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Autoinflation: an Effective Nondrug Intervention for Glue Ear

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Autoinflation: an Effective Nondrug Intervention for Glue Ear CMAJ Commentary Autoinflation: an effective nondrug intervention for glue ear Chris Del Mar MD, Tammy Hoffmann PhD See also page 961 and www.cmaj.ca/lookup/doi/10.1503/cmaj.141608 n a linked research paper, Williamson and found that antibiotics are not effective.4 Further­ Competing interests: See colleagues1 evaluated the effect of auto­ more, unnecessary antibiotic use exposes pa­ end of article. inflation, by nostril, of a purpose­designed tients to potential adverse effects5 and contrib­ This article was solicited I 6 rubber balloon in 320 children aged 4–11 years utes to the development of antibiotic resistance. and has not been peer with glue ear. Glue ear (also known as secre­ Use of autoinflation as a first­line treatment for reviewed. tory otitis media or otitis media with effusion) glue ear may reduce the number of children who Correspondence to: affects as many as 80% of children, with peaks need to undergo surgery for grommet tube place­ Chris Del Mar, [email protected] in incidence at two and five years of age.2 The ment. Some cases will have resolved before sur­ consequent deafness may interfere with lan­ gery (an estimated 1 in 10 if surgery is delayed by CMAJ 2015. DOI:10.1503 /cmaj.150527 guage acquisition, behaviour and education, three months3), and some parents who are con­ which worries parents of affected children. cerned about the risks of surgery, hospital admis­ Effective treatment options are few. sion and anesthetic may elect to persevere with One of the main findings of the linked study autoinflation beyond three months. is that glue ear had resolved — by objective Autoinflation is one of a number of effec­ measurement using tympanometry — at three tive nondrug interventions typically underrep­ months in a greater proportion of children in the resented in research and clinical practice. Get­ intervention group than in the control group. The ting the message to clinicians about effective number needed to treat was only nine. The nondrug treatments is much harder than it is objective outcome measure was important in this for drug treatments. Furthermore, prescribing trial because participants could not be masked to nondrug interventions requires clinicians to allocation. The intention­to­treat analysis also know the details of the intervention (as op­ showed improvements in the quality of life of posed to being able to look up details on pre­ children in the intervention group at three scribing information in a pharmacopeia), and months. Possible adverse effects were common many nondrug trials do not describe the inter­ colds and earaches, with a slightly higher num­ ventions in enough detail for them to be used ber of these among the children who used auto­ in practice.7 In the case of the intervention inflation. Child and parent acceptance of the evaluated in the current trial, once the physi­ intervention was good, with a compliance rate of cian knows about autoinflation and its effec­ 80% at three months. tiveness, the device needs to be available for At last, there is something effective to offer purchase or dispensing, and the physician must children with glue ear other than surgery. Surgi­ know how to use it and be able to instruct the cal insertion of grommet ventilation tubes patient and parents in how and when to use it through the tympanic membrane is immediately (in the current trial, the prescription was three effective, as shown by a Cochrane review times per day for three months). involving 1728 participants in 10 trials.3 How­ Williamson and colleagues mostly follow the ever, it has no benefit beyond six months, at TIDieR (Template for Intervention Description which time the deafness of most children in the and Replication) guidelines for intervention control groups resolves naturally, and no effect reporting8 and therefore provide most of the has been shown on the important outcomes of speech and language development.3 Key points This important trial by Williamson and col­ leagues effectively addresses the lack of medical • Glue ear is common, affecting most children, and can interfere with language acquisition and education. treatments for glue ear available to primary care • Effective therapeutic options, other than surgical insertion of grommet clinicians. Clinicians are often tempted to use ventilation tubes, are few. antibiotics in children with glue ear in the futile • A new trial found that autoinflation is effective, with a number hope that they might help. A Cochrane system­ needed to treat of nine. atic review involving 3027 children in 23 studies All editorial matter in CMAJ represents the opinions of the authors and not necessarily those of the Can adian Medical Association. ©2015 8872147 Canada Inc. or its licensors CMAJ, September 22, 2015, 187(13) 949 Commentary detail that a physician will need to prescribe the 4. van Zon A, van der Heijden GJ, van Dongen T, et al. Antibiotics for otitis media with effusion in children. Cochrane Database intervention. A physician who wishes to pre­ Sys Rev 2012;(9):CD009163. scribe autoinflation might be wise to obtain a 5. Gillies M, Ranakusuma A, Hoffmann T, et al. Common harms from amoxicillin: a systematic review and meta­analysis of ran­ balloon device to use for demonstration and domized placebo­controlled trials for any indication. CMAJ might choose to teach a practice nurse to dem­ 2015;187:E21­31. 6. Costelloe C, Metcalfe C, Lovering A, et al. Effect of antibiotic onstrate the intervention to the parent and child. prescribing in primary care on antimicrobial resistance in indi­ To overcome the lack of a pharmacopeia vidual patients: systematic review and meta­analysis. BMJ equivalent for effective nondrug interventions, 2010;340:c2096. 7. Hoffmann TC, Erueti C, Glasziou PP. Poor description of non­ the Royal Australian College of General Practi­ pharmacological interventions: analysis of consecutive sample tioners has recently launched the freely available of randomised trials. BMJ 2013;347:f3755. 8. Hoffmann TC, Glasziou PP, Boutron I, et al. Better reporting of Handbook of Non­Drug Interventions (HANDI) interventions: template for intervention description and replica­ (www.racgp.org.au/handi). Autoinflation is an tion (TIDieR) checklist and guide. BMJ 2014;348:g1687. intervention that will soon be included in Affiliation: Centre for Research in Evidence Based Practice, HANDI. Inclusion in this resource will mean Bond University, Gold Coast, Queensland, Australia that physicians will be able to access details Contributors: Both authors wrote and revised the article, about this nondrug intervention in future, long gave final approval of the version to be published and agreed after reading the article by Williamson and to act as guarantors of the work. colleagues. Competing interests: Chris Del Mar has received personal fees from Key Pharmaceuticals for consultancy about a new References product (topical analgesia for acute otitis media), personal fees 1. Williamson I, Vennik J, Harnden A, et al. Effect of nasal bal­ from GlaxoSmithKline Pharmaceuticals for consultancy about loon autoinflation in children with otitis media with effusion in a proposed vaccine for otitis media, and grants from the primary care: an open randomized controlled trial. CMAJ 2015 National Health and Medical Research Council and the July 27 [Epub ahead of print]. National Institute for Health Research. He is also the coordinat­ 2. Zielhuis G, Rach G, Van Den Broek P. Screening for otitis ing editor of the Cochrane Acute Respiratory Infections Group. media with effusion in preschool children. Lancet 1989; 333: Tammy Hoffmann reports personal fees from the Royal Aus­ 311­4. 3. Browning GG, Rovers MM, Williamson I, et al. Grommets tralian College of General Practitioners as a member of the (ventilation tubes) for hearing loss associated with otitis media Handbook of Non­Drug Interventions (HANDI) committee, with effusion in children. Cochrane Database Sys Rev and is a member of the team that authored the TIDieR (Tem­ 2010;(10):CD001801. plate for Intervention Description and Replication) checklist. 2986 - CMAJ CME Horiz Filler 7X4.pdf 1 2015-01-22 1:24 PM A credit to you! CMA members can earn CME credits for Dr. Stephen Pomedli Family physician reading CMAJ articles Toronto, Ont. The CMAJ is committed to helping meet your accredited learning goals. CMA members can earn CME credits simply by reading the CMAJ. Selected CMAJ articles are eligible for Mainpro-M1 credits from The College of Family Physicians of Canada (CFPC). Members can also obtain Mainpro-M2 credits or MOC (Section 2) credits from Royal College of Physicians and Surgeons of Canada (RCPSC) for reading any article in CMAJ. Learn more www.cmaj.ca/site/cme 2986 950 CMAJ, September 22, 2015, 187(13) .
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