Adenoidectomy performed concurrently with tympanostomy failed to drop AOM recurrence

Jerome Klein, MD

Our Finnish colleagues have again shown the way in performing a randomized trial to obtain important information about management of recurrent acute otitis media. In this publication, they evaluate the efficacy of tympanostomy tubes with or without adenoidectomy.

They randomly assigned 300 children aged 10 months to 2 years who had recurrent acute otitis media (RAOM; defined as three or more AOM in 6 months) to three groups: tympanostomy tubes; tympanostomy tubes plus adenoidectomy; and neither. The children were followed for 12 months, and the primary outcome was failure (two AOM in 2 months, three AOM in 6 months or persistent middle ear effusion lasting more than 2 months). Tympanostomy tubes only or with adenoidectomy were equally efffective and more effective than neither. We can conclude that adenoidectomy does not substantially add to the efficacy of tubes in prevention of AOM.

But there are management issues that may be substantial that were not considered. First is that conjugate pneumococcal vaccine has been identified as effective in reducing the need for tympanostomy tubes and was not yet introduced in Finland. Future studies will need to evaluate management of RAOM in infants who have received the currently available 13-valent pneumococcal conjugate vaccine (Prevnar13, Pfizer). Second is that annual influenza virus vaccine may also reduce the incidence of at least one episode of AOM each respiratory season. The third management issue relates to the quality of the adenoids and was not evaluated. Is it possible that all adenoids are not created equal and that some are large and more likely to be obstructive at the base of the eustachian tube and result in a higher incidence of RAOM? Fourth is that chemoprophylaxis was not evaluated. A number of studies have demonstrated that children with RAOM who receive a modified daily dose of amoxicillin have a reduced incidence of AOM; inclusion of a medical arm would be of interest in future studies. The last issue is that it is likely that RAOM is a genetically determined disease, but the authors did not include family history in the baseline characteristics.

The study by Kujala and colleagues adds insight into the value of tympanostomy tubes for management of RAOM, but there are other features related to the management of patients who have RAOM and need an immediate plan to prevent further episodes of AOM.