Clinical Guidelines And Primary Care J Am Board Fam Pract: first published as 10.3122/jabfm.8.4.305 on 1 July 1995. Downloaded from Alfred O. Berg, MD, MPH, Series Editor Otitis Media With Effusion In Young Children: Treatment In Search Of A Problem? Lany Culpepper, MD, MPH, andJack Froom, MD Family physicians and pediatricians see patients We based our review on the published Clinical who have otitis media with effusion (OME), also Practice Guideline, research reports used to derive known as serous otitis or "glue ear," on a daily ba­ the panel recommendations, research reports not sis. OME is a common sequela of acute otitis me­ considered by the panel, one author's (LC) per­ dia, but the timing and appropriate types of inter­ sonal participation on the panel, and clinical vention are subject to debate. Current practice practice experience. Presentation and discussion includes observation only, treatment with antibi­ (by LC) of the guideline at a Hastings Center for otics and decongestants, referral for ear tubes, Ethics meeting further enriched this review. In and even adenoidectomy with or without tonsil­ the following sections we present a summary of lectomy. Both the utility of these interventions the content of the report and conclude with our for resolving OME and the value of resolving critique of the guideline. OME to prevent long-term complications, par­ ticularly compromised development of language Importance of the Problem skills, are uncertain. Otitis media with effusion is one of the most Otitis Media with Effusion in Young Children. common reasons for prescribing antibiotics to Clinical Practice Guideline l addresses these and re­ children and the most common reason for a sur­ lated issues. A consortium of the American Acad­ gical procedure. The number of visits to physi­ emy of Pediatrics, the American Academy of cians for otitis media, including both acute otitis Family Physicians, and the American Academy of media and OME, increased from 9.9 million in Otolaryngology-Head and Neck Surgery under 1975 to 24.5 million in 1990.2 The AHCPR contract with the Agency for Health Care and panel estimated that 25 to 35 percent of these Policy Research (AHCPR) convened an expert cases represented OME. Visits to pediatricians http://www.jabfm.org/ panel to produce the guideline. On the basis of accounted for 56.4 percent of otitis media visits; limited evidence and expert opinion, the panel those to family physicians and general practition­ recommended that antibiotics or insertion of ear ers 30.4 percent. Only 7.2 percent of otitis media tubes (if a hearing deficit exists) be offered to chil­ visits were to otolaryngologists (percentage ob­ dren whose OME has not resolved by 3 months tained from a special analysis at our request by and that children with hearing deficits of 20 dB the National Center for Health Statistics using on 1 October 2021 by guest. Protected copyright. or more receive ear tubes by 4 to 6 months. We National Ambulatory Medical Care Survey data). advise physicians to question both recommenda­ The US Food and Drug Administration found tions. Figure 1 displays the practice algorithm that about 14 percent of all courses of antibiotics published as part of the Clinical Practice Guideline prescribed in the United States were for otitis and incorporates its recommendations. media. In 1986, 44.5 million courses were prescribed for children 10 years old or younger for otitis media, constituting 42 percent of all Submitted, revised, 15 March 1995. antibiotic prescriptions they received. 3 Using From the Depar1:1TIent of Family Medicine, Memorial Hospi­ tal of Rhode Island/Brown University, Pawtucket (LC), and the federal data, one recent estimate is that approxi­ Department of Family Medicine, Health Sciences Center, State mately 800,000 children received 1.3 million University of New York at Stony Brook OF). Address reprint re­ tympanostomy tubes in 1988. Of these, 30 per­ quests to LarryCulpepper, MD, MPH, Department of Family 4 Medicine, Memorial Hospital of Rhode Island/Brown Univer­ cent were replacements. In 1986, 31 million sity, 255 Main Street, Suite 201, Pawnlcket, RI, 02860. visits to physicians were due to otitis media, and Otitis Media in Young Children 305 J Am Board Fam Pract: first published as 10.3122/jabfm.8.4.305 on 1 July 1995. Downloaded from Primary care clinician examining an otherwise healthy child age ...-------------. 1-3 years with no craniofacial or neurologic abnormalities or Note: The asymptomatic patient sensory deficits suspects otitis with fluid in the ear and no media with effusion (OME) signs or symptoms of ear (A, B). infection by definition does not have acute otitis media. 21------%.-----. Clinician performs pneumatic otoscopy (C). 41------------, Is the clinician Clinician may confirm certain of the No -. clinical diagnosis of OME diagnosis of by tympanometry (D). OME? Does tympanometry Yes confirm the diagnosis of OME? No http://www.jabfm.org/ Yes 61--------...::1::.....-.----, 7~--------~L-----------~ Exit this algorithm to Options for management of this individualized patient patient with OME should include: management appropriate (1) a. observati08 ~E) to the clinical situation. b. Oral antibiotic therapy (F) on 1 October 2021 by guest. Protected copyright. AND (2) Environmental risk factor control counseling (G). ATTENTION Management of the patient at this point in the clinical course should not include: (1) Surgery, including myringotomy with or without tube insertion, tonsillectomy, or adenoidectomo~H) (2) Decongestants and/or antihistamines (I) OR (3) Oral steroid therapy (J). Figure 1. Algorithm for managing otitis media with effusion in an otherwise healthy child aged 1 through 3 years. I 306 JABFP July-August 1995 Vo l. 8 0.4 J Am Board Fam Pract: first published as 10.3122/jabfm.8.4.305 on 1 July 1995. Downloaded from Figure 1 (continued) Does the patient still have OME 6 weeks after diagnosis by pneumatic otoscopy r-------------No--------------~ with optional confirmation by tympanometry? Yes 9~ __________~ __---- ____--1 ATTENTION Management of this patient at this Management of this patient with OME point should not include: for 6 weeks should include: (1) Surgery. including myringotomy (1) a. Observation with or without tube Insertion, OR tonsillectomy, or adenoidectomy b. Oral antibiotic therapy OR AND (2) Decongestants and/or (2) Environ~ental risk factor control antihisfamines counseling OR http://www.jabfm.org/ AND (3) Oral steroid therapy. (3) Option of hearing evaluation now. on 1 October 2021 by guest. Protected copyright. Does the patient still have OME 3 months after diagnosis by pneumatic otoscopy r-------------No--------------~ with optional confirmation by tympanometry? 11r---------____~~ Exit this algorithm to individualized patient management appropriate to the clinical situation. Otitis Media in Young Children 307 J Am Board Fam Pract: first published as 10.3122/jabfm.8.4.305 on 1 July 1995. Downloaded from Figure 1 (continued) Refer patient for hearing evaluation. Management of this patient with OME and With unilateral or insignificant hearing loss, 3 or more months after diagnosis with OME should include: No-+ (1) a. Observation OR b. Oral antibiotic therapy AND (2) Environmental risk factor control Yes counseling. 15~ _______~ __________~ Management of this patient with OME and hearing loss, 3 or more months ...-----------. after diagnosis with OME should include: ATTENTION (1) a. Oral antibiotic therapy Management of this patient OR at this point should not b. Bilateral myringotomy with include: tube placement (1) Tonsillectomy and/or AND adenoidectomy (2) Environmental risk factor control OR counseling. (2) Decongestants and/or antihistamines http://www.jabfm.org/ OR (3) Oral steroid therapy. Does the j)atient still have OME 4-6 months Exit this algorithm to after diagnosis by individualized patient on 1 October 2021 by guest. Protected copyright. pneumatic otoscopy ">--- No --....... management appropriate with optional to the clinical situation. confirmation by tympan ometry1 18'~----------------------~ Management of this patient with OME for 4-6 months and a history of Yes significant (at least 20 db) bilateral hearing loss should include: (1) Bilateral myringotomy with tube placement AND (2) Environmental risk factor control counseling AND (3) Management appropriate to the clinical situation. 308 JABFP July-August 1995 Vo l. 8 No. 4 the total direct and indirect costs for that year without treatment. The natural history of this have been estimated at $3.5 billion.s Surgical group of children, therefore, is unknown. J Am Board Fam Pract: first published as 10.3122/jabfm.8.4.305 on 1 July 1995. Downloaded from costs for procedures for otitis media exceed $1.2 billion annually. 6 The Guideline Development Process With AHCPR approval, the consortium con­ Prevalence and Epidemiology of Otitis Media vened an interdisciplinary panel selected from with Effusion individuals recommended by specialty organi­ OME is a common experience for children. Cassel- zations. The panel included 3 family physi­ brant, et al. 7 reported that among 103 children aged cians (Alfred O. Berg, MD, MPH, Douglas G. 2 to 6 years participating in group child care and Long, MD, and Larry Culpepper, MD, MPH), monitored for 2 years, 53 percent had at least one 2 pediatricians, 5 otolaryngologists, an infectious episode of OME during the first year of study and disease specialist, a psychologist, a speech-language 61 percent in the second year; 30 percent had re­ pathologist, 3 nurse practitioners, an audiologist, current bouts. OME is present in at least 20 per­ an economist-health policy analyst, and a con­ cent of cases 2 months following an attack of acute sumer. Most are in academic and research posi­ otitis media. l In studies that used pneumatic otos­ tions. Following the first panel meeting, 2 initial copy and tympanometry to detect effusion, higher panelists were replaced because of pharmaceutical rates of effusion at 2 months have been reported.