Editorials
Otitis Media with Effusion Clinical Practice Guideline
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| See related "Practice Guidelines" on page 2929. | ||
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RICHARD M. ROSENFELD, M.D., M.P.H.
SUNY Health
Sciences Center
Brooklyn, New York
LARRY CULPEPPER, M.D., M.P.H.
Boston University
School of Medicine
Boston, Massachusetts
BARBARA YAWN, M.D., M.SC.
Olmsted Medical
Center
Rochester, Minnesota
MARTIN C. MAHONEY, M.D., PH.D.
State University
of New York at Buffalo
Buffalo, New York
For the AAP, AAFP, AAO-HNS Subcommittee on Otitis Media with Effusion
In 1994, a clinical practice guideline1 on the diagnosis and management of otitis media with effusion (OME) was developed by the Agency for Health Care Policy and Research (now the Agency for Healthcare Research and Quality [AHRQ]). An update2 to this clinical practice guideline, developed by a committee with representatives from the American Academy of Pediatricians (AAP), the American Academy of Family Physicians (AAFP), the American Academy of Otolaryngology-Head & Neck Surgery (AAO-HNS), and other organizations, recently was issued. This updated guideline informs clinicians of evidence-based methods to identify, monitor, and manage OME in children ages two months through 12 years with or without developmental disabilities or underlying conditions that predispose to OME. A summary of this clinical practice guideline appears in this issue of American Family Physician.3 The 1994 guideline1 was limited to children ages one to three years with no craniofacial or neurologic abnormalities or sensory deficits.
Recommendations in this practice guideline2 are based on the best available published data, primarily the AHRQ report on OME from the Southern California Evidence-Based Practice Center,4 through April 2003. Evidence-based statements follow AAP definitions reflecting both the quality of evidence and the balance of benefit and harm.5
Consistent with the 1994 guideline1 and the AHRQ evidence report,4 this updated 2004 clinical practice guideline2 emphasizes making an accurate diagnosis of OME. Differentiating OME from acute otitis media (AOM) can avoid unnecessary antimicrobial use.6
• Clinicians should use pneumatic otoscopy as the primary diagnostic method for distinguishing OME from AOM. [Strong recommendation] Tympanometry may be used to confirm diagnosis of OME. [Option]
The updated guideline2 is distinct from the 1994 guideline1 in areas relating to risk stratification, management, and monitoring.
• Clinicians should distinguish the child with OME who is at risk for speech, language, or learning problems from other children with OME, and should more promptly evaluate hearing, speech, language, and need for intervention in these at-risk children. [Recommendation]
As defined in this updated guideline,2 an at-risk child "is at increased risk for developmental difficulties (delay or disorder) because of sensory, physical, cognitive, or behavioral factors" that "make the child less tolerant of hearing loss or vestibular problems secondary to middle-ear effusion." Evaluation of at-risk children with OME should include hearing testing and evaluation of speech and language. Repeat hearing testing should be performed after OME resolves to document improvement, because OME may mask a permanent underlying hearing loss and cause a delay in detection.
• Clinicians should manage children with OME who are not at risk with watchful waiting for three months from the date of effusion onset (if known), or from the date of diagnosis (if onset is unknown). [Recommendation]
This recommendation is based on the self-limited nature of most cases of OME as documented in cohort studies and in control groups of randomized trials.4,7 About 75 to 90 percent of residual cases of OME after an AOM episode resolve spontaneously within three months,7 and the three-month period of observation is consistent with avoiding unnecessary intervention or surgery.1 At the discretion of the clinician, watchful waiting may include interval examinations.
• Hearing testing should be conducted when OME persists for three months or longer, or at any time that language delay, learning problems, or a significant hearing loss is suspected in a child with OME. [Recommendation]
Hearing testing for children aged four years or older can be done in a quiet area of the physician's office. Conventional audiometry with earphones is performed with a fail criterion of greater than 20 decibels (dB) hearing loss at one or more frequencies (500; 1,000; 2,000; 4,000 Hz) in either ear. Comprehensive audiologic evaluation is indicated for children who fail office testing, are younger than four years of age, or cannot be tested in the primary care setting. Language testing should be conducted for children with hearing loss greater than 20 dB on comprehensive audiometric evaluation.
• Children with persistent OME who are not at risk should be re-examined at three- to six-month intervals until the effusion clears, significant hearing loss is identified, or structural abnormalities of the eardrum or middle ear are suspected. [Recommendation]
If OME is asymptomatic and likely to resolve spontaneously, intervention is unnecessary even if OME persists for more than three months. In contrast, the 1994 OME guideline1 recommended surgery for OME persisting four to six months with hearing loss greater than 20 dB. The current updated guideline2 recommends surgery if a bilateral hearing loss of 40 dB or greater persists; otherwise, the decision to pursue surgery should be individualized. As long as OME persists, the child should be evaluated periodically for hearing loss or structural abnormality to determine the need for intervention.
• When a child becomes a candidate for surgery, tympanostomy tube insertion is the preferred initial procedure; adenoidectomy should not be performed unless a distinct indication exists (nasal obstruction, chronic adenoiditis). Tonsillectomy alone or myringotomy alone should not be used. [Recommendation]
• Antihistamines and decongestants are ineffective in the treatment of OME and are not recommended. [Continued negative recommendation] While antimicrobials and corticosteroids may yield short-term improvements, there is no demonstrated long-term efficacy, and neither should be used for routine management. [Continued negative recommendation]
• The 2004 guideline2 makes "no recommendation" regarding the use of complementary and alternative medicine for OME because of the lack of evidence documenting therapeutic efficacy.
• Similar to the 1994 guidelines,1 the 2004 guideline2 reached no conclusion regarding allergy management as treatment for OME based on insufficient evidence of therapeutic efficacy and the lack of a distinct causal associated between allergy and OME. [No recommendation]
• The updated guideline2 recommends against population-based screening programs for OME among healthy, asymptomatic children. [Negative recommendation] Given the favorable natural history, there is no demonstrable benefit to such screening. Family physicians involved in school health programs should not allow OME screening on every child.
Updating this guideline serves to identify research issues relating to OME diagnosis, management, and surveillance that would be appropriate for family medicine researchers and primary care practice-based research networks to address. The complete OME guideline can be found at http://www.aafp.org/ x1596.xml.
Richard M. Rosenfeld, M.D., M.P.H., is associate professor of otolaryngology and director of pediatric otolaryngology at the State University of New York (SUNY) Health Sciences Center, Brooklyn. Dr. Rosenfeld served as co-chair of the American Academy of Pediatrics (AAP), American Academy of Family Physicians (AAFP), American Academy of Otolaryngology-Head & Neck Surgery (AAO-HNS) Subcommittee on Otitis Media with Effusion.
Larry Culpepper, m.d., m.p.h., is professor and chair of the Department of Family Medicine at the Boston University School of Medicine. Dr. Culpepper served as co-chair of the AAP, AAFP, AAO-HNS Subcommittee for Otitis Media with Effusion.
Barbara Yawn, M.D., M.Sc., is director of research at the Olmsted Medical Center and adjunct professor of family medicine at the University of Minnesota, Rochester. Dr. Yawn served on the AAP, AAFP, AAO-HNS Subcommittee on Otitis Media with Effusion.
Martin C. Mahoney, M.D., Ph.D., is associate professor in the Department of Family Medicine, SUNY School of Medicine & Biomedical Sciences, Buffalo. Dr. Mahoney served on the AAP, AAFP, AAO-HNS Subcommittee on Otitis Media with Effusion.
Address correspondence to Martin C. Mahoney, M.D., Ph.D., Department of Family Medicine, 462 Grider Street, Buffalo, NY 14215 (e-mail: mmahone@acsu.buffalo.edu). Reprints are not available from the authors.
REFERENCES
1. Stool SE, et al. Otitis media with effusion in young children. Otitis Media Guideline Panel. Clinical practice guideline, No. 12; AHCPR publication No. 94-0622. Rockville, MD: U.S. Dept. of Health and Human Services, Public Health Service, Agency for Health Care Policy and Research; 1994.
2. Subcommittee on Otitis Media with Effusion. Otitis media with effusion. Pediatrics 2004;113:1412-29.
3. AAP, AAFP, AAO-HNS Release Guideline on Diagnosis and Management of Otitis Media with Effusion. Am Fam Physician 2004;69:2929-31.
4. Takata G, Chan LS, Mangione-Smtih RM, Agency for Healthcare Resesarch and Quality. Diagnosis, natural history, and late effects of otitis media with effusion. Evidence report/technology assessment No. 55, AHRQ Publication No. 03-E023. Rockville, MD: U.S. Dept. of Health and Human Services, Public Health Service, Agency for Healthcare Research and Quality; 2003.
5. American Academy of Pediatrics. Steering Committee on Quality Improvement and Management. Classifying recommendations for clinical practice guidelines. Pediatrics. In press.
6. Dowell SF, Marcy SM, Phillips WR, Gerber MA, Schwartz B. Otitis media: principles of judicious use of antimicrobial agents. Pediatrics 1998;101 (suppl):165-71.
7. Burke P, Bain J, Robinson D, Dunleavey J. Acute red ear in children: controlled trial of non-antibiotic treatment in general practice. BMJ 1991;303:558-62.
Preventing Unintended Pregnancy: Implications for Physicians
RUTH LESNEWSKI, M.D.
Institute for Urban Family
Health
New York, New York
The U.S. Preventive Services Task Force,1 Healthy People 2010,2 and the World Health Organization3 all recommend that more attention be focused on prevention of unintended pregnancy. Although unintended pregnancy has declined over the past decade, U.S. rates remain much higher than those in other developed countries-particularly among low-income women and teenagers.4,5 Analysis of these disparities can help guide the efforts of family physicians to prevent unintended pregnancy.
Unintended pregnancy is associated with health risks for mothers and children, including domestic violence, drug and alcohol use, delayed prenatal care, and low birth weight.5 Furthermore, a study comparing cohorts born before and after 1973 suggests that unwanted children are more likely to commit crimes as youths and young adults.6 These negative medical and psychosocial correlations underscore the importance of this issue-not just for women, but also for their families and society. Family physicians should put themselves at the forefront of the effort to make every child a wanted child.
The National Survey of Family Growth provides the most recent information on unintended pregnancy in the United States. Between 1987 and 1994, the percentage of unintended pregnancies decreased from 57 to 49 percent.5 About one half of unintended pregnancies end in abortion. The U.S. abortion rate fell by 17 percent from 1992 to 2000 (from 25.7 to 21.3 abortions per 1,000 women 15 to 44 years of age), reaching its lowest level since the 1970s.7
This decline varied considerably by subgroup. High-income women, college-educated women, and teenagers had the greatest decline. In contrast, the abortion rate increased in low-income women and low-income teenagers. Until the mid-1980s, U.S. abortion rates varied little across economic subgroups. After 1987, the rates started to diverge, and by 2000, the rate of abortion among low-income women was nearly double that in wealthy women. The ethnic differences in abortion rates diminish greatly when statistics control for income level.4 The economic disparities in U.S. abortion rates parallel the widening gap between rich and poor, and limitations in access to basic health care.
During the 1990s, women increased their use of contraception and became more likely to choose the most effective methods. In addition, the level of sexual activity among teenagers declined, their use of contraception at first episode of intercourse increased, and an increasing percentage of sexually active teenagers used more effective contraceptive methods. An Alan Guttmacher Institute group analyzed the decline in teenage pregnancy from 1988 to 1995, concluding that improved contraception among sexually active teenagers accounted for 75 percent of the decline and that increased abstinence explained the remaining 25 percent.8
Dedicated products for emergency postcoital contraception were released in the late 1990s. Despite the low level of public awareness of emergency contraception and significant barriers to its use (i.e., availability only by prescription, unreliable stocking in pharmacies), this option had a positive effect on the rate of unintended pregnancy. In 2000, emergency contraception prevented approximately 51,000 pregnancies.7
Little is known about the most effective ways to promote methods of preventing unintended pregnancy. Although community-based programs abound, evaluation has been sparse and outcomes often disappointing. Recent reviews of programs to prevent teenage pregnancy, including those with abstinence-based and multifaceted content, reveal mixed results. There is a similar knowledge gap about how physicians can optimize contraceptive counseling. However, one study suggests that providing women with comprehensive information about contraceptive options and using a patient-centered, respectful approach correlates with better adherence.9
Implications for Physicians. Physicians should:
- Focus preventive efforts on high-risk groups (especially teenagers and low-income women).
- Regularly ask all patients of reproductive age (men and women) about contraception needs, even at office visits initiated for other reasons.
- Use a patient-centered strategy to help patients choose a contraceptive method, acknowledging concerns that can interfere with adherence.
- Inform patients about efficacy rates for different methods and recommend use of high-efficacy options.
- Encourage patients to call or return to the office if they experience problems with the method chosen.
- Prescribe emergency postcoital contraception when indicated. Employ advance prescription of emergency contraception as a backup, especially for patients using barrier methods.
Lowering the rate of unintended pregnancy requires an effective partnership between patients and physicians. Research on the most effective preventive strategies is essential for further progress in this area.
Ruth Lesnewski, M.D., is an attending physician at Beth Israel Residency in Urban Family Practice in New York, N.Y.
Address correspondence to Ruth Lesnewski, M.D., Institute for Urban Family Health, 16 E. 16th St., New York, NY 10003 (e-mail: rlesnewski@institute2000.org). Reprints are not available from the author.
REFERENCES
1. Counseling. Unintended pregnancy. Accessed online April 1, 2004, at: http://www.ahrq.gov/clinic/uspstf/uspspreg.htm.
2. Healthy people. What are the leading health indicators? Accessed online April 1, 2004, at: http://www.healthypeople.gov/lhi/lhiwhat.htm.
3. 2002-2003 Plan of work. Promoting family planning. Accessed online April 1, 2004, at: http://www.who.int/reproductive-health/hrp/plan_of_work/ fplanning.en.html.
4. Jones RK, Darroch JB, Henshaw SK. Patterns in the socioeconomic characteristics of women obtaining abortions in 2000-2001. Perspect Sex Reprod Health 2002;34:226-35.
5. Santelli J, Rochat R, Hatfield-Timajchy K, Gilbert BC, Curtis K, Cabral R, et al. The measurement and meaning of unintended pregnancy. Perspect Sex Reprod Health 2003;35:94-101.
6. Donohue JJ, Levitt SD. The impact of legalized abortion on crime. Cambridge, Mass.: National Bureau of Economic Research, 2000.
7. Finer LB, Henshaw SK. Abortion incidence and services in the United States in 2000. Perspect Sex Reprod Health 2003;35:6-15.
8. Boonstra H. Teen pregnancy: trends and lessons learned. New York, N.Y.: Alan Guttmacher Institute, 2002:1-4.
9. RamaRao S, Lacuesta M, Costello M, Pangolibay B, Jones H. The link between quality of care and contraceptive use. Int Fam Plan Perspect 2003;29:76-83.
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Copyright © 2004 by the American Academy
of Family Physicians. |
