Gates G A, Avery C A, Cooper J C, Prihoda T J
Division of Otorhinolaryngology, University of Texas Health Science Center, San Antonio.
Ann Otol Rhinol Laryngol Suppl. 1989 Jan;138:2-32. doi: 10.1177/00034894890981s202.
To study the effectiveness of adenoidectomy and tympanostomy tubes in the treatment of chronic otitis media with effusion, we randomly assigned 578 4- to 8-year-old children to receive one of the following: bilateral myringotomy and no additional treatment (group 1), tympanostomy tubes (group 2), adenoidectomy and myringotomy (group 3), or adenoidectomy and tympanostomy tubes (group 4). The 491 who accepted surgical treatment were evaluated at 6-week intervals for up to 2 years. Treatment effect was assessed by four main outcomes: time with effusion, time with hearing loss, time to first recurrence of effusion, and number of surgical re-treatments. For the groups (in order), the mean percent of time with any effusion in either ear was 49, 35, 30, 26 (p less than .0001); the mean percent of time with hearing thresholds 20 dB or greater was 19, 10, 8, and 7 (p less than .0001) in the better ear; and 38, 30, 22 and 22 in the worse ear (p less than .0001); the median number of days to first recurrence was 54, 222, 92, and 240 (p less than .0001); and the number of surgical re-treatments was 66, 36, 17, and 17 (p less than .0001). The most notable adverse sequela, purulent otorrhea, occurred in 22%, 29%, 11%, and 24% of the patients assigned to groups 1 through 4, respectively (p less than .001). In severely affected children who have chronic otitis media with effusion resistant to medical therapy, adenoidectomy is an effective treatment. Adenoidectomy plus bilateral myringotomy lowered posttreatment morbidity more than tympanostomy tubes alone and to the same degree as did adenoidectomy and tympanostomy tubes. Adenoidectomy appears to modify the underlying pathophysiology of chronic otitis media with effusion. This effect is independent of the preoperative size of the adenoid. Tympanostomy tube drainage and ventilation of the middle ear provide adequate palliation so long as the tubes remain in place and functioning. We recommend that adenoidectomy be considered in the initial surgical management of 4- to 8-year-old children with hearing loss due to chronic secretory otitis media that is refractory to medical management and, further, that the size of the adenoid not be used as a criterion for adenoidectomy. Concomitant bilateral myringotomy with suction aspiration of the middle ear contents also should be done, with or without placement of tympanostomy tubes at the discretion of the surgeon.
为研究腺样体切除术及鼓膜置管术治疗慢性分泌性中耳炎的疗效，我们将578名4至8岁儿童随机分为以下几组：双侧鼓膜切开术且不进行其他治疗（第1组）、鼓膜置管术（第2组）、腺样体切除术及鼓膜切开术（第3组）、腺样体切除术及鼓膜置管术（第4组）。491名接受手术治疗的儿童在长达2年的时间里每隔6周接受评估。治疗效果通过四个主要指标进行评估：积液时间、听力损失时间、首次积液复发时间以及手术再治疗次数。对于各治疗组（按顺序），任一耳朵出现积液的平均时间百分比分别为49%、35%、30%、26%（p<0.0001）；较好耳朵听力阈值达到或超过20分贝的平均时间百分比分别为19%、10%、8%、7%（p<0.0001），较差耳朵分别为38%、30%、22%、22%（p<0.0001）；首次复发的中位数天数分别为54天、222天、92天、240天（p<0.0001）；手术再治疗次数分别为66次、36次、17次、17次（p<0.0001）。最显著的不良后遗症——脓性耳漏，分别发生在第1至4组22%、29%、11%、24%的患者中（p<0.001）。对于患有慢性分泌性中耳炎且药物治疗无效的重度患儿，腺样体切除术是一种有效的治疗方法。腺样体切除术加双侧鼓膜切开术比单纯鼓膜置管术能降低更多的治疗后发病率，且与腺样体切除术及鼓膜置管术降低的程度相同。腺样体切除术似乎改变了慢性分泌性中耳炎的潜在病理生理过程。这种效果与术前腺样体大小无关。只要鼓膜置管保持在位且功能正常，其对中耳的引流和通气能提供充分的缓解作用。我们建议，对于因慢性分泌性中耳炎导致听力损失且药物治疗无效的4至8岁儿童，在初始手术治疗时应考虑腺样体切除术，此外，腺样体大小不应作为腺样体切除术的标准。还应根据外科医生的判断，酌情在进行或不进行鼓膜置管的情况下，同时进行双侧鼓膜切开术并抽吸中耳内容物。
