Benefits of Adding Adenoidectomy to Tympanostomy Tube Insertion

Source: Qian ZJ, Truong MT, Alyono JC, et al. Tympanostomy tube insertion with and without adenoidectomy. JAMA Otolaryngol Head Neck Surg. Published online ahead of print October 17, 2024. doi: 10.1001/jamaoto.2024.3584.Investigators from UC San Diego School of Medicine, La Jolla, CA, and Stanford University, Stanford, CA, conducted a retrospective matched cohort study to compare repeat tympanostomy tube (TT) insertion and subsequent antibiotic prescriptions in children who initially underwent TT placement and adenoidectomy simultaneously (Ad + TT), or TT alone. Study participants were identified by reviewing insurance claims included in the Merative MarketScan Reseasch Databases, which include demographic, diagnostic and procedure codes, and prescription information on >20 million patients enrolled in employer-sponsored insurance plans. Study participants were children <12 years old who underwent Ad + TT between 2007 and 2021. These patients were matched 1:1 with children who underwent TT without adenoidectomy, with matching on age, sex, number of prior TT insertions, and date of the index procedure. Study outcomes were ≥1 additional TT insertions and subsequent antibiotic prescriptions after the date of the index procedure. Logistic regression analyses were used to compare these outcomes among those in the Ad + TT or TT alone treatment groups, after adjusting for comorbidities. Separate analyses were conducted for children <4 years old and those ≥4 years old at the time of the index procedure.Data were analyzed on 201,932 children who underwent Ad + TT and on a similar number in the matched cohort who underwent TT alone. Median age of study participants at the time of the index procedure was 2 years. Of those in the Ad + TT cohort, 16.0% had repeat TT insertion, compared with 14.5% of those who underwent TT alone. Among patients <4 years old, those in the Ad + TT group were significantly more likely to undergo repeat TT insertion than those with TT alone at the index procedure (odds ratio [OR], 1.24; 95% confidence interval [CI], 1.22, 1.27). However, for those >4 years old, Ad + TT was associated with a lower risk of repeat TT insertion (OR, 0.78; 95% CI, 0.75, 0.81). Ad + TT was associated with a significantly lower risk of subsequent antibiotic prescriptions, both among children <4 years old at the time of the index procedure (OR, 0.59; 95% CI, 0.58, 0.60) and those ≥4 years old (OR, 0.63; 95% CI, 0.62, 0.65).The authors conclude that, in children <4 years old, adenoidectomy at the time of TT insertion was associated with a lower risk of subsequent antibiotic prescriptions. For patients ≥4 years old, adenoidectomy in addition to TT insertion was associated with a lower risk of both repeat TT insertion and subsequent antibiotic prescriptions compared to TT alone.Dr Goyal has disclosed no financial relationship relevant to this commentary. This commentary does not contain a discussion of an unapproved/investigative use of a commercial product/device.TT insertion is the most common pediatric ambulatory surgical procedure, performed in about 9% of all children.1,2 Compared with younger infants and older children, toddlers aged 2–3 years are the most likely to undergo the procedure.2 Current expert guidelines outline the indications for offering TT insertion, emphasizing the need to balance the potential risks and benefits using shared decision-making with the family. These guidelines suggest Ad + TT for children aged 4 years or older, or for children experiencing symptoms of adenoid infection or nasal obstruction.1The current investigators compared the effectiveness of Ad + TT with TT alone in a retrospective sample of more than half a million children. Primary outcomes were repeat TT and subsequent oral antibiotic courses. Analyses adjusted for multiple comorbidities, including obstructive sleep apnea and stratified comparisons by age <4 and ≥4 years. The authors observed that for children <4 years, Ad + TT was associated with a decreased likelihood of subsequent antibiotics but increased likelihood of repeat TT insertion. For children ≥4 years, Ad + TT was associated with decreased subsequent antibiotics and repeat TT insertion. Results were similar when lowering the stratification age to 3 years.These results support previous evidence, corroborating current guidelines about the potential utility of adjunctive adenoidectomy for children undergoing TT insertion. (See AAP Grand Rounds. 2007;18[3]:30-31.)3 Of course, this decision should be made in partnership with the family and include discussion of risks of the additional procedure, which could include bleeding and nasopharyngeal scarring. For primary care pediatricians, careful attention to and documentation of nasal symptoms when referring for surgical consultation can help inform these decisions.Adjunctive adenoidectomy is an option with TT insertion, particularly for children ≥4 years old in whom improved otologic outcomes have been found.