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Proposed OME Guideline Offers New Recommendations

0928-OME

Richard M. Rosenfeld, MD, MPH, discusses the proposed guideline for otitis media with effusion.

Otitis media with effusion (OME) is one of the most common conditions in children, and the existing clinical practice guideline is more than 11 years old. A proposed clinical practice guideline has been completed, and it offers new recommendations concerning the treatment of infants, avoiding the use of intranasal steroids, and indications for adenoidectomy.

The new guideline is expected to be released in the first quarter of 2016, but a Monday Miniseminar, “Otitis Media with Effusion Update,” previewed the important changes the new guideline recommends.

The guideline was exclusively developed by AAO-HNSF. However, the guideline committee included pediatricians, family physicians, and non-physicians, including patient representatives. As a result, the proposed document has a greater emphasis on patient education and shared decision-making with families of patients, said Richard M. Rosenfeld, MD, MPH, chair of the guideline committee.

Approximately 2.2 million new cases of OME are diagnosed annually in the United States, and 50-90 percent of children have OME by age five. The new guideline reports that 32 percent of primary care physicians inappropriately treat OME with antibiotics, resulting in unnecessary adverse events and bacterial resistance. Additionally, it is the most common cause of hearing impairment in children, affecting quality of life.

Three other members of the committee that developed the new guideline reviewed its content during the Miniseminar. They discussed how the guideline uses a series of statements to clarify recommendations, emphasizing the importance of diagnosis and monitoring of OME because of its negative impact on development.

The first statement is that pneumatic otoscopy should be the primary diagnostic method for OME in children with otalgia, hearing loss, or both. Dr. Rosenfeld added that studies show it improves diagnostic accuracy. The second statement recommends using tympanometry if diagnosis of OME is uncertain after performing pneumatic otoscopy.

If a newborn child fails a hearing screening, statement three recommends follow-up exams to ensure that hearing is normal when OME resolves. It has been found that one in nine children may have persistent hearing loss that needs further attention.

Statement four emphasizes that “…a child with OME is at increased risk for speech, language, or learning problems from middle ear effusion because of baseline sensory, physical, cognitive, or behavioral factors. Clinicians should evaluate at-risk children for OME at the time of diagnosis of an at-risk condition and at 12 to 18 months of age (if diagnosed as being at-risk prior to this time).”

Other statements in the proposed guideline:

  • 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 effusion for three months or longer.
  • Clinicians should educate families of children with OME regarding the natural history of OME, need for follow-up, and the possible sequelae.
  • Clinicians should manage the child with OME who is not at risk with watchful waiting for three months from the date of effusion onset (if known) or from the date of diagnosis (if onset is unknown).
  • Clinicians should recommend against using intranasal steroids or systemic steroids for treating OME.
  • Clinicians should recommend against using systemic antibiotics for treating OME.
  • Clinicians should recommend against using antihistamines, decongestants, or both for treating OME.
  • Clinicians should counsel families of children with bilateral OME and documented hearing loss about the potential impact on speech and language development.
  • Clinicians should recommend tympanostomy tubes when surgery is indicated for OME in a child under age four; adenoidectomy should not be performed unless a distinct indication exists other than OME. Clinicians should recommend tympanostomy tubes, adenoidectomy, or both when surgery is indicated for OME in a child aged four or older.
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