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AMERICAN ACADEMY of PEDIATRICS Otitis Media With AMERICAN ACADEMY OF PEDIATRICS CLINICAL PRACTICE GUIDELINE American Academy of Family Physicians, American Academy of Otolaryngology-Head and Neck Surgery, and American Academy of Pediatrics Subcommittee on Otitis Media With Effusion Otitis Media With Effusion ABSTRACT. The clinical practice guideline on otitis struction, chronic adenoiditis); repeat surgery consists of media with effusion (OME) provides evidence-based rec- adenoidectomy plus myringotomy with or without ommendations on diagnosing and managing OME in tubeinsertion. Tonsillectomy alone or myringotomy alone children. This is an update of the 1994 clinical practice should not be used to treat OME. guideline “Otitis Media With Effusion in Young Chil- The subcommittee made negative recommendations dren,” which was developed by the Agency for Health- that 1) population-based screening programs for OME care Policy and Research (now the Agency for Healthcare not be performed in healthy, asymptomatic children, Research and Quality). In contrast to the earlier guide- and 2) because antihistamines and decongestants are line, which was limited to children 1 to 3 years old ineffective for OME, they should not be used for treat- with no craniofacial or neurologic abnormalities or sen- ment; antimicrobials and corticosteroids do not have sory deficits, the updated guideline applies to children long-term efficacy and should not be used for routine aged 2 months through 12 years with or without devel- management. opmental disabilities or underlying conditions that pre- The subcommittee gave as options that 1) tympanom- dispose to OME and its sequelae. The American Acad- etry can be used to confirm the diagnosis of OME and 2) emy of Pediatrics, American Academy of Family when children with OME are referred by the primary Physicians, and American Academy of Otolaryngology- clinician for evaluation by an otolaryngologist, audiolo- Head and Neck Surgery selected a subcommittee com- gist, or speech-language pathologist, the referring clini- posed of experts in the fields of primary care, otolaryn- cian should document the effusion duration and specific gology, infectious diseases, epidemiology, hearing, reason for referral (evaluation, surgery) and provide ad- speech and language, and advanced-practice nursing to ditional relevant information such as history of acute revise the OME guideline. otitis media and developmental status of the child. The The subcommittee made a strong recommendation that subcommittee made no recommendations for 1) comple- clinicians use pneumatic otoscopy as the primary diagnos- mentary and alternative medicine as a treatment for tic method and distinguish OME from acute otitis media. OME, based on a lack of scientific evidence documenting The subcommittee made recommendations that clini- efficacy, or 2) allergy management as a treatment for cians should 1) document the laterality, duration of effu- OME, based on insufficient evidence of therapeutic effi- sion, and presence and severity of associated symptoms cacy or a causal relationship between allergy and OME. at each assessment of the child with OME, 2) distinguish Last, the panel compiled a list of research needs based on the child with OME who is at risk for speech, language, limitations of the evidence reviewed. or learning problems from other children with OME and The purpose of this guideline is to inform clinicians of more promptly evaluate hearing, speech, language, and evidence-based methods to identify, monitor, and manage need for intervention in children at risk, and 3) manage OME in children aged 2 months through 12 years. The the child with OME who is not at risk with watchful guideline may not apply to children more than 12 years old, waiting for 3 months from the date of effusion onset (if because OME is uncommon and the natural history is known) or diagnosis (if onset is unknown). likely to differ from younger children who experience rapid The subcommittee also made recommendations that 4) developmental change. The target population includes chil- hearing testing be conducted when OME persists for 3 dren with or without developmental disabilities or under- months or longer or at any time that language delay, learn- lying conditions that predispose to OME and its sequelae. ing problems, or a significant hearing loss is suspected in a The guideline is intended for use by providers of health child with OME, 5) children with persistent OME who are care to children, including primary care and specialist phy- not at risk should be reexamined at 3- to 6-month intervals sicians, nurses and nurse practitioners, physician assistants, until the effusion is no longer present, significant hearing audiologists, speech-language pathologists, and child-de- loss is identified, or structural abnormalities of the eardrum velopment specialists. The guideline is applicable to any or middle ear are suspected, and 6) when a child becomes a setting in which children with OME would be identified, surgical candidate (tympanostomy tube insertion is the monitored, or managed. preferred initial procedure). Adenoidectomy should not This guideline is not intended as a sole source of be performed unless a distinct indication exists (nasal ob- guidance in evaluating children with OME. Rather, it is designed to assist primary care and other clinicians by providing an evidence-based framework for decision- This document was approved by the American Academy of Otolaryn- making strategies. It is not intended to replace clinical gology–Head and Neck Surgery Foundation, Inc and the American Acad- judgment or establish a protocol for all children with this emy of Pediatrics, and is published in the May 2004 issue of Otolaryngology- Head and Neck Surgery and the May 2004 issue of Pediatrics. condition and may not provide the only appropriate ap- PEDIATRICS (ISSN 0031 4005). Copyright © 2004 by the American Acad- proach to diagnosing and managing this problem. Pedi- emy of Otolaryngology–Head and Neck Surgery Foundation, Inc and the atrics 2004;113:1412–1429; acute otitis media, antibacte- American Academy of Pediatrics. rial, antibiotic. 1412 PEDIATRICS Vol.Downloaded 113 No. 5 from May www.aappublications.org/news 2004 by guest on September 26, 2021 ABBREVIATIONS. OME, otitis media with effusion; AOM, acute The AAP subcommittee on OME updated the AHRQ review otitis media; AAP, American Academy of Pediatrics; AHRQ, with articles identified by an electronic Medline search through Agency for Healthcare Research and Quality; EPC, Southern Cal- April 2003 and with additional material identified manually by ifornia Evidence-Based Practice Center; CAM, complementary subcommittee members. Copies of relevant articles were distrib- and alternative medicine; HL, hearing level. uted to the subcommittee for consideration. A specific search for articles relevant to complementary and alternative medicine (CAM) was performed by using Medline and the Allied and titis media with effusion (OME) as discussed Complementary Medicine Database through April 2003. Articles relevant to allergy and OME were identified by using Medline in this guideline is defined as the presence of through April 2003. The subcommittee met 3 times over a 1-year fluid in the middle ear without signs or period, ending in May 2003, with interval electronic review and O 1,2 symptoms of acute ear infection. OME is consid- feedback on each guideline draft to ensure accuracy of content and ered distinct from acute otitis media (AOM), which is consistency with standardized criteria for reporting clinical prac- tice guidelines.11 defined as a history of acute onset of signs and In May 2003, the Guidelines Review Group of the Yale Center symptoms, the presence of middle-ear effusion, and for Medical Informatics used the Guideline Elements Model12 to signs and symptoms of middle-ear inflammation. categorize content of the present draft guideline. Policy statements Persistent middle-ear fluid from OME results in de- were parsed into component decision variables and actions and then assessed for decidability and executability. Quality appraisal creased mobility of the tympanic membrane and 13 3 using established criteria was performed with Guideline Ele- serves as a barrier to sound conduction. Approxi- ments Model-Q Online.14,15 Implementation issues were predicted mately 2.2 million diagnosed episodes of OME occur by using the Implementability Rating Profile, an instrument under annually in the United States, yielding a combined development by the Yale Guidelines Review Group (R. Shiffman, direct and indirect annual cost estimate of $4.0 bil- MD, written communication, May 2003). OME subcommittee 2 members received summary results and modified an advanced lion. draft of the guideline. OME may occur spontaneously because of poor The final draft practice guideline underwent extensive peer eustachian tube function or as an inflammatory re- review by numerous entities identified by the subcommittee. sponse following AOM. Approximately 90% of chil- Comments were compiled and reviewed by the subcommittee dren (80% of individual ears) have OME at some cochairpersons. The recommendations contained in the practice 4 guideline are based on the best available published data through time before school age, most often between ages 6 April 2003. Where data are lacking, a combination of clinical months and 4 years.5 In the first year of life, Ͼ50% of experience and expert consensus was used. A scheduled review children will experience OME, increasing to Ͼ60% process will occur 5 years
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