Paediatric otitis media surgery in Norway

Association of Prenatal Antibiotics and Mode of Birth With Otolaryngology Surgery in Offspring: A National Data Linkage Study

BACKGROUND

Pediatric otolaryngology surgery is commonly performed after recurrent infections and allergy/atopy. Prenatal antibiotic exposure and cesarean section deliveries increase the risk of severe infection and allergy/atopy in the offspring, but the relationship with common, related surgical outcomes is unknown. This study measures the associations between prenatal antibiotic use and mode of birth with common pediatric otolaryngology surgery.

METHODS

Data linkage analysis of all live-born, singleton children, born between 2008 and 2018 was done using Norwegian national health registry data. Exposures of interest were prenatal antibiotics and mode of birth. The primary outcome was common otolaryngology surgery before 10 years of age. Exposure-outcome associations were estimated through multivariable Cox proportional hazards models adjusting for predefined covariates. Interaction between exposures was explored.

RESULTS

Of 539,390 children, 146,832 (27.2%) had mothers who were prescribed antibiotics during pregnancy, 83,473 (15.5%) were delivered via cesarean section, and 48,565 (9.0%) underwent an otolaryngology surgery during the study period. Prenatal antibiotic exposure [adjusted hazard ratio (aHR), 1.22; 95% CI: 1.20-1.24] and cesarean section (aHR, 1.14; 95% CI: 1.11-1.16) were each associated with otolaryngology surgery after mutual adjustment. There was some evidence of an interaction between the 2 exposures (P = 0.03).

CONCLUSIONS

Antibiotic exposure in pregnancy and cesarean section may adversely affect early immune development and increase the risk of recurrent upper airway infections and allergy/atopy that may require otolaryngology surgery. Mechanistic studies are warranted to explore genetic and/or molecular pathways that explain these findings. This may identify potential therapeutic targets to reduce the burden of otolaryngology surgery.

The impact of new evidence on regional variation in paediatric tonsillectomy and adenoidectomy: a historical review

BACKGROUND

Tonsillectomy and adenoidectomy have been among the most commonly performed procedures in children for approximately 100 years. These procedures were the first for which unwarranted regional variation was discovered, in 1938. Indications for these procedures have become stricter over time, which might have reduced regional practice variation.

METHODS

This paper presents a historical review on practice variation in paediatric tonsillectomy and adenoidectomy rates. Data on publication year, region, level of variation, methodology and outcomes were collected.

RESULTS

Twenty-one articles on practice variation in paediatric tonsil surgery were included, with data from 12 different countries. Significant variation was found throughout the years, although a greater than 10-fold variation was observed only in the earliest publications.

CONCLUSION

No evidence has yet been found that better indications for tonsillectomy and adenoidectomy have reduced practice variation. International efforts are needed to reconsider why we are still unable to tackle this variation.

Variation in Utilization and Need for Tympanostomy Tubes across England and New England

OBJECTIVES

To compare rates of typmanostomy tube insertions for otitis media with effusion with estimates of need in 2 countries.

STUDY DESIGN

This cross-sectional analysis used all-payer claims to calculate rates of tympanostomy tube insertions for insured children ages 2-8 years (2007-2010) across pediatric surgical areas (PSA) for Northern New England (NNE; Maine, Vermont, and New Hampshire) and the English National Health Service Primary Care Trusts (PCT). Rates were compared with expected rates estimated using a Monte Carlo simulation model that integrates clinical guidelines and published probabilities of the incidence and course of otitis media with effusion.

RESULTS

Observed rates of tympanostomy tube placement varied >30-fold across English PCT (N = 150) and >3-fold across NNE PSA (N = 30). At a 25 dB hearing threshold, the overall difference in observed to expected tympanostomy tubes provided was -3.41 per 1000 child-years in England and -0.01 per 1000 child-years in NNE. Observed incidence of insertion was less than expected in 143 of 151 PCT, and was higher than expected in one-half of the PSA. Using a 20 dB hearing threshold, there were fewer tube insertions than expected in all but 2 England and 7 NNE areas. There was an inverse relationship between estimated need and observed tube insertion rates.

CONCLUSIONS

Regional variations in observed tympanostomy tube insertion rates are unlikely to be due to differences in need and suggest overall underuse in England and both overuse and underuse in NNE.

Increasing rate of middle ear ventilation tube insertion in children in Denmark

OBJECTIVE

To study the incidence rates of middle ear ventilation tube insertion in children aged 0 to 15 years in Denmark from 1997 to 2010.

METHODS

Using two national registers, the Danish National Health Service Register and the Danish National Patient Register, practically all cases of middle ear ventilation tube insertion performed in Denmark in the period were identified. A possible change in incidence rate over time was examined using Poisson regression analysis, while the cumulative incidence proportion was estimated using life-tables.

RESULTS

A total of 502,569 uni- or bilateral ventilation tube insertions distributed among 269,459 different children were identified. From 1997 to 2010 the age standardized incidence rate in 0-15-year-olds increased from 26 to 40 per 1000 person years with an estimated annual increase of 2.0% (95% confidence interval 1.9-2.1%). The largest increase in incidence rate was found in 1-year-olds with an annual increase of 4.5% (95% confidence interval 4.4-4.6%). Age-specific incidence rates remained at maximum around the age of 14 months throughout the period. The cumulative incidence proportion for the 2010 birth cohort by the time they reach the age of 5 years was estimated to 29% (95% confidence interval 28-29%).

CONCLUSION

The rate for middle ear ventilation tube insertion in Denmark was high compared to other developed countries, and an estimated 3 in 10 children born in 2010 will undergo at least one ventilation tube insertion before their fifth birthday.

National Institute for Clinical Excellence guidelines on the surgical management of otitis media with effusion: are they being followed and have they changed practice?

OBJECTIVE

UK National Institute of Clinical Excellence (NICE) guidelines on surgical management of otitis media with effusion (OME) in children call for an initial 3 month period of observation, with ventilation tube (VT) insertion considered for children with persistent bilateral OME with a hearing level in better ear of 25-30 dB HL or worse ("core criteria"), or for children not meeting those audiologic criteria but when OME has significant impact on developmental, social or educational status (exceptional circumstances). We aimed to establish whether guidelines are followed and whether they have changed clinical practice.

METHODS

Retrospective case-notes review in five different centres, analysing practice in accordance with guidelines in all children having first VT insertion before (July-December 06) and after (July-December 08) guidelines introduction.

RESULTS

Records of 319 children were studied, 173 before and 146 after guidelines introduction. There were no significant differences in practice according to guidelines before and after their introduction with respect to having 2 audiograms 3 months apart (57.8 vs. 54.8%), OME persisting at least 3 months (94.8 vs. 92.5%), or fulfilment of the 25 dB audiometric criteria (68.2 vs. 61.0%). Practice in accordance with the core criteria fell significantly from 43.9 to 32.2% (Chi squared p=0.032). However, if the exceptional cases were included there was no significant difference (85.5 vs. 87.0%), as the proportion of exceptional cases rose from 48.3 to 62.2% (Chi squared p=0.021).

CONCLUSION

This study shows that 87.0% of children have VTs inserted in accordance with NICE guidelines providing exceptional cases are included, but only 32.2% comply with the core criteria. A significant number have surgery due to the invoking of exceptional criteria, suggesting that clinicians are personalising the treatment to each individual child.

Transmyringeal ventilation tube treatment: a 10-year cohort study

OBJECTIVE

This ten-year cohort study was intended to determine the incidence and expected outcome of ventilation tube treatment at a clinic that serves a community with 300,000 inhabitants.

METHODS

All children aged 0-10 years, who received their first ventilation tube during 1996, were followed over 10 years, at the department of Otorhinolaryngology, county hospital Ryhov, Jönköping, Sweden. All acute and planned visits were recorded and analyzed, but no extra visits were scheduled due to participation in the study.

RESULTS

In 1996 the overall incidence of tube insertion in the age group 0-10 years was 1 percent. A total of 155 children were entered, and 146 (94 percent) fulfilled the study. During the 10 years' follow up, a total of 409 acute visits and 1485 planned visits were made. In approximately 50 percent of the cases the first ventilation tube was still in place after one year. Infection occurred in 53 percent of the treated ear(s) at least once; the risk for infection was higher if the indication for ventilation tube placement was recurrent acute otitis media. In 45 percent of the children at least one more tube insertion was needed. A permanent perforation after tube treatment was seen in 2 percent of the treated ears. After 5 years, one half of the children were declared free from middle ear disease, but at the termination of the study 17 percent of the children were still in need of regular visits to an otologist due to residual ear problems.

CONCLUSION

This study shows the natural course of treatment with middle ear ventilation tubes in a cohort of children aged 0-10 years during a ten-year period. The incidence of ventilation tube treatment was 1 percent. It is evident that many children need a prolonged contact with an ear-nose and throat specialist when treated with a ventilation tube.

Variability of adenoidectomy/tonsillectomy rates among children of the Veneto Region, Italy

BACKGROUND

Despite national guidelines in 2003 aimed at limiting the recourse to tonsillectomy and/or adenoidectomy (A/T), the latter are among the most frequent pediatric surgeries performed in Italy. Aim of the study is to investigate variability of A/T rates among children of the Veneto Region, Italy.

METHODS

All discharges of Veneto residents with Diagnosis-Related Groups 57-60 and ICD9-CM intervention codes 28.2 (tonsillectomy), 28.3 (adenotonsillectomy), 28.6 (adenoidectomy) were selected in the period 2000-2006 for a descriptive analysis. A multilevel Poisson regression model was applied to estimate Incidence Rate Ratios (IRR) with 95% Confidence Intervals (CI) for A/T surgery among children aged 2-9 years in 2004-2006, while taking into account clustering of interventions within the 21 Local Health Units.

RESULTS

Through 2000-2006, the overall number of A/T surgeries decreased (-8%); there was a decline of adenoidectomies (-20%) and tonsillectomies (-8%), whereas adenotonsillectomies raised (+18%). Analyses on children aged 2-9 resulted in an overall rate of 14.4 surgeries per 1000 person-years (16.1 among males and 12.5 among females), with a wide heterogeneity across Local Health Units (range 8.1-27.6). At random intercept Poisson regression, while adjusting for sex and age, intervention rates were markedly lower among foreign than among Italian children (IRR = 0.57, CI 0.53-0.61). A/T rates in the 10-40 age group (mainly tonsillectomies) computed for each Local Health Unit and introduced in the regression model accounted for 40% of the variance at Local Health Unit level of pediatric rates (mainly adenoidectomies and adenotonsillectomies).

CONCLUSION

A/T rates in the Veneto Region, especially adenoidectomies among children aged 2-9 years, remain high notwithstanding a decrease through 2000-2006. A wide heterogeneity according to nationality and Local Health Units is evident. The propensity to A/T surgery of each Local Health Unit is similar in different age groups and for different surgical indications.

Overuse of tympanostomy tubes in New York metropolitan area: evidence from five hospital cohort

OBJECTIVES

To compare tympanostomy tube insertion for children with otitis media in 2002 with the recommendations of two sets of expert guidelines.

DESIGN

Retrospective cohort study.

SETTING

New York metropolitan area practices associated with five diverse hospitals.

PARTICIPANTS

682 of 1046 children who received tympanostomy tubes in the five hospitals for whom charts from the hospital, primary care physician, and otolaryngologist could be accessed.

RESULTS

The mean age was 3.8 years. On average, children with acute otitis media had fewer than four infections in the year before surgery. Children with otitis media with effusion had less than 30 consecutive days of effusion at the time of surgery. Concordance with recommendations was very low: 30.3% (n=207) of all tympanostomies were concordant with the explicit criteria developed for this study and 7.5% (n=13) with the 1994 guideline from the American Academy of Pediatrics, American Academy of Family Medicine, and American Academy of Otolaryngology-Head and Neck Surgery. Children who had previously had tympanostomy tube surgery, who were having a concomitant procedure, or who had "at risk conditions" were more likely to be discordant.

CONCLUSIONS

A significant majority of tympanostomy tube insertions in the largest and most populous metropolitan area in the United States were inappropriate according to the explicit criteria and not recommended according to both guidelines. Regardless of whether current practice represents a substantial overuse of surgery or the guidelines are overly restrictive, the persistent discrepancy between guidelines and practice cannot be good for children or for people interested in improving their health care.