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Rapid Responses: Rapid Responses published:
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adenoidectomy!
- zia.s rizvi, karachi.pakistan. (2 March 2004)
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If it doesn´t work, stop it; but working for what?
- Erkki V.M. Hopsu (5 March 2004)
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Erroneous outcome measure
- Valerie J. Brousseau, Lili Nguyen, Sam Daniel (10 March 2004)
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Surgical Beakthrough?
- Graham, J. C. Smelt (15 March 2004)
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oter preventive methods
- Reber M. kalila al sufig (12 June 2004)
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zia.s rizvi, ENT specialist Liaquat National hospital, karachi.pakistan., karachi.pakistan.
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I agree with the authors and would like to share my experiences. In my practice, i have seen that feeding the child flat on it's back, is more responsible for the acute attacks of otis media than any other cause. I ask routinely whether the child is being fed while lying flat on his back and the answer is mostly yes. Avoidance in the future is very helpful in reducing the otitis media attacks. Second most common cause is the cattarrh of the upper respiratory tract and treating it with anti allergics and decongestants is very helpful. Competing interests: None declared |
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Erkki V.M. Hopsu, ENT specialist ENT Clinic, HUS, 00029 Helsinki, Finland
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The conclusion "We cannot recommended it as the primary method of prophylaxis for children aged under 2 years." As said the recommendation is for the recurrent acute otitis media only. The possible efficacy of adenoidectomy to reduce chronic middle ear disease is not considered in this study, and it is to be remembered that the recommendation to avoid adenoidectomy does not mean that the operation should not be performed at all in this age. The investigation was made for common, but limited clinical and pathological conditions; to investigate the acute episode and the usefulness of the adenoidectomy in profylaxis against renewed episodes. Acute otitis media is benign disease in most of cases. Severe complications are nowadays rare. Even chronic otitis media has / seems to have reduced in incidence along the last century. But we still have chronic otitis media, reducing the capacity of middle ear function, its aeration, causing atelectasis and impairing the hearing. Atelectasis and chronic middle ear infection is more harmful for the future function of the middle ear than recurrent acute otitis episodes or even chronic, inflammatory secretory otitis media. Competing interests: None declared |
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Valerie J. Brousseau, McGill University Department of Otolaryngology, Head and Neck Surgery H3G2A4, Lili Nguyen, Sam Daniel
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The main difficulty with this article is the lack of differentiation between acute otitis media (AOM), and otitis media with effusion (OME). AOM implies the presence of middle ear effusion (MEE) with associated symptoms such as fever, otalgia, otorrhea, or irritability. On the other hand, OME refers to MEE in the absence of acute symptoms. AOM and OME represent a spectrum of disease. In our opinion, the protocol used lead to confusion in diagnosis and over treatment of ear disease and thus decreased the study’s capacity to effectively evaluate the use of adenoidectomy and chemoprophylaxis for AOM in this population. Indeed, the outcome measure qualifying the presence of MEE for more than 2 months as treatment failure is inappropriate because it can take up to 3 months for MEE to resolve after AOM(1) . Furthermore, given that the prevalence of MEE on screening is currently estimated at 20%(2) , and that all children with MEE received antibiotic treatment upon screening followed by myringotomy within 2 weeks of persistent MEE followed by tubes and treatment assignment after 2 months of MEE, we consider that the authors were inappropriately biased towards treatment and subsequent enrollment. There is no indication as to the occurrence of AOM symptoms during this enrollment period, suggesting that authors effectively enrolled and treated patients with a history of recurrent AOM but without symptoms of AOM at the time of enrollment or treatment (hence enrolling patients with current OME). Similarly, follow-up assessment of ear status by an otolaryngologist at an interval of at least every 4 months (suggesting that some patients were seen at intervals less than 4 months) is likely to have resulted in bias towards treatment failure because of the length of time required for MEE to resolve. Finally, analysis of secondary outcome measures in table 3 reveals a low incidence of AOM after enrollment suggesting that most treatment failures were inappropriately attributed to MEE lasting more than 2 months. Therefore, this study was biased against the potential positive impact of adenoidectomy and prophylactic pharmacotherapy because of an inappropriate outcome measure. (1)Rovers, M.M., Schilder, A.G.M., Zielhuis, G.A., Rosenfeld, R.M. Otitis Media. Lancet 2004;363:465-73. (2)Casselbrant, M.L., Mandel, E.M. Epidemiology. In: Rosenfeld, R.M., Bluestone C.D., eds. Evidence-based otitis media. Hamilton, ON: BC Decker, 1999;117-36. Competing interests: None declared |
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Graham, J. C. Smelt, Consultant ENT Surgeon to the Calderdale and Huddersfield Trust Huddersfield Royal Infirmary, HD3 3EA
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The Editor when making his "Choices" and Koivunen P. et al. when writing their paper "Adenoidectomy versus chemoprophylaxis and placebo for recurrent acute otitis media in children under 2 years: randomised, controlled trial." appeared unaware of the surgical scoop they had on their hands. 'DESIGN Randomised, double blind, controlled trial.'implies that neither the patient(understandable if under 2), the parents, the relatives and the staff (including the surgeon) did not know if the patient had undergone an operation or was taking medicines! If this were true then other surgeons should be told about this not 'general' but 'global anaesthetic' so they can better assess their surgical interventions against this gold standard of clinical research. If it were not true then the rest of the paper should be viewed with great caution. Competing interests: I am an ENT surgeon |
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Reber M. kalila al sufig, ENT specialist iraq
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i want to add that i noticed that aom and even chronic suppurative otitis media are highly associated with socioeconomical status of the patient as i noticed that they are high in low socioeconomical status may be because of bad feeding habbit, delay doctors consultation even if they do, they didnot consult a specialist one, also i want to add that in a case with recurrent otitis media, if they recieve treatment early if upper respiratory infection occur it will decrease incidice of reperforation of the tympanic membrane and when i said treatment i mean antibiotic and nasal decongestant Competing interests: None declared |
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