, 10 ears (20%) in the conventional group and 4 ears (8%) in the endoscopic microdebrider assisted group had a type B or C curve (p value 0.085) (Tab. V).
Discussion
Adenoidectomy has been the cornerstone of treatment in children suffering from otitis media with effusion (OME) for many decades 8. There have been various researches in the field of adenoidectomy, but sparse literature is available on its outcomes on middle ear function. We thus conducted this study to critically compare middle ear function following conventional and endoscopic microdebrider assisted adenoidectomy.
Adenoid hypertrophy in children is the most common cause of eustachian tube blockage leading to fluid collection in the middle ear, i.e. otitis media with effusion leading to derangement of middle ear functions, and various modalities of treatment have used to treat it 9.
In a recent Cochrane review by Van den Aardweg et al. 9, it was reported that there is a significant benefit of adenoidectomy in resolution of middle ear effusion in children with OME, but the benefit to hearing is small and the effects on changes in the tympanic membrane are unknown.
Although adenoid hypertrophy is the most common cause for OME, it is often multifactorial 9,10. Hence, studies have shown that a short course of steroids is beneficial in improving middle ear function overweighing the side effects 10.
Coyle et al. 11 also concluded that adenoidectomy is a useful procedure to correct medically resistant chronic OME and should be considered as the first line procedure when surgical treatment is chosen.
However, dissatisfaction of conventional curettage adenoidectomy for many years has prompted the use of endoscopic assisted powered shaver adenoidectomy with microbebrider in recent times.
Setliff and Parsons, as stated by Christmas 12, introduced microdebrider use in nasal surgery in 1994. The unique design equipped with powered shaver, continuous irrigation and suction port makes this instrument superior in clearing tissue from the field under direct vision with minimal complications.
Stainslaw et al. 13 found that tissue dissection was more complete and at appropriate depth with a microdebrider compared to the depth being too shallow in the conventional method which leaves behind significant tissue.
Various studies conducted by Murray et al. and Rodigruez et al. 14,15 demonstrated that endoscopic assisted powered shaver adenoidectomy is more effective in cleaning adenoid tissue under direct visualisation; thus requiring less operating time, causing less blood loss, and providing more complete removal of the adenoid tissue and less post-operative pain.
By using endoscopic assisted adenoidectomy with a microdebrider, the adenoid remnants along the superior portion of the nasopharynx, the choanae and the peritubal region can be clearly visualised easily and thus removed completely. Moreover, the likelihood of damage to the Eustachian tube and/or to the pharyngeal muscles is reduced, thereby reducing the post-operative scarring. Haemorrhage can also be effectively controlled by direct identification of bleeding points 16,17.
Tympanometry has been a novel approach to study the function of the middle ear including middle ear pressures, volume and compliance. This study used these modalities to test middle ear function. According to another study, stapedial reflex is considered too sensitive to be used as a screening test in the diagnosis of OME and thus we excluded it from our criteria 18.
All our patients were post-operatively treated with a short course deflazacort (15 days) given according to age and weight followed by the combination of montelukast and levocetirizine for 15 days and mometasone nasal spray for 2 months post-operatively. Patients were encouraged to perform Valsalva manoeuver and swallowing exercises for a period of 2 months. Repeat pure tone audiometry and tympanometry were conducted at both the follow-up visits suggesting improvement of middle ear function in all group 2 patients and few group 1 patients without need for myringotomy by the second visit. They showed significant improvement in hearing thresholds following endoscopic microdebrider assisted adenoidectomy and only 4% of patients had abnormal hearing threshold in comparison to the conventional method (24%; p value = 0.004). There was no significant difference in peak compliance between groups, although peak middle pressures were significantly improved post-surgery in children undergoing endoscopic microdebrider assisted adenoidectomy compared to the conventional method.
The initial pre-operative tympanograms of patients showed type B and C curves, which were significantly improved (normal type A) in children who underwent endoscopic microdebrider assisted adenoidectomy in our study.
Similar studies have evaluated the conversion rates of tympanograms by Sarafoleanu et al. 19 in 2010 which revealed a type B curve in 41% of cases, compared with type A in 22% and type C in 37% of cases. Re-evaluation after 4 weeks of surgery (classical adenoidectomy) in their study also documented very good relief of disease by subjective and objective evaluation. Another study by Mori et al. 20 in 1980 also observed a type B tympanogram in 50% of cases pre-operatively with post-operative conversion to type A.
A few studies suggested to perform myringotomy as a therapeutic measure for children with OME undergoing adenoidectomy. In contrast, our study revealed considerable improvement in children with OME undergoing adenoidectomy alone after a short course of steroids as already mentioned.
Thus, clinical outcomes and middle ear function were improved drastically in children who underwent microdebrider assisted adenoidectomy compared to the conventional method.
The main limitation of this study was differences in cultural background which lead to selection bias. Other limitations include lack of long-term follow-up and the small sample size.
Conclusions
Adenoidectomy in hypertrophied adenoids with OME is a simple and effective procedure for resolution of OME and improvement in hearing post-operatively. Visual aided clearance of adenoids using a microdebrider with complete clearance of tissue over the Eustachian tube opening has a major advantage over the conventional method. Middle ear function tests, pre- and post-operatively not only give a good idea about the operative outcome, but also help in following up the patient and the disease process. Microdebrider assisted adenoidectomy, compared to the conventional method, was shown to have promising results with a significant improvement in middle ear function not only in terms of clearance of adenoid tissue, but also in otological outcomes without the need for myringotomy as seen in our study.
Acknowledgements
The authors acknowledge all the colleagues of Otorhinolaryngology Head and Neck Surgery Unit of Kasturba Medical College and Hospital, MAHE for their contribution to this study.
Conflict of interest statement
The authors declare no conflict of interest.
Author contributions
OG, VS: conceptualisation and validation; OG, DS: operating surgeons; NR, PP: draft preperation; VS, NR: draft review; DS, NR: draft editing.
Ethical consideration
This study was approved by the Institutional Ethics Committee (Kasturba medical college, Mangalore, MAHE) (approval number: IEC KMC MLR 10-13/193).
The research was conducted ethically, with all study procedures being performed in accordance with the requirements of the World Medical Association’s Declaration of Helsinki.
Written informed consent was obtained from each participant/patient for study participation and data publication.
Figures and tables
| Variables | Conventional (n = 25) | Endoscopic (n = 25) |
|---|---|---|
| Age | ||
| Mean ± SD | 6.68 ± 2.96 | 8.08 ± 2.72 |
| Median (Q1,Q3) | 6.00 (4.50, 8.00) | 7.00 (6.00, 11.00) |
| Min, max | 3, 13 | 4, 13 |
| Mann Whitney U | 214.50 | |
| P value # | 0.055 | |
| Gender | ||
| Male | 13 (52%) | 19 (76%) |
| Female | 12 (48%) | 06 (24%) |
| Chi square test statistic | 3.125 | |
| P value $ | 0.077 | |
| Socioeconomic status | ||
| Low | 18 (72%) | 04 (16%) |
| High | 07 (28%) | 21 (84%) |
| Chi square test statistic | 15.909 | |
| P value $ | < 0.001* | |
| #: P value is obtained from Mann Whitney U test comparing median age between conventional and endoscopic techniques which is found to be not significant. | ||
| $: P value is obtained from two sided chi square test seeing the association of gender and socioeconomic status with conventional and endoscopic group. It was found that only socioeconomic status is significant. | ||
| Group | Normal | Abnormal | Mann-Whitney test to compare between the groups | |||
|---|---|---|---|---|---|---|
| N. of ears | % | N. of ears | % | P value | ||
| Presentation | Group 1 | 8 | 16 | 42 | 84 | 0.604 |
| Group 2 | 10 | 20 | 40 | 80 | NS | |
| First follow-up | Group 1 | 20 | 40 | 30 | 60 | 0.047 |
| Group 2 | 30 | 60 | 20 | 40 | significant* | |
| Second follow-up | Group 1 | 38 | 76 | 12 | 24 | 0.004 |
| Group 2 | 48 | 96 | 2 | 4 | significant* | |
| * P value is significant; NS: not significant. | ||||||
| Group | Normal | Abnormal | Mann-Whitney test to compare between the groups | |||
|---|---|---|---|---|---|---|
| N. of ears | % | N. of ears | % | P value | ||
| Presentation | Group 1 | 29 | 58 | 21 | 42 | 0.549 |
| Group 2 | 26 | 52 | 24 | 48 | NS | |
| First follow-up | Group 1 | 43 | 86 | 7 | 14 | 0.340 |
| Group 2 | 46 | 92 | 4 | 8 | NS | |
| Second follow-up | Group 1 | 46 | 92 | 4 | 8 | 0.697 |
| Group 2 | 47 | 94 | 3 | 6 | NS | |
| NS: not significant. | ||||||
| Group | Normal | Abnormal | Mann-Whitney test to compare between the groups | |||
|---|---|---|---|---|---|---|
| N. of ears | % | N. of ears | % | P value | ||
| Presentation | Group 1 | 12 | 24 | 38 | 76 | 0.650 |
| Group 2 | 14 | 28 | 36 | 72 | NS | |
| First follow-up | Group 1 | 35 | 70 | 15 | 30 | 0.045 |
| Group 2 | 43 | 86 | 7 | 14 | significant* | |
| Second follow-up | Group 1 | 44 | 88 | 6 | 12 | 0.507 |
| Group 2 | 46 | 92 | 4 | 8 | NS | |
| * P value is significant; NS: not significant. | ||||||
| Group | Normal | Abnormal | Mann-Whitney test to compare between the groups | |||
|---|---|---|---|---|---|---|
| N. of ears | % | N. of ears | % | P value | ||
| Presentation | Group 1 | 12 | 24 | 38 | 76 | 0.813 |
| Group 2 | 11 | 22 | 39 | 78 | NS | |
| First follow-up | Group 1 | 30 | 60 | 20 | 40 | 0.016 |
| Group 2 | 41 | 82 | 9 | 18 | significant* | |
| Second follow-up | Group 1 | 40 | 80 | 10 | 20 | 0.085 |
| Group 2 | 46 | 92 | 4 | 8 | NS | |
| * P value is significant; NS: not significant. | ||||||
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