Association Between Enlarged Adenoid and Otitis Media with Effusion in Children

Objectives: To assess the association between enlarged adenoid and otitis media with effusion in children. Methods: This cross sectional comparative study was carried out in the Department of Otolaryngology-Head & Neck Surgery in Bangabandhu Sheikh Mujib Medical University, from July 2013 to June 2015. Thirty children with enlarged adenoids (case) and 30 children without enlarged adenoids (control) were included in this study. All patients subjected for history, local physical examination and evaluation of adenoid size by lateral X-ray of post nasal space. Tympanometry and pure tone audiometry are also done. Information’s recorded on a specially designed data sheet. Result: Among 30 case and 30 control, 12 (40.0%) and 2 (6.7%) patient had OME in case and control group respectively, mean age was 9.5 (2.76%) years and 9.96 (2.95%) in case and control group respectively. Male were predominant (70%) than female (30.0%) in cases. Among cases, gradeI was 20.0%, grade IIwas 33.3% and grade-III was 46.7%. Hearing loss was found in 14 (46.7%) children. According to tympanometry, type A curve was in 17 (56.7%) children, type B in 9 (30.0%) and type C in 4 (13.3%) cases. Conclusion: Enlarged adenoids can be relevant in the pathogenesis of otitis media with effusion.


Introduction:
The adenoid (pharyngeal tonsil) is a triangular mass of lymphoid tissue located on the posterior aspect of the nasopharynx. Together with the lingual tonsils anteriorly, the palatine tonsils laterally, all together form a ring of lymphoid tissue known as Waldeyer's tonsillar ring. 1 The adenoid appears to be at largest in size at 7 years of age. However, clinical symptoms are more common in the younger age group, due to the relative small volume of the nasopharynx and the increased frequency of the upper respiratory tract infections. 2 Nasal obstruction, rhinorrhoea, and hyponasal voice are the usual presenting symptoms of adenoid hypertrophy. 3 The adenoid may be implicated in the upper respiratory disease due to partial or complete obstruction of the nasal choanae or as a result of sepsis. Pathological manifestations include rhinitis, rhinosinusitits, otitis media with effusion.
Otitis media with effusion is characterized by an accumulation of fluid in the middle ear cleft behind an intact tympanic membrane, in the absence of signs and symptoms of acute infection. 4,5 Due to the anatomical difference in the Eustachian tube, children are more sufferer of OME. In children Eustachian tube are more horizontal and shorter. 6 Adenoid hypertrophy can contribute to the incidence of OME through direct obstruction of Eustachian tube, secondary to chronic infection in the adenoidal tissue and, allergic reaction in the mucosa of adenoid and nasopharynx. 7 OME is very common in children, especially between the ages of 1 and 3 years, with a prevalence of 10% to 30% and a cumulative incidence of 80% at the 4 years old. Its incidence decreases with age, so it is uncommon in teenagers (1% at 11 years). It is also more common in cold weather and in boys more than girls, children with cleft palate, Down syndrome, and allergic rhinitis. 8 OME is the most common cause of hearing loss in children. It causes to a conductive hearing loss (HL) of variable severity. Hearing impairment usually discovered at routine screening or noticed by the parents and teachers. Over 80% of OME results in conductive HL, averaging 30 dB HL, ranging from 5 to 50 dB HL. HL is significant, especially in bilateral cases. It lasts longer than 3 months, with speech delay and learning difficulties in 20%. Most cases of OME present between 1 to 6 years of age. 9 Enlarged adenoids is the most common cause of OME in children which subsequently causes hearing loss, delayed speech and language acquisition, altered behavior & negatively impact quality of life. Enlarged adenoids associated with OME are one of the important aspects of otolaryngological practice. Children may be missed from diagnosis because they may not complain about it. This study will help to aware otolaryngologist about enlarged adenoids & OME and to realize the importance of tympanometric evaluation along with PTA in early detection of OME.

Objectives: General Objectives
Observation of the association between enlarged adenoids and otitis media with effusion in children.

Specific Objectives
• To find out the frequency of OME in enlarged adenoids and non enlarged adenoids group.
• To find out degree of hearing loss in children with enlarged adenoids.
• To determine the association between grade of enlarged adenoids and hearing loss due to OME.

Methods:
Study design: Cross Sectional Comparative study Study period: The total period of study was 2 years (from July 2013 to June 2015). Data collection technique: Data were collected recorded in preformed data collection sheet. The relevant sociodemographic data of these patients were collected and recorded.
Statistical Analysis: All data were recorded systematically in preformed data collection form (questionnaire) and quantitative data were expressed as mean and standard deviation and qualitative data were expressed as frequency distribution and percentage. Statistical analysis was performed by using window based computer software devised with Statistical Packages for Social Sciences (SPSS-20). 95% confidence limit was taken. Chi-square test was done to see the association between categorical data and unpaired t test was done to see the association between numerical data. All statistical tests were considered significant at a level of p < 0.05. The summarized data was interpreted accordingly and was then presented in the form of tables. Majority of children in both groups was in the age range of 6-10 years. In our study boys was comparatively more than girls which was not statistically significant. Result shows proportion of hearing loss increase with the severity of nasopharyngeal obstruction by adenoid hypertrophy. Hearing loss was significantly more in group-I. Rate of moderate hearing loss was more in group:I  OME was significantly higher in children of gtoup I than that of group II.

Discussion:
This Study was performed upon 60 children divided into two groups (Group:I and Group:II) depending on presence or absence of enlargement of adenoids. In group: II 30 age matched children without enlarged adenoids were taken for better precision.
In our study, most of the children with enlarged adenoids (56.7%) were in the age group of 6 to 10 years. Enlarged adenoids was found among 60% patients in 5 to 6 years old group in a study which is not concordance with us. 10 Another study reported that large adenoids were most frequently observed between the ages of 6-8 years, this result is partially consistent with this study. 11 In our study, male (70%) were predominant than female (30%). In one study it was found that 22 (64.7%) were males and 12 (35.3%) were females. 12 which is similar to this. Male has more outdoor environmental exposure than female.
In our study according to size of adenoids, maximum children study group (46.7%) had grade-III followed by grade-II (33,3%) and grade I (20.0%). It was seen in a study that maximum children (54.2%) had grade-III followed by grade-II (16.7%), grade-IV (16.7%) and grade-I (12.5%). 7  In our study OME were found in 12 (40.0%) children with enlarged adenoids and 2 (6.7%) children with non-enlarged adenoids. The difference between these two groups was statistically significant (p<0.05).The incidence of OME was significantly higher in the children with enlarged adenoids (35.0%) than the normal control (7.0%) (p<0.001) and the risk of OME was more than 7.5 times as more among adenoidal group than among the non-adenoidal control, 14 our result was concordance with this result. The causes of development of OME other than enlarged adenoids are excluded as much as possible. We tried to match the control group with the study group in respect of age, socioeconomic condition and residence. So, the difference of the rate of OME between these two groups is due to enlargement of adenoids.

Conclusion:
Enlarged adenoid is associated with otits media with effusion (OME) in children. Rate of OME was higher in children with enlarged adenoids and lower in control group. Increase severity of nasopharyngeal obstruction is directly associated with increased rate of OME. At least tympanometric evaluation should be done for early diagnosis of the OME and to reduce its long term effects.