Otitis Media: New Guideline Includes Screening At-Risk Kids

Marcia Frellick

February 04, 2016

New guidelines from the American Academy of Otolaryngology—Head and Neck Surgery Foundation recommend practice changes for otitis media with effusion (OME). The updates were published in the February issue of Otolaryngology–Head and Neck Surgery.

Changes from the previous guidelines issued in 2004 include a recommendation for screening "at-risk" children or those with developmental issues, syndromes, or conditions that place them at higher risk for OME, said lead author Richard M. Rosenfeld, MD, MPH, from the Department of Otolaryngology, State University of New York Downstate Medical Center in Brooklyn. Dr Rosenfeld chaired the committee for both the 2004 guideline and the 2016 update.

Children in the high-risk groups are disproportionately affected by middle ear fluid, and the symptoms can be very easy to miss, he said.

"We're recommending for the first time that at age 12 to 18 months, these children be screened to see if they have otitis media with effusion," Dr Rosenfeld told Medscape Medical News. "The previous guidelines said don't screen anybody, it's not helpful. We're still saying don't screen the otherwise-healthy child."

Another recommendation strengthens a previous guideline against using medical therapy except under exceptional circumstances.

"In this version, we say don't do it. Period. There aren't any good reasons to do it, and that includes antibiotics, steroids, antihistamines, and decongestants," Dr Rosenfeld said. "The biggest change here is we've added nasal steroid sprays...which are often prescribed to treat middle ear fluid even though all the best evidence [including] several randomized trials say it doesn't work."

This was one of the biggest gaps in care the researchers found. "It seems that about 30% still do treat with antibiotics, despite recommendations in 2004 against the practice," Dr Rosenfeld said. Another gap is found with hearing tests, as about 15% to 20% of the children who should be getting hearing tests are not getting them routinely.

A third gap is that many physicians are not following recommended procedure to diagnose OME using pneumatic otoscopy. Dr Rosenfeld said surveys show that only about 20% are using that procedure in primary care.

According to the new recommendations, removing the adenoids is no longer recommended to treat OME in children younger than 4 years. The previous guidelines had options for this for a child with a second set of ear tubes, but current evidence does not show any benefit for adenoidectomy as a primary intervention for OME in patients younger than 4 years, he said.

The guidelines "were long overdue," Dr Rosenfeld noted, adding that the current philosophy on clinical guidelines is that they should be updated every 5 years.

"You have a ubiquitous condition that's one of the leading causes of primary care visits and surgery among kids, and there's been a host of new evidence and trials," he said.

About 90% of children have ear fluid by age 5 years, and it is especially prevalent in those with developmental challenges. About 2.2 million new cases of OME are diagnosed every year in the United States, at a cost of $4.0 billion, the authors say.

The previous version of the guidelines also did not engage consumers in their development. This version has two consumer representatives on the committee who advocated for patients, making these guidelines particularly relevant and understandable to them.

"There's a relentless focus on patient education and shared decision making, and there are tools in the guidelines to facilitate that objective," including frequently asked question lists and decision aids, Dr Rosenfeld said.

The study was funded by the American Academy of Otolaryngology—Head and Neck Surgery Foundation. Various coauthors report receiving royalties from Springer International, Plural Publishing, and Engage Learning; a Harvard Medical School Shore Foundation Faculty Grant; teaching/speaking honoraria from Interacoustics Inc and the Arizona Ear Foundation; research funding from the National Institute on Deafness and Other Communication Disorders and the Centers for Disease Control and Prevention; consulting fees or research funding from Acclarent, Medtronic, Styker, and Cook; financial interest in nasal spray for OM (not yet in phase I trials); and stock holdings in Otodyne. One coauthor also reports being a salaried employee of the American Academy of Otolaryngology—Head and Neck Surgery Foundation.

Otolaryngol Head Neck Surg. 2016;154:201-214. Full text

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