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Mulvaney CA, Galbraith K, Webster KE, Rana M, Connolly R, Tudor-Green B, Marom T, Daniel M, Venekamp RP, Schilder AG, MacKeith S. Topical and oral steroids for otitis media with effusion (OME) in children. Cochrane Database Syst Rev 2023; 12:CD015255. [PMID: 38088821 PMCID: PMC10718197 DOI: 10.1002/14651858.cd015255.pub2] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/18/2023]
Abstract
BACKGROUND Otitis media with effusion (OME) is an accumulation of fluid in the middle ear cavity, common amongst young children. The fluid may cause hearing loss. Although most episodes of OME in children resolve spontaneously within a few months, when persistent it may lead to behavioural problems and a delay in expressive language skills. Management of OME includes watchful waiting, medical, surgical and other treatments, such as autoinflation. Oral or topical steroids are sometimes used to reduce inflammation in the middle ear. OBJECTIVES To assess the effects (benefits and harms) of topical and oral steroids for OME in children. SEARCH METHODS We searched the Cochrane ENT Register, CENTRAL, Ovid MEDLINE, Ovid Embase, Web of Science, ClinicalTrials.gov, ICTRP and additional sources for published and unpublished studies on 20 January 2023. SELECTION CRITERIA We included randomised controlled trials (RCTs) and quasi-randomised trials in children aged 6 months to 12 years with unilateral or bilateral OME. We included studies that compared topical or oral steroids with either placebo or watchful waiting (no treatment). DATA COLLECTION AND ANALYSIS We used standard Cochrane methods. Our primary outcomes, determined by a multi-stakeholder prioritisation exercise, were: 1) hearing, 2) OME-specific quality of life and 3) systemic corticosteroid side effects. Secondary outcomes were: 1) presence/persistence of OME, 2) other adverse effects (including local nasal effects), 3) receptive language skills, 4) speech development, 5) cognitive development, 6) psychosocial outcomes, 7) listening skills, 8) generic health-related quality of life, 9) parental stress, 10) vestibular function and 11) episodes of acute otitis media. We used GRADE to assess the certainty of evidence. Although we included all measures of hearing assessment, the proportion of children who returned to normal hearing was our preferred method to assess hearing, due to challenges in interpreting the results of mean hearing thresholds. MAIN RESULTS We included 26 studies in this review (2770 children). Most studies of oral steroids used prednisolone for 7 to 14 days. Studies of topical (nasal) steroids used various preparations (beclomethasone, fluticasone and mometasone) for between two weeks and three months. All studies had at least some concerns regarding risk of bias. Here we report our primary outcomes and main secondary outcome, at the longest reported follow-up. Oral steroids compared to placebo Oral steroids probably result in little or no difference in the proportion of children with normal hearing after 12 months (69.7% of children with steroids, compared to 61.1% of children receiving placebo, risk ratio (RR) 1.14, 95% confidence interval (CI) 0.97 to 1.33; 1 study, 332 participants; moderate-certainty evidence). There is probably little or no difference in OME-related quality of life (mean difference (MD) in OM8-30 score 0.07, 95% CI -0.2 to 0.34; 1 study, 304 participants; moderate-certainty evidence). Oral steroids may reduce the number of children with persistent OME at 6 to 12 months, but the size of the effect was uncertain (absolute risk reduction ranging from 13.3% to 45%, number needed to treat (NNT) of between 3 and 8; low-certainty evidence). The evidence was very uncertain regarding the risk of systemic corticosteroid side effects, and we were unable to conduct any meta-analysis for this outcome. Oral steroids compared to no treatment Oral steroids may result in little or no difference in the persistence of OME after three to nine months (74.5% children receiving steroids versus 73% of those receiving placebo; RR 1.02, 95% CI 0.89 to 1.17; 2 studies, 258 participants; low-certainty evidence). The evidence on adverse effects was very uncertain. We did not identify any evidence on hearing or disease-related quality of life. Topical (intranasal) steroids compared to placebo We did not identify data on the proportion of children who returned to normal hearing. However, the mean change in hearing threshold after two months was -0.3 dB lower (95% CI -6.05 to 5.45; 1 study, 78 participants; very low-certainty evidence). The evidence suggests that nasal steroids make little or no difference to disease-specific quality of life after nine months (OM8-30 score, MD 0.05 higher, 95% CI -0.36 to 0.46; 1 study, 82 participants; low-certainty evidence). The evidence is very uncertain regarding the effect of nasal steroids on persistence of OME at up to one year. Two studies reported this: one showed a potential benefit for nasal steroids, the other showed a benefit with placebo (2 studies, 206 participants). The evidence was also very uncertain regarding the risk of corticosteroid-related side effects, as we were unable to provide a pooled effect estimate. Topical (intranasal) steroids compared to no treatment We did not identify data on the proportion of children who returned to normal hearing. However, the mean difference in final hearing threshold after four weeks was 1.95 dB lower (95% CI -3.85 to -0.05; 1 study, 168 participants; low-certainty evidence). Nasal steroids may reduce the persistence of OME after eight weeks, but the evidence was very uncertain (58.5% of children receiving steroids, compared to 81.3% of children without treatment, RR 0.72, 95% CI 0.57 to 0.91; 2 studies, 134 participants). We did not identify any evidence on disease-related quality of life or adverse effects. AUTHORS' CONCLUSIONS Overall, oral steroids may have little effect in the treatment of OME, with little improvement in the number of children with normal hearing and no effect on quality of life. There may be a reduction in the proportion of children with persistent disease after 12 months. However, this benefit may be small and must be weighed against the potential for adverse effects associated with oral steroid use. The evidence for nasal steroids was all low- or very low-certainty. It is therefore less clear if nasal steroids have any impact on hearing, quality of life or persistence of OME. Evidence on adverse effects was very limited. OME is likely to resolve spontaneously for most children. The potential benefit of treatment may therefore be small and should be balanced with the risk of adverse effects. Future studies should aim to determine which children are most likely to benefit from treatment, rather than offering interventions to all children.
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Affiliation(s)
- Caroline A Mulvaney
- Cochrane ENT, Nuffield Department of Surgical Sciences, University of Oxford, Oxford, UK
| | - Kevin Galbraith
- Cochrane ENT, Nuffield Department of Surgical Sciences, University of Oxford, Oxford, UK
| | - Katie E Webster
- Cochrane ENT, Nuffield Department of Surgical Sciences, University of Oxford, Oxford, UK
| | - Mridul Rana
- ENT Department, Frimley Health NHS Foundation Trust, Slough, UK
| | - Rachel Connolly
- National Institute for Health and Care Excellence, London, UK
| | - Ben Tudor-Green
- Department of Otorhinolaryngology - Head & Neck Surgery, University Hospitals Plymouth NHS Trust, Plymouth, UK
| | - Tal Marom
- Department of Otolaryngology - Head and Neck Surgery, Samson Assuta Ashdod University Hospital, Ben Gurion University Faculty of Health Sciences, Ashdod, Israel
| | - Mat Daniel
- Nottingham Children's Hospital, Nottingham, UK
| | - Roderick P Venekamp
- Julius Center for Health Sciences and Primary Care, University Medical Center Utrecht, Utrecht University, Utrecht, Netherlands
| | - Anne Gm Schilder
- evidENT, Ear Institute, University College London, London, UK
- NIHR UCLH Biomedical Research Centre, University College London, London, UK
| | - Samuel MacKeith
- ENT Department, Oxford University Hospitals NHS Foundation Trust, Oxford, UK
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Giri O, Shenoy SV, Parvathareddy N, Puvvula P, Shetty D, Reddy N. Assessment of middle ear function after conventional or endoscopic microdebrider assisted adenoidectomy. ACTA OTORHINOLARYNGOLOGICA ITALICA : ORGANO UFFICIALE DELLA SOCIETA ITALIANA DI OTORINOLARINGOLOGIA E CHIRURGIA CERVICO-FACCIALE 2023; 43:417-423. [PMID: 37814977 PMCID: PMC10773544 DOI: 10.14639/0392-100x-n2593] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 04/11/2023] [Accepted: 06/05/2023] [Indexed: 10/11/2023]
Abstract
Objectives To compare pre- and post-operative pure tone audiometric and impedance audiometric analysis following conventional and endoscopic microdebrider assisted adenoidectomy and compare the outcomes. Methods Patients diagnosed with chronic adenoiditis were divided in groups of 25 each. Patients in the first group underwent conventional curettage adenoidectomy, while those in second group underwent endoscopic microdebrider assisted adenoidectomy. Pre- and post-operative pure tone and impedance audiometry were performed for all patients and outcomes were compared. Results The endoscopic microdebrider assisted method resulted in significantly better outcomes compared to conventional curettage. Criteria such as hearing threshold (p value 0.004 at second follow-up), peak pressure (p value 0.045 at first follow-up) and tympanogram (p value 0.016) showed that the endoscopic method was better, while peak compliance (p value 0.340 at first follow-up) did not show any significant difference between groups. Conclusions The endoscopic microdebrider assisted method for adenoidectomy has a definite advantage of better visualisation resulting in better clearance of tissue, leading to enhanced middle ear function compared to conventional curettage.
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Affiliation(s)
| | - S Vijendra Shenoy
- Department of ENT and Head & Neck Surgery, Kasturba Medical College, Mangalore, Manipal Academy of Higher Education, Manipal, India
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Utama MAS, Kentjono WA, Ekorini HM. Association between Adenoid-Nasopharyngeal Ratio and Tympanogram Width in Adenoid Hypertrophy Patients. ASIAN JOURNAL OF ONCOLOGY 2021. [DOI: 10.1055/s-0041-1735332] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/19/2022] Open
Abstract
Abstract
Introduction Adenoid hypertrophy is a change in adenoid size that can lead to obstruction the Eustachian tube and become a risk factor for otitis media effusion (OME) in children. Standard objective examination of adenoid hypertrophy uses adenoid-nasopharyngeal ratio (A-N ratio) based on correct lateral skull radiography. Adenoid hypertrophy is one of the factors causing OME in children. There is still much debate about the association between A-N ratio and tympanogram width (Tw). Determining the association of A-N ratio and Tw in adenoid hypertrophy patients.
Methods Participants performed a true lateral radiographic examination using Fujioka method to determine A-N ratio, and Tw to determine middle-ear pressure. The distance between examination of A-N ratio and tympanogram examination was at maximum of ~1 week. The association between A-N ratio and Tw in patients with adenoid hypertrophy used the Pearson correlation test. This research employed significance level p < 0.05.
Results Most participants were aged between 6 and 10 years (38.10%), male patients (57.14%), and the symptom most participants complained of was snoring during sleep (38.10%). Most participants had A-N ratio of 0.53 to 0.70 (61.90%) with an average of 0.60 ± 0.05. The average value of Tw measurement was 102.83 ± 50.03 daPa (r = 0.605; p < 0.001).
Conclusion There is a significant association between A-N ratio base on true lateral radiographic examination and Tw in adenoid hypertrophy patients.
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Affiliation(s)
- Muhammad Arif Sudianto Utama
- Department of Otorhinolaryngology Head and Neck Surgery, Faculty of Medicine, Universitas Airlangga – Dr. Soetomo General Academic Hospital, Surabaya, Indonesia
| | - Widodo Ario Kentjono
- Department of Otorhinolaryngology Head and Neck Surgery, Faculty of Medicine, Universitas Airlangga – Dr. Soetomo General Academic Hospital, Surabaya, Indonesia
| | - Haris Mayagung Ekorini
- Department of Otorhinolaryngology Head and Neck Surgery, Faculty of Medicine, Universitas Airlangga – Dr. Soetomo General Academic Hospital, Surabaya, Indonesia
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Aurich B, Jacqz-Aigrain E. Drug Safety in Translational Paediatric Research: Practical Points to Consider for Paediatric Safety Profiling and Protocol Development: A Scoping Review. Pharmaceutics 2021; 13:pharmaceutics13050695. [PMID: 34064872 PMCID: PMC8151265 DOI: 10.3390/pharmaceutics13050695] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/08/2021] [Revised: 05/05/2021] [Accepted: 05/07/2021] [Indexed: 12/28/2022] Open
Abstract
Translational paediatric drug development includes the exchange between basic, clinical and population-based research to improve the health of children. This includes the assessment of treatment related risks and their management. The objectives of this scoping review were to search and summarise the literature for practical guidance on how to establish a paediatric safety specification and its integration into a paediatric protocol. PubMed, Embase, Web of Science, and websites of regulatory authorities and learned societies were searched (up to 31 December 2020). Retrieved citations were screened and full texts reviewed where applicable. A total of 3480 publications were retrieved. No article was identified providing practical guidance. An introduction to the practical aspects of paediatric safety profiling and protocol development is provided by combining health authority and learned society guidelines with the specifics of paediatric research. The paediatric safety specification informs paediatric protocol development by, for example, highlighting the need for a pharmacokinetic study prior to a paediatric trial. It also informs safety related protocol sections such as exclusion criteria, safety monitoring and risk management. In conclusion, safety related protocol sections require an understanding of the paediatric safety specification. Safety data from carefully planned paediatric research provide valuable information for children, parents and healthcare providers.
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Affiliation(s)
- Beate Aurich
- Department of Pharmacology, Saint-Louis Hospital, 75010 Paris, France;
| | - Evelyne Jacqz-Aigrain
- Department of Pharmacology, Saint-Louis Hospital, 75010 Paris, France;
- Paris University, 75010 Paris, France
- Correspondence:
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Ju HJ, Park M, Park JH, Shin GR, Choi HS, Suh MW, Kim MS. In Vivo Imaging of Click-Crosslinked Hydrogel Depots Following Intratympanic Injection. MATERIALS 2020; 13:ma13143070. [PMID: 32660032 PMCID: PMC7412526 DOI: 10.3390/ma13143070] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 06/11/2020] [Revised: 06/30/2020] [Accepted: 07/06/2020] [Indexed: 12/19/2022]
Abstract
In this study, we developed injectable intratympanic hyaluronic acid (HA) depots for the treatment of hearing loss. We prepared an injectable click-crosslinking formulation by modifying HA with tetrazine (HA-TET) and trans-cyclooctene (HA-TCO), which crosslinked to form an HA depot (Cx-HA). Preparation of the click-crosslinking HA formulation was facile, and Cx-HA depot formation was reproducible. Additionally, the Cx-HA hydrogel was significantly stiffer than HA hydrogel. To monitor the degradation pattern of hydrogels, we mixed a zwitterionic near-infrared (NIR) fluorophore (e.g., ZW800-1C) in the click-crosslinking HA formulation. Then, HA-TET and HA-TCO solutions containing ZW800-1C were loaded separately into the compartments of a dual-barrel syringe for intratympanic injection. The Cx-HA depots formed quickly, and an extended residence time in the tympanic cavity was confirmed by performing NIR fluorescence imaging. We have successfully prepared an injectable click-crosslinking HA formulation that has promise as an intratympanic drug depot.
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Affiliation(s)
- Hyeon Jin Ju
- Department of Molecular Science and Technology, Ajou University, Suwon 443-749, Korea; (H.J.J.); (J.H.P.); (G.R.S.)
| | - Mina Park
- Department of Otorhinolaryngology-Head and Neck Surgery, Seoul Medical Center, Seoul 05505, Korea;
| | - Ji Hoon Park
- Department of Molecular Science and Technology, Ajou University, Suwon 443-749, Korea; (H.J.J.); (J.H.P.); (G.R.S.)
| | - Gi Ru Shin
- Department of Molecular Science and Technology, Ajou University, Suwon 443-749, Korea; (H.J.J.); (J.H.P.); (G.R.S.)
| | - Hak Soo Choi
- Gordon Center for Medical Imaging, Department of Radiology, Massachusetts General Hospital and Harvard Medical School, Boston, MA 02114, USA
- Correspondence: (H.S.C.); (M.-W.S.); (M.S.K.); Tel.: +1-617-726-5784 (H.S.C.); +82-2-2072-3649 (M.-W.S.); +82-31-219-2608 (M.S.K.); Fax: +1-617-643-2604 (H.S.C.); +82-2-745-2387 (M.-W.S.); +82-31-219-3931 (M.S.K.)
| | - Myung-Whan Suh
- Department of Otorhinolaryngology-Head and Neck Surgery, Seoul Medical Center, Seoul 05505, Korea;
- Correspondence: (H.S.C.); (M.-W.S.); (M.S.K.); Tel.: +1-617-726-5784 (H.S.C.); +82-2-2072-3649 (M.-W.S.); +82-31-219-2608 (M.S.K.); Fax: +1-617-643-2604 (H.S.C.); +82-2-745-2387 (M.-W.S.); +82-31-219-3931 (M.S.K.)
| | - Moon Suk Kim
- Department of Molecular Science and Technology, Ajou University, Suwon 443-749, Korea; (H.J.J.); (J.H.P.); (G.R.S.)
- Correspondence: (H.S.C.); (M.-W.S.); (M.S.K.); Tel.: +1-617-726-5784 (H.S.C.); +82-2-2072-3649 (M.-W.S.); +82-31-219-2608 (M.S.K.); Fax: +1-617-643-2604 (H.S.C.); +82-2-745-2387 (M.-W.S.); +82-31-219-3931 (M.S.K.)
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Liu PZ, Ismail-Koch H, Stephenson K, Donne AJ, Fergie N, Derry J, Stynes G, Kamani T, Birchall JP, Daniel M. A core outcome set for research on the management of otitis media with effusion in otherwise-healthy children. Int J Pediatr Otorhinolaryngol 2020; 134:110029. [PMID: 32272377 DOI: 10.1016/j.ijporl.2020.110029] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/12/2020] [Revised: 03/27/2020] [Accepted: 03/27/2020] [Indexed: 10/24/2022]
Abstract
INTRODUCTION A Core Outcome Set (COS) is an agreed list of outcome domains to be reported by all studies investigating a condition. A COS for Otitis Media with Effusion (OME) in children with cleft palate exists (called MOMENT), but there isn't one for otherwise-healthy children. This study investigates whether the MOMENT COS could also be applicable to otherwise-healthy children. METHODS A long list of potential outcomes was generated (independently of MOMENT) via three methods: literature review to establish which outcomes are reported by OME studies, a review of outcomes contained in OME questionnaires, and a focus group asking parents of children with OME what matters to them. The long list drawn up using these sources identified no outcomes additional to ones in the MOMENT long list. An online questionnaire was subsequently undertaken, asking parents/guardians and professionals/researchers whether they think that the MOMENT final list outcomes would also be applicable to otherwise healthy children. RESULTS A total of 134 people took part: 53 parents/guardians (recruited through UK NHS hospitals) and 81 professionals/researchers (recruited internationally). Overall, 128 (95.5%) agreed that the MOMENT outcomes can also apply to otherwise healthy children (100% parents/guardians, 92.6% professionals/researchers). CONCLUSIONS The outcome domains identified in the COS for OME management in children with cleft palate can also be used in otherwise-healthy children.
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Affiliation(s)
- Paul Zhaobo Liu
- Nottingham University Hospital / Nottingham Children's Hospital, United Kingdom.
| | | | - Kate Stephenson
- Birmingham Women's and Children's NHS Foundation Trust, United Kingdom
| | - Adam J Donne
- Alder Hey Children's NHS Foundation Trust, United Kingdom
| | - Neil Fergie
- Nottingham University Hospital / Nottingham Children's Hospital, United Kingdom; Sherwood Forest Hospitals, United Kingdom
| | - Jo Derry
- Nottingham University Hospital / Nottingham Children's Hospital, United Kingdom
| | - Gill Stynes
- Nottingham University Hospital / Nottingham Children's Hospital, United Kingdom
| | - Tawakir Kamani
- Nottingham University Hospital / Nottingham Children's Hospital, United Kingdom
| | - John P Birchall
- Nottingham University Hospital / Nottingham Children's Hospital, United Kingdom
| | - Mat Daniel
- Nottingham University Hospital / Nottingham Children's Hospital, United Kingdom; Mat Daniel Consulting, United Kingdom
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Sanyaolu LN, Cannings-John R, Butler CC, Francis NA. The effect of ventilation tube insertion on quality of life in children with persistent otitis media with effusion. Clin Otolaryngol 2020; 45:239-247. [PMID: 31869494 DOI: 10.1111/coa.13502] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/01/2019] [Revised: 12/06/2019] [Accepted: 12/12/2019] [Indexed: 11/29/2022]
Abstract
OBJECTIVES To determine the effect of ventilation tube (VT) surgery on quality of life (QoL) in children with persistent otitis media with effusion (OME). DESIGN Secondary analysis of trial data (oral steroids versus placebo for persistent OME), comparing QoL by history of VT surgery performed between 5 weeks and 12 months post-randomisation. Multilevel regression models were used to identify the association between VT surgery and QoL scores at 12 months, controlling for pre-exposure risk factors associated with surgery, including pre-surgery hearing level. SETTING Ear, nose and throat (ENT), paediatric audiology and audiovestibular medicine (AVM) departments in Wales and England. PARTICIPANTS A total of 327 children aged 2-8 years with OME symptoms for at least three months and audiometry-proven bilateral hearing loss with VT surgery status. MAIN OUTCOME MEASURES Otitis Media questionnaire (OM8-30) and Paediatric Quality of Life Inventory (PedsQL) total and subscale scores, and the Health Utilities Index Mark 3 (HUI3) at 12 months post-randomisation. RESULTS Participants who had VT surgery had no significant difference in OM8-30, PedsQL or HUI total scores. OM8-30 hearing difficulty (HD) subscale scores at 12 months were better in those who had VT surgery (adjusted mean difference (aMD) = -0.46 (95% confidence interval: -0.69 to -0.23), P < .001), and this varied by when the surgery occurred (aMD for surgery between 5 weeks and 6 months = -0.4 [-0.67 to -0.13], P = .004 and between 6 and 12 months = -0.54, [-0.87 to -0.22], P = .001). CONCLUSION Ventilation tube surgery was associated with an improvement in HD-related functional health status but no change in overall QoL.
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Affiliation(s)
| | | | | | - Nick A Francis
- The Division of Population Medicine, Heath Park, Cardiff, UK
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Francis NA, Waldron CA, Cannings-John R, Thomas-Jones E, Winfield T, Shepherd V, Harris D, Hood K, Fitzsimmons D, Roberts A, Powell CV, Gal M, Jones S, Butler CC. Oral steroids for hearing loss associated with otitis media with effusion in children aged 2-8 years: the OSTRICH RCT. Health Technol Assess 2019; 22:1-114. [PMID: 30407151 DOI: 10.3310/hta22610] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/27/2022] Open
Abstract
BACKGROUND Children with hearing loss associated with otitis media with effusion (OME) are commonly managed through surgical intervention, hearing aids or watchful waiting. A safe, inexpensive, effective medical treatment would enhance treatment options. Small, poorly conducted trials have found a short-term benefit from oral steroids. OBJECTIVE To determine the clinical effectiveness and cost-effectiveness of a 7-day course of oral steroids in improving hearing at 5 weeks in children with persistent OME symptoms and current bilateral OME and hearing loss demonstrated by audiometry. DESIGN Double-blind, individually randomised, placebo-controlled trial. SETTING Ear, nose and throat outpatient or paediatric audiology and audiovestibular medicine clinics in Wales and England. PARTICIPANTS Children aged 2-8 years, with symptoms of hearing loss attributable to OME for at least 3 months, a diagnosis of bilateral OME made on the day of recruitment and audiometry-confirmed hearing loss. INTERVENTIONS A 7-day course of oral soluble prednisolone, as a single daily dose of 20 mg for children aged 2-5 years or 30 mg for 6- to 8-year-olds, or matched placebo. MAIN OUTCOME MEASURES Acceptable hearing at 5 weeks from randomisation. Secondary outcomes comprised acceptable hearing at 6 and 12 months, tympanometry, otoscopic findings, health-care consultations related to OME and other resource use, proportion of children who had ventilation tube (grommet) surgery at 6 and 12 months, adverse effects, symptoms, functional health status, health-related quality of life, short- and longer-term cost-effectiveness. RESULTS A total of 389 children were randomised. Satisfactory hearing at 5 weeks was achieved by 39.9% and 32.8% in the oral steroid and placebo groups, respectively (absolute difference of 7.1%, 95% confidence interval -2.8% to 16.8%; number needed to treat = 14). This difference was not statistically significant. The secondary outcomes were consistent with the picture of a small or no benefit, and we found no subgroups that achieved a meaningful benefit from oral steroids. The economic analysis showed that treatment with oral steroids was more expensive and accrued fewer quality-adjusted life-years than treatment as usual. However, the differences were small and not statistically significant, and the sensitivity analyses demonstrated large variation in the results. CONCLUSIONS OME in children with documented hearing loss and attributable symptoms for at least 3 months has a high rate of spontaneous resolution. Discussions about watchful waiting and other interventions will be enhanced by this evidence. The findings of this study suggest that any benefit from a short course of oral steroids for OME is likely to be small and of questionable clinical significance, and that the treatment is unlikely to be cost-effective and, therefore, their use cannot be recommended. FUTURE WORK Studies exploring optimal approaches to sharing natural history data and enhancing shared decision-making are needed for this condition. TRIAL REGISTRATION Current Controlled Trials ISRCTN49798431 and EudraCT 2012-005123-32. FUNDING This project was funded by the National Institute for Health Research (NIHR) Health Technology Assessment programme and will be published in full in Health Technology Assessment; Vol. 22, No. 61. See the NIHR Journals Library website for further project information.
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Affiliation(s)
- Nick A Francis
- Division of Population Medicine, School of Medicine, Cardiff University, Cardiff, UK
| | | | | | | | - Thomas Winfield
- College of Human and Health Sciences, Swansea University, Swansea, UK
| | | | - Debbie Harris
- Centre for Trials Research, Cardiff University, Cardiff, UK
| | - Kerenza Hood
- Centre for Trials Research, Cardiff University, Cardiff, UK
| | | | - Amanda Roberts
- Cardiff & Vale University Health Board, Child Health Directorate, St David's Children Centre, Cardiff, UK
| | - Colin Ve Powell
- Department of General Paediatrics, Children's Hospital for Wales, Cardiff, UK
| | - Micaela Gal
- Division of Population Medicine, School of Medicine, Cardiff University, Cardiff, UK
| | - Sarah Jones
- Involving People Network, Health and Care Research Wales, Cardiff, UK
| | - Christopher C Butler
- Division of Population Medicine, School of Medicine, Cardiff University, Cardiff, UK.,Nuffield Department of Primary Care Health Sciences, University of Oxford, Oxford, UK
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Francis NA, Cannings-John R, Waldron CA, Thomas-Jones E, Winfield T, Shepherd V, Harris D, Hood K, Fitzsimmons D, Roberts A, Powell C, Gal M, Butler CC. Oral steroids for resolution of otitis media with effusion in children (OSTRICH): a double-blinded, placebo-controlled randomised trial. Lancet 2018; 392:557-568. [PMID: 30152390 PMCID: PMC6099122 DOI: 10.1016/s0140-6736(18)31490-9] [Citation(s) in RCA: 22] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/12/2018] [Revised: 06/21/2018] [Accepted: 06/27/2018] [Indexed: 12/31/2022]
Abstract
BACKGROUND Children with persistent hearing loss due to otitis media with effusion are commonly managed by surgical intervention. A safe, cheap, and effective medical treatment would enhance treatment options. Underpowered, poor-quality trials have found short-term benefit from oral steroids. We aimed to investigate whether a short course of oral steroids would achieve acceptable hearing in children with persistent otitis media with effusion and hearing loss. METHODS In this individually randomised, parallel, double-blinded, placebo-controlled trial we recruited children aged 2-8 years with symptoms attributable to otitis media with effusion for at least 3 months and with confirmed bilateral hearing loss. Participants were recruited from 20 ear, nose, and throat (ENT), paediatric audiology, and audiovestibular medicine outpatient departments in England and Wales. Participants were randomly allocated (1:1) to sequentially numbered identical prednisolone (oral steroid) or placebo packs by use of computer-generated random permuted block sizes stratified by site and child's age. The primary outcome was audiometry-confirmed acceptable hearing at 5 weeks. All analyses were by intention to treat. This trial is registered with the ISRCTN Registry, number ISRCTN49798431. FINDINGS Between March 20, 2014, and April 5, 2016, 1018 children were screened, of whom 389 were randomised. 200 were assigned to receive oral steroids and 189 to receive placebo. Hearing at 5 weeks was assessed in 183 children in the oral steroid group and in 180 in the placebo group. Acceptable hearing was observed in 73 (40%) children in the oral steroid group and in 59 (33%) in the placebo group (absolute difference 7% [95% CI -3 to 17], number needed to treat 14; adjusted odds ratio 1·36 [95% CI 0·88-2·11]; p=0·16). There was no evidence of any significant differences in adverse events or quality-of-life measures between the groups. INTERPRETATION Otitis media with effusion in children with documented hearing loss and attributable symptoms for at least 3 months has a high rate of spontaneous resolution. A short course of oral prednisolone is not an effective treatment for most children aged 2-8 years with persistent otitis media with effusion, but is well tolerated. One in 14 children might achieve improved hearing but not quality of life. Discussions about watchful waiting and other interventions will be supported by this evidence. FUNDING National Institute for Health Research (NIHR) Health Technology Assessment programme.
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Affiliation(s)
- Nick A Francis
- Division of Population Medicine, School of Medicine, Cardiff University, Neuadd Meirionnydd, Heath Park, Cardiff, UK.
| | - Rebecca Cannings-John
- Centre for Trials Research, College of Biomedical & Life Sciences, Cardiff University, Neuadd Meirionnydd, Heath Park, Cardiff, UK
| | - Cherry-Ann Waldron
- Centre for Trials Research, College of Biomedical & Life Sciences, Cardiff University, Neuadd Meirionnydd, Heath Park, Cardiff, UK
| | - Emma Thomas-Jones
- Centre for Trials Research, College of Biomedical & Life Sciences, Cardiff University, Neuadd Meirionnydd, Heath Park, Cardiff, UK
| | - Tom Winfield
- Swansea Centre for Health Economics, College of Human Health Sciences, Swansea University, Singleton Park, Swansea, UK
| | - Victoria Shepherd
- Centre for Trials Research, College of Biomedical & Life Sciences, Cardiff University, Neuadd Meirionnydd, Heath Park, Cardiff, UK
| | - Debbie Harris
- Centre for Trials Research, College of Biomedical & Life Sciences, Cardiff University, Neuadd Meirionnydd, Heath Park, Cardiff, UK
| | - Kerenza Hood
- Centre for Trials Research, College of Biomedical & Life Sciences, Cardiff University, Neuadd Meirionnydd, Heath Park, Cardiff, UK
| | - Deborah Fitzsimmons
- Swansea Centre for Health Economics, College of Human Health Sciences, Swansea University, Singleton Park, Swansea, UK
| | - Amanda Roberts
- Cardiff and Vale University Health Board, Child Health Directorate, St David's Children Centre, Cowbridge Road East, Cardiff, UK
| | - Colin Powell
- Department of General Paediatrics, Children's Hospital for Wales, Heath Park, Cardiff, UK
| | - Micaela Gal
- Division of Population Medicine, School of Medicine, Cardiff University, Neuadd Meirionnydd, Heath Park, Cardiff, UK
| | - Christopher C Butler
- Nuffield Department of Primary Care Health Sciences, University of Oxford, Radcliffe Observatory Quarter, Oxford, UK
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The nasal cycle 122 years on – are we any wiser? The Journal of Laryngology & Otology 2017; 131:845. [DOI: 10.1017/s0022215117001980] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
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Gkiousias V, Butler CC, Shepherd V, Kilgour JM, Waldron CA, Thomas-Jones E, Francis N. Parental perceptions and understanding of information provision, management options and factors influencing the decision-making process in the treatment of children with glue ear. Int J Pediatr Otorhinolaryngol 2016; 89:6-12. [PMID: 27619020 DOI: 10.1016/j.ijporl.2016.07.021] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/04/2016] [Revised: 07/20/2016] [Accepted: 07/21/2016] [Indexed: 12/01/2022]
Abstract
OBJECTIVES Otitis media with effusion (OME) is a common cause of hearing loss and possible developmental delay in children, and there are a range of 'preference sensitive' treatment options. We aimed to evaluate the attitudes and beliefs of parents of affected children to treatment options including watchful-waiting, hearing aids, grommets, and, oral steroids with the intention of developing our understanding of decision-making and the factors influencing it, sources of parental information, and satisfaction with information provision. DESIGN We recruited a convenience sample of twelve parents of eleven children with OME at a single ENT department of a teaching hospital into a qualitative research study. The children of the parents interviewed had already been recruited into the Oral Steroids for the Resolution of Otitis Media with effusion In Children (OSTRICH) study. Semi structured interviews were audio recorded, transcribed and then coded using an inductive, thematic approach. RESULTS Parents were satisfied with the verbal provision of information during the treatment consultation, although many were keen to receive supplementary printed information. Discussion with family and friends helped the decision-making process, whereas insufficient information and a paternalistic approach were viewed as obstacles. Parents were particularly influenced by the following: the immediacy of the treatment option effect, perceived efficacy, perceived risks and adverse effects, social implications (especially with hearing aids) and past personal and informant experience. CONCLUSIONS Parents appreciate clinicians tailoring information provision to parents' information needs and preferred format. Clinicians should also elicit parental attitudes towards the different management options for OME and the factors influencing their decisions, in order to optimise shared-decision making and ultimately provide a better standard of clinical care.
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Affiliation(s)
- Vasileios Gkiousias
- School of Medicine, Cardiff University, University Hospital of Wales, Heath Park Campus, Cardiff, CF 14 4XW, United Kingdom.
| | - Christopher Collett Butler
- Nuffield Department of Primary Care Health Sciences, University of Oxford, Radcliffe Primary Care Building, Radcliffe Observatory Quarter, Woodstock Rd, Oxford OX2 6GG, United Kingdom
| | - Victoria Shepherd
- South East Wales Trials Unit (SEWTU), Centre for Trials Research, College of Biomedical & Life Sciences, Cardiff University, Neuadd Meirionnydd, Heath Park, Cardiff, CF14 4YS, United Kingdom
| | - James Michael Kilgour
- School of Medicine, Cardiff University, University Hospital of Wales, Heath Park Campus, Cardiff, CF 14 4XW, United Kingdom
| | - Cherry-Ann Waldron
- South East Wales Trials Unit (SEWTU), Centre for Trials Research, College of Biomedical & Life Sciences, Cardiff University, Neuadd Meirionnydd, Heath Park, Cardiff, CF14 4YS, United Kingdom
| | - Emma Thomas-Jones
- South East Wales Trials Unit (SEWTU), Centre for Trials Research, College of Biomedical & Life Sciences, Cardiff University, Neuadd Meirionnydd, Heath Park, Cardiff, CF14 4YS, United Kingdom
| | - Nick Francis
- Division of Population Medicine, Cardiff University, 3rd Floor, Neuadd Meirionnydd, Heath Park, Cardiff, CF14 4YS, United Kingdom
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