Effectiveness of adenoidectomy in children with recurrent upper respiratory tract infections

Abstract

This thesis focuses on the effects of adenoidectomy in children with recurrent upper respiratory tract infections (URTIs).Despite being one of the most frequent operations performed in children, evidence for the effectiveness of adenoidectomy is scarce and guidance in particular for children with recurrent URTIs is lacking. We systematically reviewed the existing literature on adenoidectomy in children with recurrent URTIs and those with otitis media for the Cochrane Library. We found a significant benefit of adenoidectomy on the resolution of middle ear effusion in children with otitis media with effusion, however the effect on hearing was small and there was no significant benefit on recurrence of acute otitis media. The evidence on adenoidectomy for recurrent URTIs was sparse, inconclusive and had significant risk of bias. We therefore initiated a multi-center randomised controlled trial looking at the clinical and cost-effectiveness of adenoidectomy in 111 children aged 1-6 years with recurrent URTIs. They were randomly allocated to either adenoidectomy within 6 weeks, or to a watchful waiting strategy and followed for 2 years. We found that the number of URTI episodes and days with URTI was the same in both groups, i.e. 7.91 versus 7.8 episodes per person year and 66.10 versus 67.36 days, in the adenoidectomy and watchful waiting group, respectively. The prevalence of URTIs decreased equally over time in both groups, suggesting thatthis reflects the natural course of this condition in children rather than the effect of the operation. No differences were found between the 2 groups in episodes of otitis media, health related quality of life, or antibiotic use. We found that a strategy of immediate surgery is €541 more expensive than a watchful waiting strategy. The extra costs in the adenoidectomy group were primarily attributable to surgery and visits to the ENT surgeon. We also studied the effects of adenoidectomy on the most common potential pathogens residing in the nasopharynx and found that the prevalence of Haemophilus influenzae, Streptococcus pneumoniae, Moraxella catarrhalis, Staphylococcus aureus, Streptococcus haemolyticus, and gram negative rods was similar in the adenoidectomy and watchful waiting group throughout follow-up. Colonization by these potential pathogens at baseline and/or 3 months was not associated with recurrence of URTIs. We therefore conclude that in children selected for adenoidectomy for recurrent URTIs, immediate adenoidectomy confers no clinical benefit over an initial watchful waiting strategy and results in an increase in costs. We recommend updating current clinical guidance on adenoidectomy in children with recurrent URTIs accordingly. Future research should look at why certain children are more susceptible to recurrent URTIs than others and develop risk-based management strategies.