The Rise and Fall of Radium Adenoid Ablation

In the early 20th century, childhood hearing loss from middle ear effusion was recognized as a significant contributor to inattention and poor school performance. The tools available to treat middle ear disease—eustachian tube insufflation and blind curette adenoidectomy—often proved ineffective. In 1929, the Rockefeller Foundation endowed a laboratory at Johns Hopkins Hospital to study hearing loss. Samuel J. Crowe, the young professor of otology and laryngology, directed the laboratory. ¹ Using one of the first practical audiometers, an electric otoscope, and a basic nasopharyngoscope, he identified residual adenoid tissue following conventional adenotonsillectomy in 70% of children. The presence of lymphoid tissue around the tori tubarii seemed to correlate with persistent hearing loss. ²

Crowe was familiar with the work of Samuel Heinicke at the University of Leipzig. In 1904, Heinicke demonstrated that lymphoid tissue was more radiosensitive than epithelium, muscle, or bone, and that radiation could safely reduce lymphoid tissue without destroying it. ³ Eager to clear residual adenoid tissue without injuring the eustachian tube orifices, Crowe enlisted the help of Curtis Burnam, a Hopkins surgeon with an interest in radiation therapy. Together, they experimented with external beam radiation and subsequently developed a trans-nasal applicator with a capsule at its distal end containing 1000 mCi of radon. They found that repeated treatments with radiation from the capsule could eliminate residual lymphoid tissue from the nasopharynx ⁴ (Figure 1).

Figure 1.

The applicator, composed of a threaded handle, a capillary glass tube filled with radon, and a brass cap. The applicator was inserted under topical anesthesia, guided by a nasopharyngoscope.

Soon, the team demonstrated that radiation treatment alone, rather than as a postoperative measure, was effective and could be delivered under topical anesthesia with tetracaine. Guided by nasopharyngoscopic visualization, the radon applicator was advanced along the nasal floor toward the posterior nasopharyngeal wall, just short of physical contact with the adenoid tissue. Due to radon’s brief half-life (3.8 days), the exposure time in the nasopharynx had to be adjusted twice daily. Subsequently, a radium-based applicator was developed, offering more consistent alpha emissions that allowed treatment in just 9 minutes. Children were generally cooperative with the procedure, but sometimes required restraint in a parent’s lap.

The State of Maryland embraced school hearing screenings. Before long, every county in the state was screening and referring children to a central clinic in Hagerstown, MD, led by Donald Proctor, a junior faculty member at Johns Hopkins. Proctor reported that of 7615 children screened between 1944 and 1947, 4.6% (350) were referred to the clinic, and half of these underwent radium treatments. ⁵

Data from the Hagerstown clinic showed that 90% of patients had fewer infections following treatment, 58% of chronically discharging ears healed completely, and 71% of those with recurrent ear infections experienced no further episodes.

Dozens of publications confirmed the effectiveness of adenoid radiation. Rapidly, radium treatment gained widespread acceptance in the United States and Europe. From the 1940s to the mid-1960s, between 500 000 and 2.5 million children received this treatment. ⁶

By the late 1950s, Cold War fears surrounding radiation intensified, and many parents declined what had become the standard therapy for middle ear disease. This paranoia was compounded in 1958 when a radium capsule went missing during the treatment of a 5-year-old girl in the Netherlands. The girl later vomited at home, and her father cleaned up the mess with an old newspaper, which he then burned in the family stove. The incident became a cause célèbre after a government team with Geiger counters found radiation contamination in the living room, chimney, and garden. The family was quarantined for weeks. Although the girl showed no signs of injury or residual radioactivity, she was stigmatized when parents in her village feared having their children play with her. ⁷

It was these growing concerns over radiation’s ill-effects, rather than improvements in adenoidectomy technique, that led to the decline of this popular method. The introduction of tympanostomy tubes to treat middle ear effusion in the 1960s drove the final nail into radium therapy’s coffin.

The Centers for Disease Control and Prevention estimates that the standard adenoid radium protocol delivered 2000 to 10 000 centigray to the nasopharyngeal mucosal lining, 5 to 22 centigray to the brain, and 2 to 10 centigray to the thyroid. Despite these substantial radiation exposures, several well-performed epidemiological studies following patients from the radium era for more than 3 decades failed to demonstrate an increased risk of head and neck, thyroid, or brain cancer compared to the general population. ⁸