Tympanostomy Tube Guideline Issued by Multidisciplinary Team

Laurie Barclay, MD

July 01, 2013

The American Academy of Otolaryngology–Head and Neck Surgery Foundation (AAO-HNSF) has issued the first evidence-based, multidisciplinary clinical practice guideline on use of tympanostomy tubes in children aged 6 months to 12 years with otitis media (OM). The new recommendations, published in the July 1 issue of Otolaryngology–Head and Neck Surgery, should clarify patient selection, optimize perioperative care, and improve parent counseling.

"Ear tubes are the #1 reason children get surgery or anesthesia in the United States," guidelines panel chair and lead author Richard M. Rosenfeld, MD, MPH, said in an AAO news release. "The tympanostomy tube guideline not only helps doctors and parents identify children likely to benefit most from surgery, but importantly identifies those for whom watchful waiting may be a better option."

Among children younger than 15 years, approximately 667,000 children each year undergo tympanostomy tube placement in the eardrum, and nearly 1 in 15 have tubes by age 3 years. The tubes are about .05 inch in diameter, allow air to circulate in the middle ear, and usually fall out spontaneously after 1 to 2 years. Indications may include persistent middle ear effusion, frequent ear infections, or ear infections refractory to antibiotics.

Despite the frequency of surgical placement of tympanostomy tubes, evidence-based guidelines for proper use, including appropriate surgical candidates and postoperative follow-up care, have not existed to date in the United States.

"Diagnosis of the disease is the most important aspect of these guidelines," Joseph E. Kerschner, MD, dean of the medical school, executive vice president, and professor of pediatric otolaryngology, Medical College of Wisconsin, Milwaukee, told Medscape Medical News when asked for independent comment. "Diagnosis of [OM] is not always easy. But in order to appropriately treat and manage children, making an accurate diagnosis is critical."

The guideline panel included a pediatric and adult otolaryngologist, otologist/neurootologist, anesthesiologist, audiologist, family physician, behavioral pediatrician, pediatrician, speech/language pathologist, advanced nurse practitioner, physician assistant, resident physician, and consumer advocates. To ensure valid, actionable, and trustworthy recommendations, the panel developed the guidelines using a planned protocol.

"[OM] is the most common reason for children to see a physician for illness in the United States and is responsible for billions of dollars in healthcare expenditures," Dr. Kerschner said. "So, particularly in these times of pressure on healthcare economics, making improvements in diagnosis and treatment of this very common and expensive disease is critical."

He explained that one of the most important differences between this guideline and previous recommendations is the premium placed on diagnostic accuracy.

In previous guidelines issued for otitis media with effusion, "there was a section on use of antibiotics and a recommendation regarding how to treat patients if the provider was 'unsure' of the diagnosis," Dr. Kerschner described. "The guidelines now have removed that portion so that the 'wrong' message isn't sent [regarding] the importance of making an accurate diagnosis."

Highlights of Recommendations

  • Many children with OM with effusion (OME) improve spontaneously, especially when effusion is present for less than 3 months. Children with a single OME episode lasting less than 3 months should not undergo tympanostomy tube insertion.

  • Age-appropriate hearing evaluation is recommended before surgery and for all children with persistent OME lasting 3 or more months.

  • Clinicians should offer tympanostomy tubes to children with impaired hearing and bilateral OME for 3 or more months because the effusion usually persists and tube insertion should improve hearing and quality of life.

  • Clinicians may perform tympanostomy tubes to children with unilateral or bilateral OME lasting 3 or more months and associated symptoms, such as vestibular symptoms, school or behavioral problems, ear discomfort, or lowered quality of life.

  • Children with recurrent acute OM without middle-ear effusion should not undergo tympanostomy tube placement. However, tube placement should be considered for children with middle-ear effusion to prevent most future acute OM episodes and to facilitate treatment of acute OM with ear drops instead of oral antibiotics.

  • When unilateral or bilateral OME is unlikely to resolve quickly, children who are at risk for developmental difficulties may benefit from tympanostomy tubes. At-risk children include those with permanent hearing loss; speech, language, or developmental delay or disorder; autism-spectrum disorder; Down syndrome; craniofacial disorders; and/or cleft palate.

  • For more effective treatment and fewer adverse events, children with tympanostomy tubes who develop ear infections, including uncomplicated acute tympanostomy tube otorrhea, should be treated with topical antibiotic ear drops and not with systemic antibiotics.

  • Children with tympanostomy tubes can usually swim or bathe without specific precautions such as earplugs or headbands.

Clinical Implications

"If providers improve their ability to make the diagnosis, it will improve the treatment of the disease," Dr. Kerschner said. "[Several articles] demonstrate that in patients who truly have [OM], treatment with antibiotics obviously is more efficacious. [The guidelines] will also allow providers to make better decisions on waiting on the use of antibiotics based on bilateral or unilateral disease and age."

Additional research recommended by Dr. Kerschner includes identifying the mechanisms and potential new modes of treatment for children with hearing loss associated with OM. "Not all children are affected equally with OM, so much more research is needed to understand the differences between subgroups of patients. This is an area that would have potential for profound public health implications with an increase in [National Institutes of Health] funding."

The AAO-HNSF funded development of these guidelines and provided sponsorships. Some of the guidelines authors reported various financial disclosures with Cochlear Corporation, Medtronic, Starkey Labs, Sonovion Inc, Glaxo Smith Kline Inc, Anspach Company, Advanced Bionics, Grace Medical, and for expert witness work in medical malpractice cases. Dr. Kerschner has disclosed no relevant financial relationships.

Otolaryngol Head Neck Surg. 2013;149:8-16. Full text

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