Nine out of 10 children will experience otitis media with effusion (OME) by age 5. It's a common cause of hearing impairment in children and the leading indication for ear tube insertion.
However, according to a Feb. 1 news release(www.entnet.org) from the American Academy of Otolaryngology-Head and Neck Surgery Foundation (AAO-HNSF), surveillance data suggest that some physicians treat OME inappropriately -- that is, with antibiotics -- which can lead to adverse events and bacterial resistance. Antibiotic treatment has not been shown to reduce hearing loss or the need for tympanostomy tubes, and OME normally resolves on its own.
The AAO-HNSF news release accompanies an updated clinical practice guideline(oto.sagepub.com) published in Otolaryngology-Head and Neck Surgery that is intended to help physicians manage their patients' OME.
"Otitis media with effusion is a hazard of early childhood," said Richard Rosenfeld, M.D., M.P.H., chair of the guideline development group, in a related fact sheet.(www.entnet.org) "Most kids will experience ear fluid by the time they are school age. This updated guideline includes more resources to help doctors better communicate with parents and caregivers, and emphasizes that while the ear fluid usually goes away on its own, followup is still important."
- The American Academy of Otolaryngology-Head and Neck Surgery Foundation (AAO-HNSF) has updated its clinical practice guideline on otitis media with effusion (OME).
- The AAFP endorsed the updated guideline, which replaces the 2004 guideline codeveloped by the AAO-HNSF, the AAFP and the American Academy of Pediatrics.
- Surveillance data suggest that some physicians treat OME inappropriately -- that is, with antibiotics -- which can lead to adverse events and bacterial resistance.
The AAFP endorsed the updated guideline, which replaces the 2004 guideline it codeveloped along with the AAO-HNSF and the American Academy of Pediatrics. The updated guideline was informed by new evidence and an evolved methodology that included consumer input.
A multidisciplinary panel of experts representing the disciplines of otolaryngology-head and neck surgery, family medicine, pediatric otolaryngology, otology, pediatrics, allergy and immunology, audiology, speech-language pathology, advanced practice nursing, and consumer advocacy worked to update the guideline.
Significant Points Highlighted
Among changes to the guideline are the addition of information on pneumatic otoscopy and tympanometry to improve diagnostic certainty, expanded information on speech and language assessment for children with OME, and new recommendations for managing OME in children who fail a newborn hearing screen and for evaluating at-risk children.
Also included are new recommendations for assessing OME outcomes and guidance against the use of topical intranasal steroids or adenoidectomy for a primary indication of OME in children younger than age 4.
Overall, the new guideline emphasizes patient education and shared decision-making.
The AAO-HNSF recommends that physicians document the presence of middle ear effusion with pneumatic otoscopy when diagnosing OME in a child. Clinicians also should perform pneumatic otoscopy to assess for OME in a child who presents with otalgia, hearing loss or both.
After a child is diagnosed with OME, the physician should determine if the patient is at increased risk for speech, language or learning problems from middle ear effusion using his or her baseline sensory, physical, cognitive or behavioral factors. The AAO-HNSF also recommends that clinicians evaluate at-risk children for OME at the time an at-risk condition, such as cleft palate or Down syndrome, is diagnosed and again at age 12-18 months.
If a child fails a newborn hearing screen and is diagnosed with OME, the group recommends that the physician counsel the infant's parents on the importance of followup visits to ensure hearing returns to normal when OME resolves. It is important for the physician to document this discussion in the medical record.
The AAO-HNSF also noted the importance of educating families of children with OME about the condition's natural history and possible sequelae, in addition to the need for followup.
In general, clinicians should manage children with OME who aren't at particular risk with "watchful waiting" for three months from the date of effusion onset, if known, or three months from the date of diagnosis if onset is unknown. Followup also can be used to exclude underlying sensorineural hearing loss.
It's worth noting that the AAO-HNSF recommends against screening healthy children for OME who aren't at risk and who don't have OME symptoms such as hearing difficulties, vestibular problems, poor school performance, behavioral problems or ear discomfort.
Family Physician's Take
Guideline co-author and family physician David Hoelting, M.D., of Pender, Neb., told AAFP News that he thought the most important aspect of the updated guideline is to do no harm -- that is, to avoid performing unnecessary and possibly injurious procedures to treat OME. Such interventions won't improve outcomes, will increase health care costs, and could increase morbidity and mortality.
"From a family medicine point of view, this has been an important point we have been putting out front for the past five years," he said. "The Choosing Wisely program that the AAFP has (promoted) the past few years puts this front and center."
Hoelting said a primary difference between the new guideline and the old version is that the updated guidance emphasizes sticking to definitive timelines for watchful waiting. He also noted a trend away from tonsillectomies and adenoidectomies to treat OME.
Furthermore, said Hoelting, "Antibiotics have no place in the treatment of OME; they only increase the risk of resistant bacterial overgrowth and the difficulty of treating actual bacterial infections."
In addition, the guideline clearly outlines when it's appropriate to place tympanostomy tubes -- the only effective treatment for OME -- and when it's best to "let Mother Nature take care of the problem on her own," he said.
"Over the years, the Academy has greatly appreciated AAO-HNSF's emphasis on evidence-based recommendations and medicine," Hoelting explained. "It's why the AAFP has endorsed so many of the guidelines proposed by AAO-HNSF."
Related AAFP News Coverage
AAFP Releases Third List of Tests, Procedures Patients, Physicians Should Question