The frequency of otitis media with effusion in patients undergoing adenotonsillectomy

Background: Otitis media with effusion (OME) is one of the most common pediatric health problems especially among young children. It is a condition characterized by accumulation of non-purulent fluid in the middle ear cleft. It may cause serious morbidity to the patient as hearing loss and delayed speech and language development. Objectives: To study the frequency of OME in patients undergoing adenotonsillectomy and to assess the effect of adenotonsillar hypertrophy as an etiological factor. Patients and Methods: This is a clinical observational case-based study was done during the period from June 2012 to January 2013 in the Department of Otolaryngology of Al-Yarmouk Teaching Hospital including 150 patients (aged 4 to 15 years) who visit the outpatient department for various indications for tonsillectomy with or without adenoidectomy). Ear examination was done to all patients and tympanic membrance (TM) features (color, position, air-fluid level, air bubbles and mobility) were recorded. The size of palatine tonsils was evaluated by clinical examination and classified into five grades (0, +1, +2, +3, +4) while adenoid was assessed by flexible nasendoscope and classified into 4 grades (grade 1, 2, 3, 4). Hearing assessment was done using either pure tone audiometry (P.T.A) or free field test in the uncooperative patients. Impedance audiometry was done to assess middle ear pressure. Results: A total of 27 of 150 patients (18 %) were diagnosed to have OME and the majority aged 6-7 years old (12 patients, 44.5%). Seventeen patients (62.9%) were males and 10 patients (37.1%) were females. Nineteen patients (70.4%) had bilateral involvement and 8 patients (29.6%) were unilaterally involved. The TM features were dull color in 28 ears (60.8%), retracted TM in 35 ears (76.1%), impaired mobility in 24 ears (66.7%), air-fluid level in 5 ears (10.9%) and air bubbles in 4 ears (8.7%). Regarding adenotonsillar grading, the common tonsillar grade was +2 (16 patients, 33.3%) while the common adenoid grading was grade 4 (11 patients, 40.8%). Hearing loss was identified in the majority of cases (23 patients, 85.2%) to be in the range of 20-40 dB HL. Impedance audiometry showed that 41 ears (89.1%) had type B tympanogram and 40 ears (86.9%) had negative stapedial reflex. Myringotomy was done in 46 ears. Positive tap was obtained in 43 ears (93.5%). Serous fluid discovered in 26 ears (56.6%) while glue was discovered in 17 ears (36.9%). Conclusion: The frequency of OME is directly related to adenoid hypertrophy regardless the degree of palatine tonsils grading.


Introduction
OME is the chronic accumulation of mucus within the middle ear and sometimes the mastoid air cell system.The time that the fluid has to be present for the condition to be chronic is usually taken as 12 weeks [1].In children, OME usually presents because of the associated hearing impairment and sometimes with a preceding history of illness and otalgia consequent on an episode of acute otitis media.In many children, OME is preceded by an episode of acute otitis media with otalgia and fever .In the majority of children, acute otitis media is considered to have been triggered by a viral upper respiratory tract infection that damages the epithelium of the Eustachian tube, resulting in retention of middle ear fluid.These secretions then become secondarily infected with bacteria-acute otitis media.Once the infection has resolved, it can take time for the epithelium to recover [2].Goblet cells are frequently present and sometimes mucussecreting glands are formed.The ciliary lining would appear to be less efficient at moving the secretions in to nasopharynx [3].
In surgical practice, the fluid is usually characterized by its consistency as being either serous or mucoid.There will be a full spectrum of fluid type made up of a mixture of the secretions of the epithelial cells, the goblet cells and the mucus glands along with the inflammatory transudate/exudates.The main finding is that it is the mucins that come from the secretions that are responsible for the variable viscosity of the middle ear fluids [4].The incidence of pathogens was higher in younger children (less than two years) and in those with recurrent upper respiratory infections and recurrent attacks of acute otitis media.About 66% of cultures were negative [2].Children with a cleft palate, even if repaired, have deficient palatine muscles and resultant poor Eustachian tube function [2].Initial reports on the biochemical analysis of middle ear fluid in OME suggest that pepsin is present in a high proportion of effusions (approximately 80 percent) [5].The present study aimed to estimate the frequency of OME in patients undergoing adenotonsillectomy and to assess the effect of adenotonsillar hypertrophy as an etiological factor.

Material and methods
This is a clinical observational case-based study that was done during the period from June 2012 to January 2013 in the Department of Otolaryngology of Al-Yarmouk Teaching Hospital.A total of 150 patients who visit the outpatient department for various indications for tonsillectomy (with or without adenoidectomy) were included.
The age of children ranged from 4 to 15 years (both sexes).Inclusion criteria were chronic cases of OME (i.e. more than 3 months duration) and any patient referred for tonsillectomy with or without adenoidectomy.Whereas exclusion criteria were Patients with cleft lip &\or cleft palate, Patients with mixed &\or sensorineural hearing loss patients, with postnasal mass (apart from adenoids), with skull deformity, with allergic rhinitis, and acute OME.
All patients underwent clinical assessment via history & physical examination supported by audiological assessment.

Number of patients
Percentage %

Number of patients with OME
Percentage of patients with OME(%) The age distribution of our patients revealed that the commonest age of presentation was 6-7 years (46 patients, 30.7%).Of them, 12 patients (44.5%) had OME and the least common age of presentation was 14-15 years (4 patients, 2.6%) and none of them had OME (Table 1).

Figure 1 Patients Distribution According to Gender
From the total number of studied patients (i.e.150), twenty seven patients (18%) had OME.Of those, 19 patients (70.4%) had bilateral OME and 8 patients (29.6%) had unilateral OME (table 2).Seventy sex patients of the total number (50.7%) had no ear symptoms.However, the commonest ear symptom among the 74 patients (49.3%) with symptoms was hearing loss (26%) followed by otalgia (18%) (table 3).Various grades of tonsillar hypertrophy (apart from 3 patients who were previously underwent tonsillectomy) were identified and the commonest grade was grade +2 in patients with OME as shown in (table 5).
Among the studied patients, 149 patients show various grades of adenoid hypertrophy (as shown in table 6) while one patient was previously underwent adenoidectomy.The commonest grade was grade 4.   Table 8 shows the results of impedance audiometry in the studied patients.The results of tympanometry were compared with the results of intraoperative findings regarding the presence and the type of middle ear fluid (table 10).

Discussion
In the current study, results showed that patients at the age of 6-7 years old had have highest OME.Similar results obtained by Brooks [6] ) who found that 50% of the patients were in the age group of 5-7 years.Matloob [7] ( found a mean age of 6.5 years in the first decade of life.However, the results disagreed with Apostolopoulos et al. [8] who found that 93.7% of patients with OME were 11 years old or younger. The study revealed an increase in the incidence of OME in males (63.9%) in comparison to females (37.1%) with male to female ratio 1.7:1.This was nearly the same ratio found by Black et al. [9] which was 1.9:1.Tos and Stangerup [10] have shown that male children have more incidences of secretory otitis media than females due to male preponderance of childhood infection.Al-Badri and Al-Mukhtar [11] showed in their studies that there was a male predominance with male to female ratio of 2.3:1 while Paradise et al. [12] reported no sex difference in the incidence of secretory otitis media.
Hearing loss was the most common ear-related symptom and found in 21 patients (77.8%).The results agreed with Reddy [13] (74%) of patients with OME had hearing loss.However the percentage was lower than Al-Bayati [14] (91%).
Various adenotonsillar grading was detected during the current study.Collins et al. [23] showed that the total amount of Histamine in patients with bilateral otitis media with effusion was significantly higher than in patients without the condition.They suggested that adenoidectomy may reduce a potential source of inflammatory mediator from the vicinity of the Eustachian tube.
The type of fluid obtained by myringotomy and aspiration did not show a correlation with the type of tympanogram as both types of fluid (serous or mucous) can occur in any type of curve.This was consistent with the findings of Ovesen et al. [24] who showed that there was no statistical correlation between the tympanometrical findings and the viscosity of fluid.

Conclusion
OME has higher incidence in children aged 6-7 years old.The incidence in male patients was higher than femalea: sex ratio of 1.7: 1.The OME is not related to tonsillar hypertrophy without adenoid enlargement.The incidence of OME in children is directly related to adenoid size.The hearing loss in OME is most commonly of mild type.Type B tympanogram is highly correlated with OME but is not diagnostic to the type of middle ear fluid.

Table 2
Laterality of OME

Table 3
Patients Distribution According To Ear Symptoms This table 4 reveals the characteristics of the T.M. according to different variables (color, position, mobility, air-fluid level and air bubbles).

Table 4
Tympanic Membrane Features in Patients with OME P value of all features < 0.001 (significant) ; P value of mobility = 0.046 (significant)

Table 5
Results of Tonsillar Grading

Table 6
Results of Adenoid Grading

Table 7
Results of Hearing Loss

Table 8
Results of Impedance Audiometry

Table 9
Results of Middle Ear Fluid Aspirated

Table 10
Correlation between the type of Tympanogram & the type of middle ear fluid aspirated P value (for type B tympanogram) < 0.001(significant); Sensitivity of type B tympanogram = 90.69%;Specificity of type B tympanogram = 33.3%