Brief Report

Adenotonsillectomy is Ineffective in Preventing Recurrent Acute Otitis Media

Source: 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 1999;282:945-953.

Adenoidectomy and adenotonsillectomy are frequently performed in the United States in an attempt to reduce the occurrence of persistent or recurrent otitis media. Paradise and associates at the Children’s Hospital of Pittsburgh, who have conducted some of the most important and definitive studies on otitis media in children, conducted a prospective, randomized study to assess the efficacy of adenoidectomy or adenotonsillectomy in preventing otitis media. Children 3-15 years of age who had not undergone tympanostomy tube placement, who had experienced at least three episodes of acute documented otitis media in the preceding six months, or at least four episodes in the preceding six months were eligible for inclusion in the study. Four hundred sixty-one children were stratified into three age categories (3, 4-6, and 7-15 years of age) and further classified if adenoidal nasal obstruction was present. Two studies were conducted in these children. In trial one—a three-way study—394 children without tonsil- related indications for tonsillectomy were assigned to receive adenoidectomy, tonsillectomy and adenoidectomy (T&A), or be a control group without surgery.

The second parallel two-way study enrolled assigned 157 children whose tonsils appeared to be potentially obstructing or who had a history of recurrent sore throats to an adenotonsillectomy or a control group. Four hundred ten subjects were followed in the two trials (86% for 1 year, 75% for 2 years, and 61% for 3 years). Children were seen regularly and episodes of otitis media were evaluated by study personnel. The primary outcome measure was the number of acute episodes of otitis media. All episodes of otitis media were treated with conventional doses of antibiotics—chiefly amoxicillin.

The efficacy of surgery in both trial groups was modest and limited mainly to the first year after surgery. The largest difference was seen in the three-way study, where the rate of otitis media was 1.4 in the adenotonsillectomy group compared to 2.1 in the control group. There was no decrease in the number of subsequent polyethylene (PE) tube placements. Peri- and post-operative complications occurred in 14.6% of children who had adenotonsillectomy.

Paradise et al conclude that there is only a limited and short-term effect of both adenectomy and adenotonsillectomy in reducing the incidence of acute otitis media in children. Given the risks, morbidity, and costs of these surgical procedures, neither operation should be considered as a first surgical intervention in children whose only indication is recurrent otitis media. (This Brief Report was written by David E. Karas, MD, Head of Pediatric Otolaryngology at Yale University School of Medicine, New Haven, CT.)

Adenotonsillectomy:

a. has very few complications.

b. reduces the rate of otitis media during the following year by a small amount.

c. is of long-term benefit in reducing the rate of otitis media in children.

d. reduces the need for subsequent PE tube placement.