
The paper, “Tympanostomy Tube Insertion With and Without Adenoidectomy,” by Z. Jason Qian, MD, Mai Thy Truong, MD, Jennifer C. Alyono, MD, Tulio Valdez, MD, and Kay W. Chang, MD, published in JAMA Otolaryngology–Head & Neck Surgery (2025;151(1):40-46), is a landmark study offering robust evidence for guiding clinical decisions in paediatric otolaryngology. The research addresses a critical question regarding the association between adenoidectomy and otologic outcomes in children undergoing tympanostomy tube (TT) insertion. The thoughtful design and extensive dataset make this study a pivotal reference for clinicians. This article provides a comprehensive review of the study, its key findings, accompanying critiques, and the authors’ reply while appreciating the collaborative spirit of academic inquiry.
Study Overview
The study utilized claims data from the Merative MarketScan Research Databases, analyzing 601,848 children who underwent TT insertion from 2007 to 2021. It aimed to evaluate the association between adenoidectomy and two primary outcomes: repeat TT insertion and subsequent oral antibiotic prescriptions. Stratified analyses were performed to assess age-related differences in outcomes, categorizing patients into those younger than 4 years and those aged 4 years or older.
Key findings included:
- Children Younger Than 4 Years: Adenoidectomy reduced the odds of subsequent oral antibiotic prescriptions (odds ratio [OR], 0.59; 95% CI, 0.58-0.60) but was paradoxically associated with higher odds of repeat TT insertions (OR, 1.24; 95% CI, 1.22-1.27).
- Children Aged 4 Years or Older: Adenoidectomy reduced the odds of both repeat TT insertions (OR, 0.78; 95% CI, 0.75-0.81) and subsequent oral antibiotics (OR, 0.63; 95% CI, 0.62-0.65).
These findings highlight the nuanced benefits of adenoidectomy, emphasizing its age-specific effectiveness and underscoring the need for individualized patient care.
Critical Appraisal and Insights
The article drew critical commentary from a Letter to the Editor by Dr. Dmitry Tretiakow, Dr. Katarzyna Żyżyńska, and Dr. Agnieszka Kasprzyk-Tryk. Their thoughtful critique raised important considerations regarding the study’s methodology and findings.
Key Points Raised by the Letter to the Editor
- Patient Heterogeneity:
Tretiakow et al. emphasized that the benefits of adenoidectomy might depend on clinical factors such as adenoid size, immunological status, and nasal obstructive symptoms. While Qian et al.’s study provided generalizable conclusions, the lack of specific data on adenoid hypertrophy limited its ability to guide personalized treatment strategies. - Risks vs. Benefits:
The letter highlighted the need to balance adenoidectomy’s potential benefits with its risks, such as post-operative bleeding and prolonged operative time. - Long-Term Developmental Outcomes:
Tretiakow et al. pointed out the absence of data on the impact of adenoidectomy on speech and hearing development—critical metrics for evaluating the procedure’s long-term success. - Comparison with Previous Studies:
The authors compared the findings with smaller studies, such as the meta-analysis by Alamri et al., which suggested similar associations but with limitations due to smaller sample sizes and heterogeneous designs.
Authors’ Response
In their reply, Qian et al. addressed these critiques with clarity and rigor:
- Clinical Context of Adenoidectomy:
The authors reiterated that adenoidectomy should not be universally recommended but reserved for cases where clinical factors, such as significant adenoid hypertrophy or nasal symptoms, justify the procedure. They acknowledged the risks of adenoidectomy, including airway management challenges and longer operative times. - Methodological Robustness:
They defended the strengths of their study, emphasizing its unmatched cohort size of 601,848 children and consistent methodology, which offered more definitive conclusions compared to smaller-scale studies. - Limitations in Long-Term Data:
The authors candidly acknowledged the limitations of their dataset, derived from insurance claims, in capturing long-term developmental outcomes. They encouraged future research to address these gaps. - Comparison to Previous Studies:
Qian et al. clarified that the Alamri et al. meta-analysis, though informative, involved significantly smaller samples and inconsistent methodologies, limiting its generalizability compared to their own study.
Strengths of the Study and Correspondence
The original study and subsequent dialogue underscore several strengths:
- Large-Scale Data: The unprecedented cohort size provided statistical power and generalizability.
- Robust Methodology: Consistent analytical techniques minimized biases and ensured reliable conclusions.
- Constructive Critique: The exchange of ideas between Qian et al. and Tretiakow et al. highlights the value of collaboration in advancing clinical knowledge.
Opportunities for Future Research
Both the original authors and their critics agree on areas for future exploration:
- Incorporating Long-Term Outcomes:
Future studies should assess speech, language, and cognitive development following adenoidectomy, bridging the gap between immediate otologic outcomes and broader developmental impacts. - Refining Patient Selection:
Stratifying patients by factors like adenoid hypertrophy grade, immunological status, and concurrent upper airway conditions could enhance the precision of clinical recommendations. - Cost-Benefit Analysis:
Detailed analyses of operative risks, resource utilization, and long-term benefits could guide policy decisions and resource allocation.
Implications for Clinical Practice
This study and the subsequent discourse provide actionable insights for clinicians:
- Adenoidectomy should be considered for children aged 4 years or older undergoing TT insertion to reduce repeat surgeries and antibiotic use.
- In children younger than 4 years, adenoidectomy should be reserved for cases of significant adenoid hypertrophy or nasal obstruction, as its primary benefit lies in reducing antibiotic prescriptions rather than improving TT outcomes.
- Clinicians must weigh the risks of adenoidectomy, including bleeding and prolonged operative time, against its potential benefits, tailoring interventions to individual patient needs.
Appreciation for the Authors and Journal
Dr. Qian and colleagues have made a substantial contribution to paediatric otolaryngology with their meticulous research and balanced conclusions. Their openness to constructive critique reflects a commitment to advancing evidence-based practice. Similarly, the thoughtful commentary by Tretiakow et al. exemplifies the collaborative spirit of academic inquiry, ensuring that findings are scrutinized and refined.
JAMA Otolaryngology–Head & Neck Surgery deserves commendation for fostering such critical dialogue. By publishing rigorous studies and facilitating meaningful exchanges, the journal continues to serve as a cornerstone of knowledge in the field.
Conclusion
The study by Qian et al., along with the ensuing correspondence, represents a significant step forward in understanding the role of adenoidectomy in paediatric TT insertion. While the findings offer valuable guidance for clinicians, the critiques and authors’ responses highlight areas for further exploration, ensuring that future research continues to refine and enhance clinical practice. This collaboration between researchers and clinicians ultimately advances the shared goal of optimizing care for paediatric patients.
Dr. Prahlada N.B
MBBS (JJMMC), MS (PGIMER, Chandigarh).
MBA in Healthcare & Hospital Management (BITS, Pilani),
Postgraduate Certificate in Technology Leadership and Innovation (MIT, USA)
Executive Programme in Strategic Management (IIM, Lucknow)
Senior Management Programme in Healthcare Management (IIM, Kozhikode)
Advanced Certificate in AI for Digital Health and Imaging Program (IISc, Bengaluru).
Senior Professor and former Head,
Department of ENT-Head & Neck Surgery, Skull Base Surgery, Cochlear Implant Surgery.
Basaveshwara Medical College & Hospital, Chitradurga, Karnataka, India.
My Vision: I don’t want to be a genius. I want to be a person with a bundle of experience.
My Mission: Help others achieve their life’s objectives in my presence or absence!
My Values: Creating value for others.
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Dear Dr. Prahlada N. B. Sir,
Your review of the *tympanostomy tube insertion study* is a masterclass in clarity and insight, akin to a skilled surgeon's precision in the operating room! Your ability to distill complex research into practical, bite-sized nuggets is truly impressive, making even the most intricate concepts accessible to all.
As I read through your blog post, I couldn't help but think of a skilled chef, expertly blending disparate ingredients to create a culinary masterpiece. Your writing is a testament to your passion for sharing knowledge, inspiring us to elevate our own practice and stay abreast of the latest advancements in our field.
Thank you for generously sharing your expertise with us through your regular, educative blog posts. Your dedication to educating and enlightening the medical community is a beacon of hope, illuminating the path forward for us all.
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