University of Toronto study shows more, not less, surgery improves outcomes for children with ear infections

University of Toronto researchers have found that children who are hospitalized with ear infections are much less likely to need further surgery if they undergo a two-part procedure - an adenoidectomy (the removal of adenoid glands) in conjunction with the insertion of tiny tubes in the ear drums - instead of just tube surgery.

Ear infections are the most common reason for visits by children to physicians and can cost the Canadian economy over $600 million annually. When medical therapy fails, standard treatment is a myringotomy - the removal of excess fluid from the middle ear through an incision in the eardrum, followed by the insertion of tiny tubes to maintain proper drainage of the infected fluid. Annually, over 20,000 children in Ontario receive tube surgery.

With funding from the Canadian Institutes of Health Research, U of T researchers found that the two-pronged approach reduced the need for further surgery and hospital readmissions for ear infection-related reasons by half when compared to the tube surgery alone. "This study demonstrates the effectiveness of adjuvant surgery, particularly adenoidectomy, for children with ear infections," says Professor Peter Coyte of the department of health administration in the Faculty of Medicine and lead author of the study that appears in the April 19 edition of the New England Journal of Medicine.

Of the 37,316 children in Ontario who received tube surgery as their first surgical intervention between 1995 and 1997, almost three-quarters received tube surgery alone while the rest also received adjuvant, or additional, surgery: 11 percent received an adenoidectomy, one per cent a tonsillectomy, while 16 per cent had both their tonsils and adenoid glands removed.

Within one year of the initial operation, 10 per cent of the children who underwent only tube surgery were readmitted, compared to four per cent of those with adjuvant adenoidectomy. Within two years, readmission rates increased to 24 and 12 per cent, respectively. "This means eight adjuvant adenoidectomies are required in order to avoid a single hospital readmission over a two-year period," says Coyte. "However, each avoided readmission probably represents a larger reduction in episodes of ear infections, including those in children who are not readmitted."

Surgical complications, such as nausea and vomiting, were rare in all children receiving tube surgery, but were higher in children receiving adjuvant adenoidectomy - 0.5 per cent versus 0.2 per cent, respectively - likely due to the increased complexity and duration of anesthesia. No deaths were reported.

"While surgical guidelines recommend against adenoidectomy to treat ear infections for children under three and against the use of tonsillectomy in all children, current practice in Ontario does not conform to these guidelines," says Dr. Warren McIsaac, associate professor of family and community medicine at U of T and a family physician at Mount Sinai Hospital.

The study found that more than seven per cent of children aged one year or less, and more than 35 per cent of children aged three years, received adjuvant surgery in Ontario. Furthermore, adjuvant surgery was found to be beneficial, even when the children were very young. Repeat surgeries and readmissions were cut in half when adjuvant adenoidectomy was performed on children younger than two, while similar outcomes were reported for adjuvant adenotonsillectomy for children as young as one, but were greatest for children aged three and older.

The authors say these findings demonstrate that current clinical practice in Ontario has deviated from recommended surgical guidelines, and that the guidelines themselves are inconsistent with the evidence regarding the benefits of adjuvant surgery in young children. "But these findings should not be interpreted as a recommendation for the routine addition of adenoidectomy to the treatment of ear infections in children," Coyte adds. "Rather they are intended to inform physicians and parents who weigh the extra risks of surgery against the demonstrated benefits of adjuvant surgery. The question of which children benefit most from adjuvant adenoidectomy remains unresolved."

The study's other authors are Ruth Croxford, a research coordinator in the Clinical Epidemiology Unit of Sunnybrook and Women's College Health Sciences, Dr. William Feldman, professor emeritus of pediatrics at U of T and Dr. Jacob Friedberg, associate professor of otolaryngology at U of T and staff otolaryngologist at the Hospital for Sick Children.

CONTACT:
Steven de Sousa
U of T Public Affairs
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