Risk Factors for Multiple Tympanostomy Tube Placements in Children: Systematic Review and Meta-Analysis

Panel 1: Epidemiology and global health, including child development, sequelae and complications

OBJECTIVE

To summarise the published research evidence on the epidemiology of otitis media, including the risk factors and sequelae associated with this condition.

DATA SOURCES

Medline (PubMed), Embase, and the Cochrane Library covering the period from 2019 to June 1st, 2023.

REVIEW METHODS

We conducted a broad search strategy using otitis [Medical Subject Heading] combined with text words to identify relevant articles on the prevalence, incidence, risk factors, complications, and sequelae for acute otitis media, otitis media with effusion, and chronic suppurative otitis media. At least one review author independently screened titles and abstracts of the retrieved records for each condition to determine whether the research study was eligible for inclusion. Any discrepancies were resolved by reviewing the full text followed by discussion with a second review author. Studies with more than 100 participants were prioritised.

RESULTS

Over 2,000 papers on otitis media (OM) have been published since 2019. Our review has highlighted around 100 of these publications. While the amount of otitis media research on the Medline database published each year has not increased, there has been an increase in epidemiological studies using routinely collected data and systematic review methodology. Most of the large incidence studies have addressed acute otitis media (AOM) in children. Several studies have described a decrease in incidence of AOM after the introduction of conjugate PCV vaccines. Similarly, a decrease was noted when rates of coronavirus disease of 2019 (COVID-19) were high and there were major public health efforts to reduce the spread of infection. There have been new studies on OM in adults and OM prevalence in a broader range of countries and population subgroups.

CONCLUSION

Overall, the rates of severe and/or suppurative OM appeared to be decreasing. However, there is substantial heterogeneity between populations. While better use of available data is informative, it can be difficult to predict rates of severe disease without accurate examination findings. Most memorably, the COVID-19 pandemic had an enormous impact on the research and clinical services for otitis media for most of the period under review.

IMPLICATIONS FOR PRACTICE

The use of routinely collected data for epidemiological studies will lead to greater variability in the definitions and diagnostic criteria used. The impact of new vaccines will continue to be important. Some of the lessons learned during the COVID-19 pandemic concerning behaviours that reduce spread of respiratory viruses can hopefully be used to decrease the burden of otitis media in the future. There are still many countries in the world where the burden of otitis media is not well described. In countries where otitis media has been studied over many years, new potential risk factors continue to be identified. In addition, a better understanding of the disease in specific subgroups has been achieved.

Efficacy of tympanostomy tube placement with adjuvant adenoidectomy in children less than 4 years of age

OBJECTIVE

About 8.6 % of children in the United States undergo tympanostomy tube (TT) placement every year. Of these, 24.1 % require a second set of tubes. Adjuvant adenoidectomy in children over 4 years is thought to improve the efficacy of TT. The goal of this study is to characterize the efficacy of adjuvant adenoidectomy at the time of TT placement in children under 4 years, to further improve middle ear function.

METHODS

All patients undergoing TT placement alone or TT placement with adenoidectomy from 2014 to 2016 were reviewed. The primary outcome was need for subsequent tube placement.

RESULTS

A total of 409 patients were included in the study (60.6 % male, 39.4 % female). Median age at initial TT placement was 18 months (range 5-48 months); extreme outliers for age were removed from further analysis. Patients were followed for 1-8 years. 250 patients received TT alone while 159 received TT with adenoidectomy. 120 required a second set of tubes. There was a statistically significant benefit to those undergoing adjuvant adenoidectomy with TT placement: 33.6 % of those receiving TT alone required subsequent tubes, whereas only 22.6 % of patients who underwent TT with adjuvant adenoidectomy required reinsertion (X2 = 5.630, p = 0.018). Adjuvant adenoidectomy in patients 0-48 months was associated with decreased likelihood of requiring subsequent tube placement (OR = 0.578, p = 0.018). There was an increased likelihood of experiencing otorrhea in those receiving TT alone compared to the TT with adenoidectomy group (X2 = 4.353, df = 1, p = 0.0369).

CONCLUSION

Adjuvant adenoidectomy at the time of initial TT placement may have a role in the management of chronic middle ear disease in patients younger than 4 years. However, further studies and prospective randomized studies are needed to explore if this benefit can also be seen in children without chronic rhinosinusitis or nasal obstruction. The benefit-risk ratio from adenoidectomy and modifications in anesthesia technique in the case of adjuvant adenoidectomy should also be further explored.

Hypoxia in non-rapid eye movement sleep in children with otitis media with effusion

Objective

This study aimed to analyze the status of hypoxia in non-rapid eye movement (NREM) sleep in children with otitis media with effusion (OME).

Methods

A total of 232 children with OME and/or adenotonsillar hypertrophy were enrolled in this retrospective study between August 2020 and November 2021. Polysomnographic monitoring was carried out, and the differences in polysomnographic results between the experimental group (children with OME and adenotonsillar hypertrophy) and control group (children with adenotonsillar hypertrophy only) were compared.

Results

The lowest oxygen saturation level during sleep was significantly lower in the experimental group (n  =  36) than in the control group (n = 196). However, the apnea-hypopnea index, respiratory disorder index, apnea index, obstructive apnea index, obstructive apnea-hypopnea index, and mixed apnea-hypopnea index were significantly higher in the experimental group than in the control group. More importantly, the apnea-hypopnea index, the oxygen desaturation index, oxygen desaturation events, the average heart rate during NREM sleep, and the NREM stage in total sleep time were also significantly higher in the experimental group than in the control group.

Conclusions

Hypoxia during NREM sleep may affect the severity of OME in children.

Clinical Practice Guideline: Tympanostomy Tubes in Children (Update)

OBJECTIVE

Insertion of tympanostomy tubes is the most common ambulatory surgery performed on children in the United States. Tympanostomy tubes are most often inserted because of persistent middle ear fluid, frequent ear infections, or ear infections that persist after antibiotic therapy. All these conditions are encompassed by the term otitis media (middle ear inflammation). This guideline update provides evidence-based recommendations for patient selection and surgical indications for managing tympanostomy tubes in children. The guideline is intended for any clinician involved in managing children aged 6 months to 12 years with tympanostomy tubes or children being considered for tympanostomy tubes in any care setting as an intervention for otitis media of any type. The target audience includes specialists, primary care clinicians, and allied health professionals.

PURPOSE

The purpose of this clinical practice guideline update is to reassess and update recommendations in the prior guideline from 2013 and to provide clinicians with trustworthy, evidence-based recommendations on patient selection and surgical indications for managing tympanostomy tubes in children. In planning the content of the updated guideline, the guideline update group (GUG) affirmed and included all the original key action statements (KASs), based on external review and GUG assessment of the original recommendations. The guideline update was supplemented with new research evidence and expanded profiles that addressed quality improvement and implementation issues. The group also discussed and prioritized the need for new recommendations based on gaps in the initial guideline or new evidence that would warrant and support KASs. The GUG further sought to bring greater coherence to the guideline recommendations by displaying relationships in a new flowchart to facilitate clinical decision making. Last, knowledge gaps were identified to guide future research.

METHODS

In developing this update, the methods outlined in the American Academy of Otolaryngology-Head and Neck Surgery Foundation's "Clinical Practice Guideline Development Manual, Third Edition: A Quality-Driven Approach for Translating Evidence Into Action" were followed explicitly. The GUG was convened with representation from the disciplines of otolaryngology-head and neck surgery, otology, pediatrics, audiology, anesthesiology, family medicine, advanced practice nursing, speech-language pathology, and consumer advocacy.

ACTION STATEMENTS

The GUG made strong recommendations for the following KASs: (14) clinicians should prescribe topical antibiotic ear drops only, without oral antibiotics, for children with uncomplicated acute tympanostomy tube otorrhea; (16) the surgeon or designee should examine the ears of a child within 3 months of tympanostomy tube insertion AND should educate families regarding the need for routine, periodic follow-up to examine the ears until the tubes extrude.The GUG made recommendations for the following KASs: (1) clinicians should not perform tympanostomy tube insertion in children with a single episode of otitis media with effusion (OME) of less than 3 months' duration, from the date of onset (if known) or from the date of diagnosis (if onset is unknown); (2) clinicians should obtain a hearing evaluation if OME persists for 3 months or longer OR prior to surgery when a child becomes a candidate for tympanostomy tube insertion; (3) clinicians should offer bilateral tympanostomy tube insertion to children with bilateral OME for 3 months or longer AND documented hearing difficulties; (5) clinicians should reevaluate, at 3- to 6-month intervals, children with chronic OME who do not receive tympanostomy tubes, until the effusion is no longer present, significant hearing loss is detected, or structural abnormalities of the tympanic membrane or middle ear are suspected; (6) clinicians should not perform tympanostomy tube insertion in children with recurrent acute otitis media who do not have middle ear effusion in either ear at the time of assessment for tube candidacy; (7) clinicians should offer bilateral tympanostomy tube insertion in children with recurrent acute otitis media who have unilateral or bilateral middle ear effusion at the time of assessment for tube candidacy; (8) clinicians should determine if a child with recurrent acute otitis media or with OME of any duration is at increased risk for speech, language, or learning problems from otitis media because of baseline sensory, physical, cognitive, or behavioral factors; (10) the clinician should not place long-term tubes as initial surgery for children who meet criteria for tube insertion unless there is a specific reason based on an anticipated need for prolonged middle ear ventilation beyond that of a short-term tube; (12) in the perioperative period, clinicians should educate caregivers of children with tympanostomy tubes regarding the expected duration of tube function, recommended follow-up schedule, and detection of complications; (13) clinicians should not routinely prescribe postoperative antibiotic ear drops after tympanostomy tube placement; (15) clinicians should not encourage routine, prophylactic water precautions (use of earplugs or headbands, avoidance of swimming or water sports) for children with tympanostomy tubes.The GUG offered the following KASs as options: (4) clinicians may perform tympanostomy tube insertion in children with unilateral or bilateral OME for 3 months or longer (chronic OME) AND symptoms that are likely attributable, all or in part, to OME that include, but are not limited to, balance (vestibular) problems, poor school performance, behavioral problems, ear discomfort, or reduced quality of life; (9) clinicians may perform tympanostomy tube insertion in at-risk children with unilateral or bilateral OME that is likely to persist as reflected by a type B (flat) tympanogram or a documented effusion for 3 months or longer; (11) clinicians may perform adenoidectomy as an adjunct to tympanostomy tube insertion for children with symptoms directly related to the adenoids (adenoid infection or nasal obstruction) OR in children aged 4 years or older to potentially reduce future incidence of recurrent otitis media or the need for repeat tube insertion.