Leaderboard Ad

Clinical Practice Guideline: Tympanostomy Tubes in Children

0929-Rosenfeld

Richard M. Rosenfeld, MD, MPH

Insertion of tympanostomy tubes is the most common ambulatory surgery performed on children in the United States.

The miniseminar “AAO-HNS/F Clinical Practice Guideline on Tympanostomy Tubes,” which will take place from Monday 8:00 am-9:20 am in West 301, will highlight key recommendations from the new AAO-HNS guideline on tympanostomy tubes, developed by a multidisciplinary panel using methodology consistent with current Institute of Medicine standards. Richard M. Rosenfeld, MD, MPH, will moderate the session.

Emphasis will be placed on surgical indications (otitis media with effusion and recurrent acute otitis media), caregiver education, management of tube otorrhea, use of water precautions, and special considerations for children who are at risk for developmental delays. The lively panel discussion will include case presentations and time for questions and answers.

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.

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 three 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 three months or longer (chronic OME) and documented hearing difficulties; (4) clinicians should re-evaluate, at three- to six-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 three 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 three months or longer (chronic OME).