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Changes in Auditory Steady-State Response and Tympanometry Post ISSN: 2572-4193 Aman et al. J Otolaryngol Rhinol 2019, 5:059 DOI: 10.23937/2572-4193.1510059 Volume 5 | Issue 2 Journal of Open Access Otolaryngology and Rhinology RESEARCH ARTICLE Changes in Auditory Steady - State Response and Tympanom- etry Post Adenotonsillectomy in Otitis Media with Effusion Aman, Jagat Singh*, Ashiya Goel, Chandni Sharma, Vikasdeep Gupta and Swati Department of ENT, Pandit Bhagwat Dayal Sharma Post Graduate Institute of Medical Sciences, Rohtak, Check for Haryana, India updates *Corresponding author: Dr. Jagat Singh, Professor, Department of ENT, Pandit Bhagwat Dayal Sharma Post Graduate Institute of Medical Sciences, Rohtak, Haryana, India, Tel: 8397971692 Introduction of fullness in the ear, a ‘popping’ sensation and a dull retracted tympanic membrane (TM) with restricted Otitis media with effusion (OME) is an important mobility on saegalisation often with air bubbles behind and common condition in paediatric age group. It is the the TM. Increased pressure can also cause a bulging TM. leading cause of hearing loss and a social morbidity in children which has long-term consequences for speech Tympanometry is a noninvasive test used for mea- and language development [1]. Adenoid hypertrophy suring middle ear pressure. OME commonly presents is an important etiological factor in the causation with a type B curve i.e, a flat curve with no compliance of OME. Recurrent attacks of rhinitis, sinusitis and peak. Other abnormal tympanometric curves including chronic tonsillitis may cause chronic adenoid infection type C and As may also be seen in OME. Pure tone au- and hyperplasia. Allergy of the upper respiratory tract diometry (PTA) has been the gold standard for the eval- may also contribute to enlarged adenoids [2]. The uation of hearing level [4]. A comparison of thresholds main reasons postulated for adenotonsillectomy as a measured by air conduction (AC) and bone conduction means of treatment and prevention of recurrence have (BC) provides separate estimates of the status of con- centred on the size of the adenoids and the role of ductive and sensorineural systems. However, PTA being recurrent tonsillitis as a focus for ascending eustachian a subjective test fails to provide adequate assessment tube infection. in very young children. Symptoms due to adenoid and tonsillar hypertrophy Auditory steady-state response (ASSR), a newly de- include nasal obstruction, snoring, mouth breathing veloped objective auditory evoked potential test pre- and hyponasal speech. Enlarged adenoids block the dicts frequency specific hearing threshold in all patients eustachian tube causing conductive hearing loss. The irrespective of age, mental state, and the degree of classical concept is that enlarged adenoid or recurrent hearing loss. ASSR being an objective test, can be easily infection of adenoids causes recurrent acute otitis used in infants and children while they are sedated or media and OME. The normal middle ear pressure is -100 asleep to assess the degree of hearing loss [5]. Post ade- notonsillectomy there is an improvement in Eustachian mm of H2O to + 50 mm of H2O and the normal middle ear compliance is 0.39 ml to 1.30 ml. Enlarged adenoid tube function and reduction in middle ear effusion. The causes tubal obstruction at its nasopharyngeal opening gain in hearing can be quantified by a Postoperative and causes reduction of middle ear pressure and ASSR. On searching the english literature, we couldn’t compliance towards negative side due to absorption find any published study assessing the changes in ASSR of gas which leads to otitis media with effusion [3]. post adenotonsillectomy in OME. Therefore, this pro- Local symptoms and signs include hearing loss, feeling spective study was planned with a specific objective to Citation: Aman, Singh J, Goel A, Sharma C, Gupta V, et al. (2019) Changes in Auditory Steady - State Response and Tympanometry Post Adenotonsillectomy in Otitis Media with Effusion. J Otolaryngol Rhinol 5:059. doi.org/10.23937/2572-4193.1510059 Accepted: April 25, 2019: Published: April 27, 2019 Copyright: © 2019 Aman, et al. This is an open-access article distributed under the terms of the Cre- ative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited. Aman et al. J Otolaryngol Rhinol 2019, 5:059 • Page 1 of 7 • DOI: 10.23937/2572-4193.1510059 ISSN: 2572-4193 evaluate the effect of adenotonsillectomy in treatment ing [7]. In grade-I hypertrophy, the tonsils were hidden in of recurrent secretory otitis media in children and the the tonsillar fossa and were barely visible behind the ante- evaluation of its effect on hearing with ASSR. rior pillars. In grade-II, the tonsils were visible behind the anterior pillars and occupied up to 50% of the pharyngeal Methods space (the distance between the medial borders of the an- With the approval of the ethical committee of our in- terior pillars). In grade-III, the tonsils occupied between 50 stitute, a prospective study was conducted on randomly and 75% of the pharyngeal space. In grade-IV, the tonsils selected 20 patients (40 ears), with recurrent otitid media occupied more than 75% of the pharyngeal space. with effusion (OME), of either sex attending the ENT out After an informed written consent, patients under- patient department of Post Graduate Institute of Medical went adenotonsillectomy under general anaesthesia. Sciences, Rohtak, India. Patients in age group of 5-15 years Adenoidectomy was carried out using St. Clair Thomp- with bilateral conductive hearing loss of more than 25 db, sons adenoid currete and tonsillectomy was done by having adenotonsillar hypertrophy confirmed by clinical dissection method under general anaesthesia. Oral hy- examination and x-ray soft tissue nasopharynx. All these giene was maintained with help of betadine and hydrox- patients underwent adenotonsillectomy after unsatisfac- yl gargles. Infusion paracetamol was given as anaelge- tory medical treatment. The patients having a perforated sia. The pure tone audiometry (PTA), ASSR and impe- tympanic membrane, cleft palate and other congenital dence audiometry were performed in all the patients anomalies of ear, recurrent rhinosinusitis and allergic rhi- preoperatively and 8 weeks after adenotonsillectomy nits were excluded from the study. on achieving complete healing. Our study was a case The size of adenoids was assessed with the help of control study/repeated measures design. The paired-t x-ray soft tissue skull lateral view and graded as follows test was applied on the recorded data. All tests were [6]. performed at 5% level of significance, thus an associa- tion was significant if the p value was less than 0.05. Grade I-adenoid occupying less than 25% of naso- pharynx. Results Grade II-adenoid occupying 25% to 50% of nasophar- • In this study, patients ranged between 5-15 years ynx. of age with mean age of 6.70 ± 2.598 years. There Grade III-adenoid occupying 50% to 75% of naso- were 12 males (60%) and 8 females (40%). Incidence pharynx. of male patients is more due to more incidence of childhood infection in males. Grade IV-adenoid occupying 75% to 100% of naso- pharynx. • Mouth breathing was the most common symptom (Figure 1). Tonsillar hypertrophy was graded by Friedman’s Grad- Distribution of symptoms in subjects 90% 80% 70% 60% 50% 40% 85% 70% 30% 55% 20% 40% 10% 10% 0% mouth breathing snoring reduced hearing recurrent sore ear pain throat Figure 1: Distribution of symptoms in subjects. Aman et al. J Otolaryngol Rhinol 2019, 5:059 • Page 2 of 7 • DOI: 10.23937/2572-4193.1510059 ISSN: 2572-4193 10% 20% 20% Dull & retracted TM 7.50% Congested Bulging 5% Ts Patch 37.50% Retracted & fluid level Normal Preoperative otoscopic findings Figure 2: Preoperative otoscopic findings. 0 0 5% 5% 7.50% Dull & reracted Congested Bulging Ts patch 82.50% Retracted & fluid level Normal Otoscopic Findings Post Operatively Figure 3: Otoscopic findings Postoperatively. • Adenoid facies were present in 14 patients, accouting hypertrophy grade of subjects was 3.10 ± 0.85224. for 70% of patients. • Out of 20 patients, 11 were having grade III tonsillar • According to radiological grading, six patients were hypertrophy (55%), 7 were having grade II tonsillar having grade II adenoids (30%), 6 were having grade hypertrophy (35%) and 2 were having grade IV III adenoid hypertrophy and 8 (40%) were having tonsillar hypertrophy. Mean tonsillar hypertrophy grade IV adenoid hypertrophy. Mean adenoid was 2.75 ± 0.639. Aman et al. J Otolaryngol Rhinol 2019, 5:059 • Page 3 of 7 • DOI: 10.23937/2572-4193.1510059 ISSN: 2572-4193 • On preoperative otoscopy, majority of patients had ± 8.47 dB. The mean gain in hearing (dB) is 16.95 ± either a bulging or a retracted tympanic membrane 11.89 and p value is less than 0.05 showing significant and only 10% tympanic membrane were normal in improvement in hearing (Table 2) (Figure 4). appearance. On Postoperative otoscopy, 33 (82.5%) • Maximum ears were having B type of curve (62.5%) tympanic membranes were normal (Figure 2 and followed by C type of curve (30%) preoperatively. Figure 3). Maximum cases were of type A curve (70%) postop- • Only 15 out of 20 patients gave reliable response on eratively. B and C type curves were considered re- PTA (n = 30 ears). The mean preoperative Air Borne flective of OME (Table 3). (AB) Gap (dB) on PTA was 25.23 ± 10.67 dB while the • On comparing adenoid hypertrophy with middle mean postoperative AB Gap (dB) was 14.27 ± 7.61 ear pressure assessed by impedance audiometry dB. The mean gain in AB Gap (dB) is 10.97 ± 12.18. P we found that with grade II adenoid hypertrophy, value was 0.000031 which is less than 0.05, making there were 8 ears with >+ 150 dPa pressure, 3 with the hearing improvement significant.
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