[Acute recurrent pharyngotonsillitis and otitis media].Acta Otorhinolaryngol Ital. 2006 Oct; 26(5 Suppl 84):30-55.AO
In the more recent randomized clinical studies, the surgical procedures adopted (adenoidectomy and adeno-tonsillectomy) for the treatment of the effusive and the acute recurrent forms of otitis media have generally shown a relatively modest and not persistent efficacy. It should be pointed out, however, that the cases studied displayed no clinical elements suggesting the existence of any aetio-pathogenic relationship between the auricular inflammation and a possible pathological disorder localized in the tonsils and/or adenoids.
AIM OF THE STUDY
The present investigation aimed to establish: a) the frequency with which the two forms of tympanic inflammation, under study, were detected in children with recurrent febrile pharyngo-tonsillar inflammation, also considering the possible presence of naso-pharyngeal respiratory obstruction and the severity of these two pathological manifestations; b) in relationship to these parameters, what might be the outcome with respect to the pathological auricular processes following surgical treatment of the pharyngeal disorder (adeno-tonsillectomy or adenoidectomy) vs. watchful waiting, c) the possible advantages offered by ventilation tube, inserted during surgical treatment, in the prevention of the two forms of otitis media studied.
MATERIAL AND METHODS
This retrospective multi-centre investigation involved 678 subjects (388 male, 290 female), age range 2 - 11 years: all subjects were followed-up for a minimum period of 2 years. Patients in this study population were submitted to 3 groups of investigations: a) in the first (487 children submitted to adeno-tonsillectomy), the study population was subdivided into 2 groups according to the frequency of the complaints of febrile pharyngo-tonsillar inflammation reported during the previous 12 months (> 4 or < or = 4); b) in the second (443 children with recurrent febrile pharyngo-tonsillar inflammation during the previous 12 months < or = 4), three groups of cases were compared; in the 1st (252 cases), patients were submitted to adeno-tonsillectomy; in the 2nd (144 subjects), adenoidectomy was carried out; in the 3rd (47 cases), the watchful waiting approach was adopted; c) in the third (193 cases, with both pathological auricular manifestations), patients were submitted to adeno-tonsillectomy (119 cases) or to adenoidectomy 74 cases); during surgery, ventilation tube was applied bilaterally in 61 cases, while 132 patients formed the control group. The results obtained were statistically analysed by chi2 and Fisher test: a "p" value of < 0.05 was considered statistically significant.
The first investigation showed: a) the incidence of cases with auricular disorders was greater in the group presenting recurrent febrile pharyngo-tonsillar inflammation < or = 4 (effusive otitis media: p < 0.05); in this group, the presence of cases with naso-pharyngeal respiratory obstruction was statistically greater (p < 0.05); b) the number of cases in which the pathological auricular process was resolved following adeno-tonsillectomy, appeared high (effusive otitis media: 136/179 = 76%; acute recurrent otitis media: 189/216 = 87.5%), not unlike the percentage of patients with positive results on recurrent febrile pharyngo-tonsillar inflammation and on naso-pharyngeal respiratory obstruction (91.6% and 92.4%, respectively); c) the percentages of recovery, for auricular disorders, were significantly higher in the group presenting more frequent recurrent febrile pharyngo-tonsillar inflammation, i.e. > 4 (p < 0.05); in this group, also the incidence of cases, in which the naso-pharyngeal respiratory obstruction was resolved, was greater. The second investigation demonstrated, in the groups in which surgical treatment was carried out, compared to controls: a) a significantly greater percentage of cases achieving recovery, for both parameters (p < 0.05); as far as concerns the effusive form of otitis media, a total of 72 (67.3%) subjects were cured following adeno-tonsillectomy; 67 (81.7%), following adenoidectomy; in acute recurrent otitis media, the subjects achieving recovery were; for adeno-tonsillectomy, 97 (82.2%); for adenoidectomy; 85 (81.7%); b) in the subjects in whom, following surgical treatment, the inflammatory auricular disorder was resolved, it was generally found that recovery had been achieved not only for the recurrent febrile pharyngo-tonsillar inflammation but also for the naso-pharyngeal respiratory obstruction; c) in the controls, the results appeared to be significantly less satisfactory (< 0.001); together with the lack of success in the watchful waiting approach, as far as concerns auricular disorders, we found, likewise, a significant lack of efficacy (p < 0.001) of this treatment in the management of naso-pharyngeal respiratory obstruction (5/35 cases cured: 14.3%). The third investigation showed that the application of the ventilation tube during adeno-tonsillectomy or adenoidectomy did not lead to any improvement in the results; indeed, the percent recovery of the pathological tympanic processes was significantly greater (p < 0.05) in those subjects in whom transtympanic drainage had not been adopted.
The results of these investigations reveal a clear relationship between the naso-pharyngeal respiratory obstruction and the pathological auricular processes in subjects with episodes of recurrent febrile pharyngo-tonsillar inflammation. These results also demonstrate that adeno-tonsillectomy and/or adenoidectomy are able to resolve the auricular inflammatory manifestations in a very large percentage of cases. These data are apparently in contrast with those described in recent reports related to randomised investigations. In effect, the two groups of investigations had different aims: the studies carried out according to a randomised approach were performed on study populations in which the findings of pathological auricular manifestations were not linked by the demonstration of a correlation with possible adenoid or adeno-tonsillar inflammation; the present study, on the other hand, was performed on patients in whom the auricular disorder was part of the clinical picture of recurrent febrile pharyngo-tonsillar inflammation. Therefore we believe that each of these study methods has precise possibilities, but also limitations; thus, one should not exclude the other, but rather be integrated.