The concept and practice of a wait-and-see approach to acute otitis media

Utilization of Video Otoscopes for Otoscopy Skills Training of Third Year Medical Students

Purpose

Effective teaching and assessment of otologic examinations are challenging. Current methods of teaching otoscopy using traditional otoscopes have significant limitations. We hypothesized that use of all-in-one video otoscopes provides students with an opportunity for real-time faculty feedback and re-practicing of skills, increasing self-reported confidence.

Methods

An otoscopy microskills competency checklist was provided to third-year medical students during their pediatric clerkship to self-assess otoscopy technique during patient examinations, and to clinical preceptors to assess and provide feedback during exams. Over the course of two years, we collected data from students randomly assigned to train on a video otoscope or a traditional otoscope during the clerkship. Pre- and post-clerkship surveys measured confidence in performing otoscopy microskills, making a diagnosis and documentation of findings. For those students who trained on the video otoscope, we solicited post-clerkship feedback on the experience of using a video otoscope.

Results

Pre-clerkship confidence did not differ between the groups, but the video otoscope trained group had significantly higher scores than the traditional otoscope trained group on all self-reported technical and diagnostic microskills confidence questions items post-clerkship. Students trained on video otoscopes had a significant increase in confidence with all microskills items (p-values<0.001), however confidence in the traditional otoscope trained group did not change over time (p-values>0.10). Qualitative feedback from the video otoscope trained group reflected positive experiences regarding "technique/positioning" and "feedback from preceptors.".

Conclusion

Teaching otoscopy skills to pediatric clerkship medical students using a video otoscope significantly enhanced confidence compared to those training on a traditional otoscope by 1. enabling preceptors and students to simultaneously visualize otoscopy findings 2. allowing preceptors to provide real-time feedback and 3. providing opportunity for deliberate practice of microskills. We encourage the use of video otoscopes to augment student confidence and self-efficacy when training in otoscopy.

How well do we know Gradenigo? A comprehensive literature review and proposal for novel diagnostic categories of Gradenigo's syndrome

Gradenigo's Syndrome is a rare complication of otitis media and/or mastoiditis resulting in inflammation of the petrous apex of the temporal bone. Here, we highlight an interesting case from our institution, summarize available pediatric cases from the past fifty years to provide an updated diagnostic categorization for this rare condition with confusing nomenclature, and suggest guidance for diagnosis and management.

Using theory to explore facilitators and barriers to delayed prescribing in Australia: a qualitative study using the Theoretical Domains Framework and the Behaviour Change Wheel

BACKGROUND

Delayed antibiotic prescribing reduces antibiotic use for acute respiratory infections in trials in general practice, but the uptake in clinical practice is low. The aim of the study was to identify facilitators and barriers to general practitioners' (GPs') use of delayed prescribing and to gain pharmacists' and the public's views about delayed prescribing in Australia.

METHODS

This study used the Theoretical Domains Framework and the Behaviour Change Wheel to explore facilitators and barriers to delayed prescribing in Australia. Forty-three semi-structured, face-to-face interviews with general practitioners, pharmacists and patients were conducted. Responses were coded into domains of the Theoretical Domains Framework, and specific criteria from the Behaviour Change Wheel were used to identify which domains were relevant to increasing the use of delayed prescribing by GPs.

RESULTS

The interviews revealed nine key domains that influence GPs' use of delayed prescribing: knowledge; cognitive and interpersonal skills; memory, attention and decision-making processes; optimism; beliefs about consequences; intentions; goals; emotion; and social influences: GPs knew about delayed prescribing; however, they did not use it consistently, preferring to bring patients back for review and only using it with patients in a highly selective way. Pharmacists would support GPs and the public in delayed prescribing but would fill the prescription if people insisted. The public said they would delay taking their antibiotics if asked by their GP and given the right information on managing symptoms and when to take antibiotics.

CONCLUSIONS

Using a theory-driven approach, we identified nine key domains that influence GPs' willingness to provide a delayed prescription to patients with an acute respiratory infection presenting to general practice. These data can be used to develop a structured intervention to change this behaviour and thus reduce antibiotic use for acute respiratory infections in general practice.

Pneumococcal conjugate vaccines for preventing otitis media

BACKGROUND

Acute otitis media (AOM) is a very common respiratory infection in early infancy and childhood. The marginal benefits of antibiotics for AOM in low-risk populations in general, the increasing problem of bacterial resistance to antibiotics and the huge estimated direct and indirect annual costs associated with otitis media (OM) have prompted a search for effective vaccines to prevent AOM.

OBJECTIVES

To assess the effect of pneumococcal conjugate vaccines (PCVs) in preventing AOM in children up to 12 years of age.

SEARCH METHODS

We searched CENTRAL (2013, Issue 11), MEDLINE (1995 to November week 3, 2013), EMBASE (1995 to December 2013), CINAHL (2007 to December 2013), LILACS (2007 to December 2013) and Web of Science (2007 to December 2013).

SELECTION CRITERIA

Randomised controlled trials (RCTs) of PCVs to prevent AOM in children aged 12 years or younger, with a follow-up of at least six months after vaccination.

DATA COLLECTION AND ANALYSIS

Two review authors independently assessed trial quality and extracted data.

MAIN RESULTS

We included 11 publications of nine RCTs (n = 48,426 children, range 74 to 37,868 per study) of 7- to 11-valent PCV (with different carrier proteins). Five trials (n = 47,108) included infants, while four trials (n = 1318) included children aged one to seven years that were either healthy (one study, n = 264) or had a previous history of upper respiratory tract infection (URTI), including AOM. We judged the methodological quality of the included studies to be moderate to high. There was considerable clinical diversity between studies in terms of study population, type of conjugate vaccine and outcome measures. We therefore refrained from pooling the results.In three studies, the 7-valent PCV with CRM197 as carrier protein (CRM197-PCV7) administered during early infancy was associated with a relative risk reduction (RRR) of all-cause AOM ranging from -5% in high-risk children (95% confidence interval (CI) -25% to 12%) to 7% in low-risk children (95% CI 4% to 9%). Another 7-valent PCV with the outer membrane protein complex of Neisseria meningitidis (N. meningitidis) serogroup B as carrier protein, administered in infancy, did not reduce overall AOM episodes, while a precursor 11-valent PCV with Haemophilus influenzae (H. influenzae) protein D as carrier protein was associated with a RRR of all-cause AOM episodes of 34% (95% CI 21% to 44%).A 9-valent PCV (with CRM197 carrier protein) administered in healthy toddlers was associated with a RRR of (parent-reported) OM episodes of 17% (95% CI -2% to 33%). CRM197-PCV7 followed by 23-valent pneumococcal polysaccharide vaccination administered after infancy in older children with a history of AOM showed no beneficial effect on first occurrence and later AOM episodes. In a study in older children with a previously diagnosed respiratory tract infection, performed during the influenza season, a trivalent influenza vaccine combined with placebo (TIV/placebo) led to fewer all-cause AOM episodes than vaccination with TIV and PCV7 (TIV/PCV7) when compared to hepatitis B vaccination and placebo (HBV/placebo) (RRR 71%, 95% CI 30% to 88% versus RRR 57%, 95% CI 6% to 80%, respectively) indicating that CRM197-PCV7 after infancy may even have negative effects on AOM.

AUTHORS' CONCLUSIONS

Based on current evidence of the effects of PCVs for preventing AOM, the licensed 7-valent CRM197-PCV7 has modest beneficial effects in healthy infants with a low baseline risk of AOM. Administering PCV7 in high-risk infants, after early infancy and in older children with a history of AOM, appears to have no benefit in preventing further episodes. Currently, several RCTs with different (newly licensed, multivalent) PCVs administered during early infancy are ongoing to establish their effects on AOM. Results of these studies may provide a better understanding of the role of the newly licensed, multivalent PCVs in preventing AOM. Also the impact on AOM of the carrier protein D, as used in certain pneumococcal vaccines, needs to be further established.

Panel 7: Treatment and comparative effectiveness research

BACKGROUND AND OBJECTIVES

Otitis media (OM) is one of the most common reasons for antibiotic treatment in children. Controversies regarding antibiotic treatment for OM have accumulated in the past decade, and there seem to be more dilemmas than certainties. The objectives of this article are to provide the state-of-the art review on achievements in treatment of all different stages of OM, including acute otitis media (AOM), otitis media with effusion (OME), and chronic suppurative otitis media, and to outline the future research areas.

DATA SOURCES

PubMed, Ovid Medline, the Cochrane Database, and Clinical Evidence (BMJ Publishing).

REVIEW METHODS

All types of articles related to OM treatment published in English between January 2007 and June 2011 were identified. A total of 286 articles related to OM treatment were reviewed by the panel members; 114 relevant quality articles were identified and summarized.

RESULTS

New evidence emerged on beneficial results of antibiotic treatment, compared with observation of AOM in young children who were diagnosed based on stringent criteria. In OME, the main results were related to a nonsignificant benefit of adenoidectomy versus tympanostomy tube placement alone in the treatment of chronic OME in younger children. Other modalities of OM treatment were studied and described herein.

CONCLUSIONS AND IMPLICATIONS FOR PRACTICE

Significant progress has been made in advancing the knowledge on the treatment of OM. Areas of potential future research have been identified and outlined.

Korean clinical practice guidelines: otitis media in children

Acute otitis media (AOM) and otitis media with effusion (OME) are common infections in children, and their diagnosis and treatment have significant impacts on the health of children and the costs of providing national medical care. In 2009, the Korean Otologic Society organized a committee composed of experts in the field of otolaryngology, pediatrics, and family medicine to develop Korean clinical practice guidelines (CPG) for otitis media in children with the goal of meeting regional medical and social needs in Korea. For this purpose, the committee adapted existing guidelines. A comprehensive literature review was carried out primarily from 2004 to 2009 using medical search engines including data from Korea. A draft was written after a national questionnaire survey and several public audits, and it was editorially supervised by senior advisors before publication of the final report. These evidence-based guidelines for the management of otitis media in children provide recommendations to primary practitioners for the diagnosis and treatment of children younger than 15 yr old with uncomplicated AOM and OME. The guidelines include recommendations regarding diagnosis, treatment options, prevention and parent education, medical records, referral, and complementary/alternative medicine for treating pediatric otitis media.

A proposal to limit otoscopy to reduce unnecessary use of antibiotics: a call for research

Acute otitis media (AOM) is the most common bacterial infection in childhood, accounting for more than 10 million prescriptions written in the USA alone. Otoscopy is the only method to diagnose AOM, is difficult to perform in young children and has been found to be inaccurate. Otoscopy has certain risks, the most common of which are child discomfort, trauma to the external ear canal and parental anxiety. Current guidelines emphasize the importance of making an accurate diagnosis of AOM, which includes the presence of fever, otalgia or both. We propose a new strategy to limit the use of otoscopy to circumstances in which the pretest probability of AOM is high. We suggest indications for mandatory otoscopy and a flow chart outlining a proposal for limiting otoscopy in the management of AOM. Clinical research evaluating the rational use of otoscopy is encouraged to evaluate outcomes and acceptance of this proposal. Limiting otoscopy to clinical conditions in which the likelihood of AOM is high may reduce unnecessary pain and anxiety associated with the procedure, reduce rates of misdiagnosis and support the more judicious use of antibiotics.

Ophthalmic complications of otitis media in children

PURPOSE

To evaluate the outcome of ophthalmic complications in children with otitis media.

METHODS

The records of children with ophthalmic complications arising from otitis media who presented to the British Columbia Children's Hospital between August 2006 and March 2008 were reviewed retrospectively.

RESULTS

Of 1,400 patients presenting to the emergency department for otitis media during the study period, 7 with ophthalmic complications were identified (age range, 1-11 years). All patients had abducens nerve palsy on presentation. Other notable ophthalmic complications included papilledema, Horner syndrome, and proptosis. Extracranial and intracranial complications included mastoiditis, petrositis, parapharyngeal abscess, hydrocephalus, epidural abscess, and cerebral venous thrombosis, including cavernous sinus thrombosis in 2. Of the 7 patients, 6 were treated with surgery, including myringotomy and tube placement (6 patients) and mastoidectomy (3 patients). All patients were initially anticoagulated and received intravenous antibiotics. Satisfactory final visual outcomes and stereopsis ranging from 40 to 100 seconds were achieved in all patients.

CONCLUSIONS

Ophthalmic complications of otitis media in children are likely to include abducens palsy. All patients in our series required anticoagulation and intravenous antibiotics. Most required otolaryngologic surgery, but none required strabismus surgery, and all patients had satisfactory visual and ocular motility outcomes.

Otitis media across nine countries: disease burden and management

OBJECTIVE

To assess the perceived disease burden and management of otitis media (OM) among an international cohort of experienced physicians.

METHODS

A cross-sectional survey conducted in France, Germany, Spain, Poland, Argentina, Mexico, South Korea, Thailand and Saudi Arabia. Face-to-face interviews conducted with 1800 physicians (95% paediatricians, 5% family practitioners).Main outcome measures were the perceived burden on clinical practice (number of cases, complications and referrals) and first- and second-line management strategies for OM. Results are expressed as mean and range across the nine countries over three continents.

RESULTS

Respondents estimated an average annual caseload of 375 (range 128-1003) children under 5 years of age with OM; 54% (range 44-71%) with an initial episode and 38% (range 27-54%) with recurrent OM (ROM). OM with complications was estimated to be approximately 20 (range 7-49) cases per year and an estimated 15% (8-41%) of children with OM was recalled as needing specialist referral. There was high awareness of Streptococcus pneumoniae and Haemophilus influenzae as causative bacterial pathogens: 77% (range 65-91%) and 74% (range 68-83%), respectively, but less recognition of non-typeable H. influenzae (NTHi); 59% (range 45-67%). Although concern over antimicrobial resistance was widespread, empirical treatment with antibiotics was the most common first-line treatment (mean 81%, range 40-96%). The burden of disease is substantial enough that many physicians would consider vaccination to prevent OM (mean score 5.1, range 4.3-6.2 on 1-7 scale).

CONCLUSIONS

This large, multinational survey shows that OM remains a significant burden for clinical practice. Despite awareness of shortcomings, antimicrobial therapy remains the most frequent treatment for OM.

Short-course antibiotics for acute otitis media

BACKGROUND

Acute otitis media (AOM) is a common illness during childhood, for which antibiotics are frequently prescribed.

OBJECTIVES

To determine the effectiveness of a short course of antibiotics (less than seven days) in comparison to a long course of antibiotics (seven days or greater) for the treatment of AOM in children.

SEARCH STRATEGY

We searched the Cochrane Central Register of Controlled Trials (CENTRAL) (The Cochrane Library 2009, issue 4) which contains the Acute Respiratory Infections Group's Specialised Register, MEDLINE, EMBASE, MEDLINE In-Process & Other Non-Indexed Citations, CINAHL, BIOSIS Previews, OCLC Papers First and Proceedings First, Proquest Dissertations and Theses (inception to November 2009); International Pharmaceutical Abstracts, the NLM Gateway, ClinicalTrials.gov and Current Controlled Trials (inception to August 2008).

SELECTION CRITERIA

Trials were included if they met the following criteria: participants aged one month to 18 years; clinical diagnosis of ear infection; no previous antimicrobial therapy; and randomisation to treatment with less than seven days versus seven days or more of antibiotics.

DATA COLLECTION AND ANALYSIS

The primary outcome of treatment failure was defined as the absence of clinical resolution, relapse or recurrence of AOM during one month following initiation of therapy. Treatment outcomes were extracted from individual studies and combined in the form of a summary odds ratio (OR). A summary OR of 1.0 indicates that the treatment failure rate following less than seven days of antibiotic treatment was similar to the failure rate following seven days or more of treatment.

MAIN RESULTS

This update included 49 trials containing 12,045 participants. Risk of treatment failure was higher with short courses of antibiotics (OR 1.34, 95% CI 1.15 to 1.55) at one month after initiation of therapy (21% failure with short-course treatment and 18% with long-course; absolute difference of 3% between groups). There were no differences found when examining treatment with ceftriaxone for less than seven days (30% failure in those receiving ceftriaxone and 27% in short-acting antibiotics administered for seven days or more) or azithromycin for less than seven days (18% failure in both those receiving azithromycin and short-acting antibiotics administered for seven days or more) with respect to risk of treatment failure at one month or less. Significant reductions in gastrointestinal adverse events were observed for treatment with short-acting antibiotics and azithromycin.

AUTHORS' CONCLUSIONS

Clinicians need to evaluate whether the minimal short-term benefit from longer treatment of antibiotics is worth exposing children to a longer course of antibiotics.

Challenges in reducing the burden of otitis media disease: an ENT perspective on improving management and prospects for prevention

Acute otitis media (AOM) is a major public health concern. This frequent disease of childhood is a leading cause of physician visits, a major component of paediatric healthcare burden, and a key contributor to antibiotic resistance. An international expert group comprising mainly ear, nose, and throat physicians met in June 2008 to discuss the optimal management of AOM, particularly with regards to unmet needs in diagnosis and management. Current guidelines do not help identify which patients are most at risk for severe or complicated AOM. Diagnosis of AOM is also complicated by a lack of correlation between clinical signs and symptoms and responsible pathogens. Consequently, treatment of AOM is not always appropriate, and the long-term overuse of antibiotics in AOM reduces the effectiveness of treatment and places children at risk for drug-resistant infections. There is a need for educational and research initiatives to improve diagnostic accuracy and management of AOM. Because there is currently no ideal treatment, vaccination is an attractive additional approach for managing AOM and reducing its burden.

Factors that affect parent perceptions of provider-family partnership for children with special health care needs

Partnering between families and their children's providers is a cornerstone of family-centered care. This study aimed to identify factors associated with family-provider partnership and determine the association between partnership and other outcome measures for children with special health care needs (CSHCN). Descriptive, bivariate, and multivariate analyses were conducted using data from the 2005-2006 National Survey of Children with Special Health Care Needs. Multivariate models showed that CSHCN who are White non-Hispanic, younger than 12, reside in households with incomes above 400% of the federal poverty level, and have a usual source of care were associated with family-provider partnership. Multivariate models showed that family-provider partnership was significantly associated with adequate insurance, early and continual screening, organized health care services, and transition preparedness. Family-provider partnership was associated with 20% fewer emergency department visits and 9% fewer school days missed. This study suggests that policies aimed at promoting family-provider partnership could increase health outcomes for CSHCN.

Risk factors for nasopharyngeal carriage of drug-resistant Streptococcus pneumoniae: data from a nation-wide surveillance study in Greece

Background

A nation-wide surveillance study was conducted in Greece in order to provide a representative depiction of pneumococcal carriage in the pre-vaccination era and to evaluate potential risk factors for carriage of resistant strains in healthy preschool children attending daycare centers.

Methods

A study group was organized with the responsibility to collect nasopharyngeal samples from children. Questionnaires provided demographic data, data on antibiotic consumption, family and household data, and medical history data. Pneumococcal isolates were tested for their susceptibility to various antimicrobial agents and resistant strains were serotyped.

Results

Between February and May 2004, from a total population of 2536 healthy children, a yield of 746 pneumococci was isolated (carriage rate 29.41%). Resistance rates differed among geographic regions. Recent antibiotic use in the last month was strongly associated with the isolation of resistant pneumococci to a single or multiple antibiotics. Serotypes 19F, 14, 9V, 23F and 6B formed 70.6% of the total number of resistant strains serotyped.

Conclusion

Recent antibiotic use is a significant risk factor for the colonization of otherwise healthy children's nasopharynx by resistant strains of S pneumoniae. The heptavalent pneumococcal conjugate vaccine could provide coverage for a significant proportion of resistant strains in the Greek community. A combined strategy of vaccination and prudent antibiotic use could provide a means for combating pneumococcal resistance.

Pneumococcal conjugate vaccines for preventing otitis media

BACKGROUND

Acute otitis media (AOM) is a very common early infancy and childhood disease. The marginal benefits of antibiotics on AOM, the increasing problem of bacterial resistance to antibiotics, and the huge estimated direct and indirect annual costs associated with otitis media (OM) have prompted a search for effective vaccines to prevent AOM.

OBJECTIVES

To assess the effect of pneumococcal conjugate vaccines (PCVs) in preventing AOM in children up to 12 years of age.

SEARCH STRATEGY

We searched the Cochrane Central Register of Controlled Trials (CENTRAL) (The Cochrane Library 2007, issue 2), which contains the Cochrane Acute Respiratory Infections Group's Specialised Register; MEDLINE (January 1995 to November 2007); and EMBASE (January 1995 to November 2007).

SELECTION CRITERIA

Randomised controlled trials of PCVs to prevent AOM in children aged 12 years or younger, with a follow up of at least six months after vaccination.

DATA COLLECTION AND ANALYSIS

Three review authors independently assessed trial quality and two review authors extracted data.

MAIN RESULTS

We included seven trials on 7- to 11-valent PCV (with different carrier proteins). There was large heterogeneity regarding study population, type of conjugate vaccine, and outcome measures between trials, therefore, results were not pooled. The only currently licensed 7-valent PCV Prevenar with CRM197 as carrier protein (CRM197-PCV7) administered during infancy was in two studies associated with a 6% (95% confidence interval (CI) -4% to 16%) and 7% (95% CI 4% to 9%) relative reduction in risk of AOM episodes. Another 7-valent PCV with the outer membrane protein complex of Neisseria meningitidis (N. meningitidis) serogroup B as carrier protein, administered in infancy, did not reduce overall AOM episodes, while an 11-valent PCV with Haemophilus influenzae (H. influenzae) protein D as carrier protein was associated with a relative reduction in risk of AOM episodes of 34% (95% CI 21% to 44%). 9-valent PCV (with CRM197 carrier protein) administered in healthy toddlers was associated with a 17% (95% CI -2% to 33%) relative reduction in risk of OM episodes. CRM197-PCV7 followed by 23-valent pneumococcal polysaccharide vaccination administered after infancy in older children with a history of AOM showed no beneficial effect on further AOM episodes.

AUTHORS' CONCLUSIONS

Based on current evidence of the effectiveness of PCVs for the prevention of AOM, the currently licensed 7-valent PCV administered during infancy has marginal beneficial effects. Discrete reductions of 6% to 7% may mean substantial reductions from a public health perspective. Administering PCV7 in older children with a history of AOM appears to have no benefit in preventing further episodes.