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Contents lists available at ScienceDirect

Auris Nasus Larynx

journal homepage: www.elsevier.com/locate/anl

Factors affecting the outcome of adenoidectomy in children treated

for chronic otitis media with effusion
Sarantis Blioskas 1, Petros Karkos 1, George Psillas 1, Stamatia Dova 1,
Marios Stavrakas 1, Konstantinos Markou 2,*
1
1st Department of Otorhinolaryngology – Head and Neck Surgery, Aristotle University of Thessaloniki, AHEPA Hospital, 1 Stilponos
Kyriakidi St, 54636 Thessaloniki, Greece
2
2nd Department of Otorhinolaryngology – Head and Neck Surgery, Aristotle University of Thessaloniki, Papageorgiou Hospital, Periferiaki
Odos Efkarpia, 56403 Thessaloniki, Greece

A R T I C L E I N F O A B S T R A C T

Article history: Objective: The aim of this cohort was to determine potential risk factors, concerning the
Received 22 January 2017 effectiveness of adenoidectomy in the treatment of chronic otitis media with effusion in children.
Accepted 12 January 2018 Methods: Ninety six children with chronic otitis media with effusion treated with adenoidectomy
Available online xxx
were enrolled in this study. A thorough medical history was taken, including family history of
otologic disease, parental smoking habits and breast feeding history. Radiographic palatal airway
Keywords:
size was measured preoperatively, whereas the presence of allergy was also investigated. All
Otitis media
Effusion
patients were, postoperatively, followed up for a period of two years, in three month intervals.
Adenoidectomy Disease course was classified as “complete remission”, “improvement” or “consistence”, in every
Allergy postoperative evaluation, according to strictly established criteria.
Results: Children’s age proved to be a significant factor in the postoperative outcome of
adenoidectomy, as a treatment of chronic otitis media with effusion, especially when comparing
patients being over and under the fifth year of age. Also, the presence of allergy, family history of
otologic disease and palatal airway size, all proved to influence postoperative outcome in a statistical
significant way (p < 0.05). On the other hand, child’s sex, passive smoking, breast feeding and
previous acute otitis media infections did not seem to alter the efficacy of adenoidectomy.
Conclusion: Adenoidectomy remains a cornerstone in the treatment of chronic otitis media with
effusion in children. Results document that young age, presence of allergy predisposition, otologic
family history and small palatal airway can be important drawbacks and should be intensively
sought for and taken into account, during treatment planning.
© 2018 Elsevier B.V. All rights reserved.

1. Introduction combined with a preceding middle ear infection (acute otitis

Otitis media with effusion (OME) is the commonest cause of
hearing difficulty and one of the most frequent reasons of
elective admission to hospital for surgery, during childhood
[1]. OME pathophysiology is thought to be related, among
others, to poor Eustachian tube function, which may be
* Corresponding author.
E-mail address: kmarkou@med.auth.gr (K. Markou).
media) [2–4]. The majority of children affected, experience a
self-limited process that resolves within a 3 month period, but it
may also run a relapsing and remitting course, before ultimately
resolving in later childhood (chronic otitis media with effusion,
COME). The clinical management of COME involves a variety
of combinations of established procedures, and has become
more evidence-based, over the past 20 years [2,6–8].
The traditional rationale of adenoidectomy in the treatment
of chronic otitis media with effusion (COME) has primarily

https://doi.org/10.1016/j.anl.2018.01.003
0385-8146/© 2018 Elsevier B.V. All rights reserved.

Please cite this article in press as: Blioskas S, et al. Factors affecting the outcome of adenoidectomy in children treated for chronic otitis media
with effusion. Auris Nasus Larynx (2018), https://doi.org/10.1016/j.anl.2018.01.003
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been to free the pharyngeal orifice of the Eustachian tube from
mechanical obstruction. Secondarily the procedure aimed to
remove a chronically infected nidus [9] on the nasopharynx,
which leads to inflammation and subsequent mucous oedema of
the Eustachian tube, but also facilitates the intrusion of
pathogens in the middle ear cavity. Recent studies have
demonstrated that the adenoids in children with OM contain
mucosal biofilms [10,11].
The aim of this cohort study was to determine whether
known risk factors implicated in COME’s pathophysiology can
play a substantial role concerning the effectiveness of
adenoidectomy as a treatment of COME in children.
2. Materials and method
Ninety six children with COME scheduled for adenoidect-
omy were enrolled in this study. All children were aged 4–8
years old, with a mean age of 4.9 years (59.6 months) and a
standard deviation of 11.4 months. Fifty three out of ninety six
children were male (55.2%) and the rest were female (44.8%)
(male to female ratio 1.2:1).
Inclusion criteria were established as follows: (i) presence of
bilateral middle ear effusion identified through examination by
both micro-otoscopy and pneumatic otoscopy and confirmed by
tympanometry (type B tympanogram), (ii) middle ear effusion
persisting for a period greater than 6 months, despite
conservative treatment (mometasone furoate nasal spray
50UG twice a day for a period of one month, amoxicillin
30 mg/kg of body weight three times a day for a period of eight
days, oral Dexamethasone sodium phosphate on a tapering
dosage for a period of ten days. The child was re-evaluated after
one month and if disease persisted, a second course of the same
treatment was administered. The child was then re-evaluated on
three months and again if disease persisted, a third course of the
same treatment was administered. Finally, the child was re-
evaluated on 6 months), (iii) mean hearing threshold worse than
25 dB HL bilaterally, in 500–1000–2000–4000 Hz frequencies,
established by pure tone audiometry, (iv) age greater than
4 years old.
On the other hand, exclusion criteria included previous
surgical intervention to the nose or nasopharynx area, any kind
of previous ear surgery, cleft palate or other congenital disorder
that may influence middle ear status (eg Kartagener syndrome,
Down syndrome etc), congenital or acquired immunodeficiency
and hereditary sensorineural hearing loss.
Preoperatively, a thorough medical history was taken, using
a study designed questionnaire, combined with a personal
interview conducted with the child’s parents. Risk factors that
were particularly sought and evaluated were of course age and
sex and also family history of otologic disease of any kind,
breast feeding, passive smoking and previous infections of
acute otitis media.
Additionally, the presence of allergy was thoroughly
investigated. In terms of medical history, the presence of
symptoms compatible with allergic rhinitis, asthma or atopy, in
general, was evaluated in detail. Moreover, in vitro and vivo
allergic tests were conducted. In particular, both total and
allergen specific (RAST) serum IgE levels were measured in all
Please cite this article in press as: Blioskas S, et al. Factors affecting the outcome of adenoidectomy in children treated for chronic otitis media
with effusion. Auris Nasus Larynx (2018), https://doi.org/10.1016/j.anl.2018.01.003
patients, followed by skin prick tests. Eosinophil count in nasal
smears was, also, evaluated. Finally, any signs or symptoms of
allergy were intensively looked for and closely monitored,
during follow up evaluations.
Radiographic palatal airway size was measured preopera-
tively, during the routine preoperative examination. A
radiographic lateral neck film was taken and the proximal
distance (in mm) between the anteroinferior surface of the
adenoids and the posterosuperior surface of the palate was
measured by the same researcher, using a simple ruler. For
analysis reasons, palatal airway size was classified as “small”
(<3 mm) “medium” sized (3–6 mm) or “large” (>6 mm).
Adenoidectomy was performed by the same surgeon in all
cases, using standard surgical procedures. Since the aim of our
study was to evaluate the efficacy of adenoidectomy alone, in
the treatment of chronic otitis media with effusion, there was no
tympanostomy tube insertion performed in any patient.
All patients were, postoperatively, followed up for a period
of two years, in three month intervals. First postoperative
evaluation, in particular, was conducted immediately after the
first postoperative month. Postoperative evaluations included
micro-otoscopy, tympanometry and pure-tone threshold audi-
ometry. A Grason-Stadler GSI 33 tympanometer and an,
annually calibrated, Interacoustics GSI 26 clinical audiometer,
with Telephonics TDH-50P headphones in a soundproof
chamber, were used in every case. In total, nine postoperative
evaluations were conducted, by the same researchers every
time, to avoid bias.
Disease course was classified as “complete remission”,
“improvement” or “consistence”, in every postoperative
evaluation, according to strictly established criteria. Criteria
for “complete remission” included a Type A or a Type C
tympanogram with a mean hearing threshold better than
20 dBHL in 500, 1000, 2000 and 4000 Hz frequencies. On the
other hand, “improved” status was defined as a type C
tympanogram but with a mean hearing threshold over 20 dBHL
in 500, 1000, 2000 and 4000 Hz frequencies, or a Type B
tympanogram with a mean hearing threshold better than
25 dBHL in 500, 1000, 2000 and 4000 Hz, and also a mean
hearing improvement of at least 10 dBHL compared to
preoperative threshold. Finally, as “consistence” was charac-
terized the case of a Type B tympanogram with a mean hearing
threshold over 25 dBHL in 500, 1000, 2000 and 4000 Hz
frequencies, or a Type B tympanogram with a mean hearing
threshold below 25 dBHL in 500, 1000, 2000 and 4000 Hz, but
with a mean hearing improvement less than 10 dBHL compared
to preoperative threshold. It is obvious, that even though micro-
otoscopy was routinely conducted in postoperative evaluations,
priority was given to objective methods like tympanometry and
pure-tone threshold audiometry, to avoid any subjective
estimation differences and thus achieve a uniform analysis. It
is, also, obvious that since disease usually runs a relapsing and
remitting course, terms like “consistence”, “improvement” and
“remission” refer to a single postoperative evaluation and do
not mirror the disease course as a whole. Thus, a patient may be
registered as “improved” in one evaluation and as “consistent”
in the next and as a result overall disease course can be better
evaluated upon completion of the follow up period.
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Statistical methods used, included the Kolmogorov–Smirnof
test, to test distribution normality and x2 test, Student’s t-test
and one way analysis of variance (ANOVA) depending on the
variable. Pearson’s correlation coefficient factor (r) was also
used. Statistical significance was set at p < 0.05.
The protocol of the investigation has been approved by the
Institutional Review Board, and the investigators have obtained
written informed consent from each participant’s guardian.
3. Results
3.1. Age
In compliance with the study design reported above, all
children were aged between 4 to 8 years old. The majority of
them (69.8%) were in their fifth or sixth year of age. Detailed
age distribution is shown in Table 1. Kolmogorov–Smirnof test
confirmed distribution normality.
Mean time of disease “consistence“ in relation to patient age,
during the two year follow up period, is shown in
Table 2. Although postoperative course seemed to be better
in older patients, difference failed to reach statistical signifi-
cance (p > 0.05).
On the other hand, as far as complete disease remission at the
end of the follow up period in relation to patient age, statistical
significance was established, when comparing patients being
over and under the fifth year of age (x2 test, p < 0.05) (Table 2).
3.2. Sex
Despite the fact that boys outnumbered girls, difference was
not statistically significant (x2 test, p > 0.05).
Differences of the mean time of disease “consistence” and
complete disease remission at the end of the follow up period
did not prove to be statistically significant (p > 0.05) (Table 2).
3.3. Family history
Family history of otologic disease was confined to parents
and brothers, since information about other relatives were often
ambiguous. Thirty five out of ninety six children (36.5%) had a
positive family history concerning otitis media with effusion,
adhesive otitis, relapsing acute otitis media, tympanic perfora-
tion or cholesteatoma. Sex distribution revealed twenty one out
of fifty three males (39.6%) and fourteen out of forty three
females (32.6%) with positive otologic family history.
Both the mean time spent with middle ear effusion and
percentages of complete remission at the end of the follow up
period are shown in Table 2. In addition percentages for
consistence or improvement but with residual disease, during
Table 1
Age distribution.
Age 4th year 5th year 6th year 7th year
n 13 39 28 16
% 13.5 40.6 29.2 16.7
Please cite this article in press as: Blioskas S, et al. Factors affecting the outcome of adenoidectomy in children treated for chronic otitis media
with effusion. Auris Nasus Larynx (2018), https://doi.org/10.1016/j.anl.2018.01.003
3
the first postoperative semester, in particular, rose to 39% and
18% respectively.
All differences proved to be statistically significant
(p < 0.05).
3.4. Breast feeding
Study designed questionnaires revealed that 37 out of
96 patients (38.5%) were breast fed for a period less than
10 days, whereas 40 of them (41.7%) did so for a period
between one to three months and only 19 (19.8%) received
breast milk for a period longer than the first trimester.
Age and sex distribution as well as disease course after
adenoidectomy did not show any statistically significant
differences between groups (p > 0.05) (Table 2).
3.5. Passive smoking
Fifty out of 96 patients (52%) were exposed to cigarette
smoke on domestic environment. In particular, 24 patients
(25%) suffered exposure to 10 cigarettes or less per day,
whereas another 24 (25%) did so for 10–20 cigarettes per day
and 2 patients (2%) were exposed to more than 20 cigarettes per
day. Age and sex distribution of groups did not show any
significant differences.
Again disease course after adenoidectomy did not show any
statistically significant differences, in terms of exposure to
smoke (p > 0.05) (Table 2).
3.6. Acute otitis media infections
Previous infections of acute otitis media proved to be a rather
common event, as expected. In fact, 60 children (62.5%) were
presented with a history of at least one episode of acute otitis
media. Specifically, half of them (30 patients) reported one to
three episodes of acute otitis media since birth, while the rest
exceeded this number, reporting more than three episodes.
Sixteen out of the 96 patients of the study (17%) reported one
episode of acute otitis media before the first year of age.
Age and sex distribution did not show any significant
differences between patients with and without history of acute
otitis media. Also disease course after adenoidectomy did not
show any statistically significant differences, in terms of
previous episodes of acute otitis media (p > 0.05) (Table 2).
3.7. Allergy
Allergy was established in 24 out of the 96 children studied
(25%). In particular, 28.3% and 20.9% of males and females
respectively, were diagnosed as allergic. Sex difference did not
prove to be of statistical significance (p > 0.05). This is a
percentage close enough to that found in the general pediatric
population in Greece. As already mentioned, allergy survey
included individual and family history, total IgE serum levels,
prick tests, RAST and eosinophil count in nasal smears.
Thus, in 22 out of 24 patients that were ultimately diagnosed
with allergy, the diagnosis was confirmed with positive results
of in vivo (prick tests) and in vitro (RAST) tests. In 14 out of
96 subjects, the specific IgE (RAST) in serum was found
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Table 2
Factors affecting adenoidectomy efficacy.

Factor n Mean time of disease p Complete p

“consistence” (months) disease
remission at
the end of the
follow up
period
n %
Age 4th year 13 6.6 >0.05 8 61.5 <0.05*
5th year 39 5.7 25 64.1
6th year 28 5.3 21 75
 7th year 16 5.5 12 75
Sex Male 53 6.2 >0.05 37 69.8 >0.05
Female 43 5.1 29 67.4
Family history of Yes 61 8 <0.05 19 54.3 <0.05
otologic disease No 35 4.3 47 77
Breast feeding <10 days 37 6 >0.05 26 70.3 >0.05
10 days–3 months 40 5.4 28 70
>3 months 19 5.2 12 63.2
Passive smoking No smoking history 46 5.4 >0.05 33 71.7 >0.05
<10 cigarettes per day 24 6.3 16 66.7
10–>20 cigarettes per day 26 6.5 17 65.4
Acute otitis media infections No episodes of acute otitis 36 5.2 >0.05 25 69.4 >0.05
media since birth
1–3 episodes of acute otitis 30 6.4 20 66.7
media since birth
>3 episodes of acute 30 5.6 21 70
otitis media since birth
Allergy Yes 24 8.1 <0.05 14 58.3 <0.05
No 72 4.6 52 72.2
Palatal airway size Small 58 4.4 <0.05 49 84.5 <0.05
Medium/large 38 7.8 17 44.7
*
When comparing children <5years and >5 years.

elevated at least to one allergen. In addition, children with
elevated serum IgE levels and negative RAST underwent prick
test against the most common antigens. Another 8 subjects were
found positive in prick tests. Allergy to perennial antigens was
more commonly found, than to seasonal ones. In the remaining
two patients, RAST and prick tests were negative but diagnosis
of allergy was confirmed by their individual and family history,
elevated total IgE in serum, the clinical evaluation of their
symptoms during the postoperative period and finally by their
positive response to antiallergic treatment.
Mean time of postoperative effusion and “complete
remission” status at the end of follow up period are shown
in Table 2. Both differences proved to be statistically
significant. In addition to these results it was particularly
striking that, upon completion of postoperative follow up
period, 31.5% of allergic patients were registered in
“consistence” category, whereas the respective percentage
for non-allergic subjects was 18.9%. Furthermore, allergic
subjects showed higher percentages (56.7%) of disease
consistence established on one or two consecutive postopera-
tive evaluations, compared to non-allergic ones (33.3%),
which indicates a higher disease consistence for a period
between 1 to 6 months.
3.8. Palatal airway size
The mean size of palatal airway measured was 3.07 mm
ranging between 1 and 9 mm, with a median of 3 mm and a
standard deviation of 1.8 mm. Kolmogorov–Smirnof test
confirmed distribution normality. Mean palatal airway size
of children younger than five years old was 2.8 mm, smaller
than the ones aged over five years (3.3 mm), yet this fact did not
prove to be of statistical significance (t test, p = 0.12 < 0.05).
On the contrary, sex differences proved to be statistically
significant (t test, p = 0.0001 < 0.05), with males showing a
mean size of 2.4 mm compared to 3.8 mm for females. In all,
60.4% (n = 58) of subjects showed a “small” (<3 mm) palatal
airway size, 33.3% (n = 32) showed a “medium” size (3–6 mm)
and the rest 6.3% (n = 6) measured as “large” (>6 mm).
In terms of the mean time spent with middle ear effusion
(“consistence”), and “complete remission” status at the end of
follow up period, all differences proved to be statistically
significant (Table 2). Finally, disease “consistence” for a period
of 6 months or more (two consecutive postoperative evalua-
tions) for “small” airway subjects compared to the ones with a
“medium” or “large” palatal airway size were 20 and 36%
respectively. Again difference was statistically significant.

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4. Discussion
The present survey indicated that child’s age is a significant
factor in the postoperative outcome of adenoidectomy, as a
treatment of COME. Current results are in line with traditional
notions established long ago [12–14] suggesting that children
older than five years old tend to show greater improvement after
adenoidectomy. This knowledge was verified by current large
meta-analysis which established that adenoidectomy is most
beneficial in children with persistent OME aged 4 years
[7]. Eustachian tube maturation in later childhood, may be a
possible explanation of better disease course, in older subjects.
Previous work [15–17] has shown that males tend to suffer
more from COME and otitis media in general compared to
females, possibly due to differences in nasopharynx and skull
base anatomy and development. The greater number of male
participants in present study seems to also mirror this fact. Yet,
sex was not found to be a factor in postoperative outcome of
adenoidectomy.
Remarkably, results suggest that family history of otologic
disease plays a significant role in the surgical outcome of
adenoidectomy. Although, genetic predisposition of otitis
media has been established [15,18], family history has not
been reported to particularly affect disease course after
adenoidectomy before. It seems that constitution and predispo-
sition factors, as expressed through family history character-
istics, can lead to disease persistence or high relapsing rates, but
also influence the success rate of therapeutic surgical
interventions, like adenoidectomy.
Other factors like breast feeding, passive smoking or
previous infections of acute otitis media did not interfere with
adenoidectomy efficacy. All these factors are known for
interfering with COME pathophysiology in significant ways.
Thus, passive smoking is found to lead to both structural and
functional disorders of respiratory and middle ear epithelium
[19,20], like goblet cells hyperplasia and mucocilliary disorder
[21,22] and high rates of acute otitis media and COME [22–28].
On the other hand, breast feeding is thought to act as an
immunological shield [29–32] against otitis media among other
infectious diseases [33,34], especially when it exceeds a
4 month period [35], although other studies question such a
protective link [17,23,36].
Finally, acute otitis media is a very common event in COME
patients, which prolongs duration and raises relapsing rates.
The fact that none of these factors influenced the
postoperative disease course in a statistically significant way,
can lead to the assumption that their role in COME is more of an
accessory nature, than a true aetiological one.
The role of allergy in COME disease course raises
researcher’s interest globally. It is impressive that reports
remain controversial concerning the link between atopic
predisposition and COME, since many authors argue in favour
of a pure allergic nature of COME, while others reject any kind
of link between them [37–44]. In our series, the presence of
allergy was thoroughly investigated both clinically and through
in vivo and in vitro allergic tests, insuring the highest possible
diagnostic efficacy. Ultimately, 25% of our COME patients
were registered as “allergic”, a figure close to that reported for
Please cite this article in press as: Blioskas S, et al. Factors affecting the outcome of adenoidectomy in children treated for chronic otitis media
with effusion. Auris Nasus Larynx (2018), https://doi.org/10.1016/j.anl.2018.01.003
5
general population in our country [45]. So, no significant
correlation between allergy and COME could be established in
the present survey. But, as far as the postoperative course of
COME is concerned, results suggest that allergy resulted to
lower rates of complete remission and greater total time of
effusion presence during the two year follow up period. Thus, it
is evident that allergy proved to be a very important factor
concerning the postoperative outcome of adenoidectomy as a
sole treatment of COME. What was particularly noticed was
that statistical significance reached far higher rates, when
relapsing rates of COME alone were compared between allergic
and non-allergic subjects. Allergic children demonstrated a
distinctive trend towards presenting persisting middle ear
effusion in two consecutive postoperative evaluations, which
indicates intermittent relapsing episodes lasting between 1 and
6 months.
Finally, palatal airway size was routinely evaluated
preoperatively and proved to influence postoperative disease
course, since children who demonstrated a “small” preoperative
palatal airway size, were benefited the most, when undergoing
adenoidectomy. Traditionally, the rationale of adenoidectomy
in the treatment of COME included possible improvement of
Eustachian tube function, since adenoids could block the
nasopharyngeal orifice of the tube [46]. However, many authors
have argued that there is no association between the size of the
adenoids and the surgical outcome of adenoidectomy [47]. Cur-
rent survey suggests that palatal airway size, as measured by
radiographic lateral neck films, remains an important factor in
the postoperative course of COME. It is worth mentioned that a
wide variety of ways, for accessing palatal airway size has been
proposed before [48], many of which may be more anatomically
accurate, than the one suggested here. Yet, most of them include
complicated calculations of a large number of distances and
angles of a variety of anatomical landmarks and often require
special cephalometric radiological analysis that encumbers
routine clinical use.
How should these findings be applied?
COME is a leading cause of medical consultations, antibiotic
prescription and surgery in children. The surgical cornerstones
of its treatment are insertion of grommets, adenoidectomy or a
combination of the two. Recent work criticizes repeated
ventilation tubes insertion quoting that “ventilation tubes cause
too much damage to be repeatedly inserted” and suggests that
perhaps adenoidectomy should be performed alone without
repeat tube insertion at any second operation, if it has not been
done previously [49]. Indeed meta-analyses suggested that
complications like tympanosclerosis or atrophy/retraction of
the tympanic membrane at the site of the tube reached 32% and
25% respectively, posing serious threats [50]. Thus, potential
benefits should be cautiously weighed against the risks of
operating.
On these grounds adenoidectomy’s role seems further
advanced. Until recently the effectiveness of adenoidectomy in
children with COME remained experience-based rather than
evidence-based. Yet, recent work [6–8] has confirmed a
significant benefit of adenoidectomy as far as the resolution of
middle ear effusion in children with COME is concerned. What
continuous to raise interest is identifying the subgroups that will
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benefit most from adenoidectomy. A large 2014 meta-analyses
quotes “ . . . We do not understand why adenoidectomy works
in different subgroups at different ages, nor its effects in special
populations . . . . We also need further research on the impact
and optimal management of otitis media in these special
situations and others . . . ” [7], stressing the need for future
research in defining the value of treatments for children with
COME by investigating their clinical effectiveness.
Our results suggest that the efficiency of adenoidectomy in
the treatment of COME can be influenced by a number of
factors easily evaluated preoperatively. Thus, one should be
open to accept to standard preoperative routine, tests like
complete allergy evaluation, thorough investigation of family
history of otologic disease or lateral neck films. Proper
preoperative evaluation can subsequently guide clinical
decisions by the surgeon and enable him to embody
adenoidectomy to a number of other surgical or non-surgical
procedures and ultimately determine optimal treatment.
5. Conclusions
Adenoidectomy remains today an invaluable surgical
procedure in the overall treatment of COME in children, both
as a sole treatment or combined with a variety of other surgical
options or medical interventions. Evaluation of underlying
preoperative factors that can influence significantly the
outcome of the procedure is of immense importance, in order
to properly handle all therapeutic options and achieve optimal
patient management. Results document that young age,
presence of allergy predisposition, otologic family history
and small palatal airway can be important drawbacks and
should be intensively sought for and taken into account, during
treatment planning and decision making.
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