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Rosenfeld RM, Schwartz SR, Pynnonen MA, Tunkel DE, Hussey HM, Fichera JS, Grimes AM, Hackell JM, Harrison MF, Haskell H, Haynes DS, Kim TW, Lafreniere DC, LeBlanc K, Mackey WL, Netterville JL, Pipan ME, Raol NP, Schellhase KG. Clinical Practice Guideline. Otolaryngol Head Neck Surg 2013; 149:S1-35. [DOI: 10.1177/0194599813487302] [Citation(s) in RCA: 234] [Impact Index Per Article: 21.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
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. Despite the frequency of tympanostomy tube insertion, there are currently no clinical practice guidelines in the United States that address specific indications for surgery. This guideline is intended for any clinician involved in managing children, aged 6 months to 12 years, with tympanostomy tubes or being considered for tympanostomy tubes in any care setting, as an intervention for otitis media of any type. Purpose The primary purpose of this clinical practice guideline is to provide clinicians with evidence-based recommendations on patient selection and surgical indications for and management of tympanostomy tubes in children. The development group broadly discussed indications for tube placement, perioperative management, care of children with indwelling tubes, and outcomes of tympanostomy tube surgery. Given the lack of current published guidance on surgical indications, the group focused on situations in which tube insertion would be optional, recommended, or not recommended. Additional emphasis was placed on opportunities for quality improvement, particularly regarding shared decision making and care of children with existing tubes. Action Statements The development group made a strong recommendation that clinicians should prescribe topical antibiotic eardrops only, without oral antibiotics, for children with uncomplicated acute tympanostomy tube otorrhea. The panel made recommendations that (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; (2) clinicians should obtain an age-appropriate hearing test if OME persists for 3 months or longer (chronic OME) 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 (chronic OME) and documented hearing difficulties; (4) clinicians should reevaluate, at 3- to 6-month intervals, children with chronic OME who did 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; (5) clinicians should not perform tympanostomy tube insertion in children with recurrent acute otitis media (AOM) who do not have middle ear effusion in either ear at the time of assessment for tube candidacy; (6) clinicians should offer bilateral tympanostomy tube insertion to children with recurrent AOM who have unilateral or bilateral middle ear effusion at the time of assessment for tube candidacy; (7) clinicians should determine if a child with recurrent AOM 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; (8) 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; (9) clinicians should not encourage routine, prophylactic water precautions (use of earplugs, headbands; avoidance of swimming or water sports) for children with tympanostomy tubes. The development group provided the following options: (1) 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 to OME including, but not limited to, vestibular problems, poor school performance, behavioral problems, ear discomfort, or reduced quality of life and (2) clinicians may perform tympanostomy tube insertion in at-risk children with unilateral or bilateral OME that is unlikely to resolve quickly as reflected by a type B (flat) tympanogram or persistence of effusion for 3 months or longer (chronic OME).
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Affiliation(s)
- Richard M. Rosenfeld
- Department of Otolaryngology, State University of New York Downstate Medical Center, Brooklyn, New York, USA
| | - Seth R. Schwartz
- Department of Otolaryngology, Virginia Mason Medical Center, Seattle, Washington, USA
| | - Melissa A. Pynnonen
- Department of Otolaryngology, University of Michigan, Ann Arbor, Michigan, USA
| | - David E. Tunkel
- Department of Otolaryngology—Head and Neck Surgery, Johns Hopkins University, Baltimore, Maryland, USA
| | - Heather M. Hussey
- Department of Research and Quality Improvement, American Academy of Otolaryngology—Head and Neck Surgery Foundation, Alexandria, Virginia, USA
| | - Jeffrey S. Fichera
- The Ear, Nose, Throat & Plastic Surgery Associates, Winter Park, Florida, USA
| | - Alison M. Grimes
- Department of Otology, Head and Neck Surgery, UCLA Medical Center, Los Angeles, California, USA
| | | | - Melody F. Harrison
- Department of Speech and Hearing Sciences, UNC School of Medicine, Chapel Hill, North Carolina, USA
| | - Helen Haskell
- Mothers Against Medical Error, Columbia, South Carolina, USA
| | - David S. Haynes
- Neurotology Division, Otolaryngology and Hearing and Speech Sciences, Vanderbilt University Medical Center, Nashville, Tennessee, USA
| | - Tae W. Kim
- Department of Anesthesiology, Johns Hopkins University, Baltimore, Maryland, USA
| | - Denis C. Lafreniere
- Division of Otolaryngology, UCONN Health Center, Farmington, Connecticut, USA
| | | | - Wendy L. Mackey
- Connecticut Pediatric Otolaryngology, Yale University School of Medicine, New Haven, Connecticut, USA
| | - James L. Netterville
- Department of Otolaryngology—Head and Neck Surgery, Vanderbilt University Medical Center, Nashville, Tennessee, USA
| | - Mary E. Pipan
- Trisomy 21 Program, Developmental Behavioral Pediatrics, Children’s Hospital of Philadelphia, Philadelphia, Pennsylvania, USA
| | - Nikhila P. Raol
- Department of Otolaryngology, Baylor College of Medicine, Houston, Texas, USA
| | - Kenneth G. Schellhase
- Department of Family and Community Medicine, Medical College of Wisconsin, Milwaukee, Wisconsin, USA
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Abstract
During most of recorded history, the application of knowledge to the care of individual patients was founded on the experience of individual medical practitioners; when published, it basically took the form of case reports. Not until the middle of the 20th Century did randomized controlled trials (RCTs) come to be the gold standard. By the beginning of the 21st Century, however, the limitations of RCTs and their syntheses, the meta-analyses, have come to be recognized, and their applicability to the individual patient questioned and, indeed, challenged. The intense increase in our knowledge base and in accompanying technology has made possible the personalization of medicine beyond the possibilities of earlier periods. The approach of personalized medicine requires evaluation of four parameters: the individual patient’s intrinsic susceptibility, intrinsic morbidity, extrinsic susceptibility, and extrinsic morbidity. The characteristics of the disease agent—how much (duration) and how virulent—also must be factored in. These individualized data define the appropriate intervention: high susceptibility and/or morbidity or low susceptibility and/or morbidity and the aggregate of the intrinsic and extrinsic risk factors are cofactored in medical decision making.
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Affiliation(s)
- Robert J. Ruben
- Departments of Otorhinolaryngology–Head and Neck Surgery and Pediatrics, Albert Einstein College of Medicine, Montefiore Medical Center, Bronx, New York, USA
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Adenoidectomy plus tympanostomy tube insertion versus adenoidectomy plus myringotomy in children with obstructive sleep apnoea syndrome. The Journal of Laryngology & Otology 2010; 125:274-8. [DOI: 10.1017/s0022215110002549] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
AbstractObjective:To determine whether tympanostomy tube insertion has benefit, compared with simple myringotomy, in children with otitis media with effusion who receive concurrent adenoidectomy as treatment for obstructive sleep apnoea syndrome caused by adenoid hypertrophy.Methods:Fifty-two children older than three years with obstructive sleep apnoea syndrome were randomly assigned to receive either adenoidectomy plus tympanostomy tube insertion (group one, n = 25) or adenoidectomy plus myringotomy (group two, n = 27). Pre- and post-operative health-related quality of life was assessed using the otitis media-6 (OM-6) tool, and audiological outcomes were recorded six and 12 months post-operatively.Results:Group one showed better quality of life scores six months post-operatively (score difference −0.38, confidence interval −0.65 to −0.10) but not 12 months post-operatively (score difference −0.23, confidence interval −0.76 to 0.11), compared with pre-operative values. Audiological outcomes did not differ significantly at either time point, compared with pre-operative values.Conclusion:Tympanostomy tube insertion confers a short term benefit, compared with simple myringotomy, in children older than three years with otitis media with effusion who receive concurrent adenoidectomy as treatment for obstructive sleep apnoea syndrome. Further studies are necessary to identify which of these children will receive long-lasting benefit from tympanostomy tube insertion.
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