Reserve Tympanostomy Tubes for Chronic Otitis Media With Effusion: Guideline

CLINICAL CONTEXT

Tympanostomy tube placement is the most common ambulatory surgery performed among children in the United States, according to the authors of the current study. By age 6 years, 40% of children have experienced 3 or more episodes of otitis media. Although tympanostomy tubes have helped many thousands of children with persistent middle ear effusions and hearing loss, precise guidelines for the application of tympanostomy tube placement are lacking. The current practice guideline from the American Academy of Otolaryngology—Head and Neck Surgery addresses this issue.

STUDY SYNOPSIS AND PERSPECTIVE

Kids with uncomplicated, short-term otitis media with effusion (OME) generally don't need tympanostomy tubes, which should be reserved for children with chronic OME, according to new guidelines from the American Academy of Otolaryngology—Head and Neck Surgery Foundation.

Dr. Richard M. Rosenfeld, who headed the guideline panel, told Reuters Health that although tympanostomy tube insertion is the most common pediatric ambulatory surgery in the United States, there have been no recent clinical practice guidelines that address specific indications for surgery.

The new guidelines, he and his colleagues write, are "intended for any clinician involved in managing children, aged six months to 12 years, with tympanostomy tubes or being considered for tympanostomy tubes in any care setting, as an intervention for otitis media of any type."

Dr. Rosenfeld, from the State University of New York Downstate Medical Center, Brooklyn, New York, and colleagues published the guidelines in the July Supplement of Otolaryngology—Head and Neck Surgery.

The document includes a dozen action statements, starting with an assertion that echoes the 1994 OME guideline from the American Academy of Pediatrics, American Academy of Family Medicine, and American Academy of Otolaryngology—Head and Neck Surgery.

Namely, clinicians should not routinely perform tympanostomy tube insertion in children with a single episode of OME of less than three months' duration.

Instead, tympanostomy tube insertion should be reserved for children with chronic OME (i.e., longer than three months) and documented hearing difficulties or structural abnormalities of the tympanic membrane or middle ear.

Other candidates for tympanostomy tube insertion include children with recurrent acute otitis media (AOM) with middle ear effusion at the time of assessment for tube candidacy and those with recurrent AOM or OME of any duration with increased risk for speech, language, or learning problems from otitis media.

Dr. Rosenfeld pointed out that including effusion as an indication for tube placement represents a significant difference from what happens today in clinical practice. Even 10 infections a year aren't an indication for tube placement, if the child's ear is pristine, Dr. Rosenfeld said. Doctors shouldn't be putting these tubes in based just on the child's history, he added.

Once the decision has been made to insert tympanostomy tubes, parents or other caregivers should be educated regarding the expected duration of tube function, recommended follow-up schedule, and detection of complications. The guidelines include sample education sheets for this purpose.

For children who have tympanostomy tubes, topical antibiotic eardrops only (not oral antibiotics) are indicated for uncomplicated acute tympanostomy tube otorrhea, Dr. Rosenfeld emphasized.

However, to avoid yeast infections in the ear canal, antibiotic eardrops shouldn't be used frequently or for more than 10 days in a row.

Also, he pointed out, for kids who do have the tubes in place, the guidelines recommend against routine prophylactic water precautions (including use of earplugs or headbands and avoidance of swimming or water sports), unless kids are symptomatic or are consistently swimming at depths greater than six feet. (The guidelines also note that water precautions may be necessary for kids who submerge in bathwater, because soapy water has a lower surface tension than plain water.)

The group placed additional emphasis on opportunities for quality improvement, particularly regarding shared decision making and care of children with existing tubes, and identified knowledge gaps they hope will guide future research.

Otolaryngol Head Neck Surg. 2013;149:S1-S35.

STUDY HIGHLIGHTS

• The panel members, who wrote the current guidelines, included otolaryngologists as well as primary care physicians and nonphysician healthcare providers.
• Systematic reviews and randomized trials were used to develop the guidelines.
• The guidelines were focused on the treatment of children between 6 months and 12 years old.
• Tympanostomy tubes should not be provided for children with a single episode of OME of less than 3 months' duration.
• Children should undergo an age-appropriate hearing test before tympanostomy tube placement. Most children 4 years and older can be tested with conventional audiometry. A more comprehensive evaluation with an audiologist is usually necessary for younger children.
• Once OME has persisted for more than 3 months, the rate of spontaneous resolution is only 30% at 1 year. Children with OME for at least 3 months and with documented hearing problems may be considered for tympanostomy tubes.
• The principal benefits of tympanostomy tube placement are improved hearing along with patient and caregiver quality of life.
• The most common adverse event related to tympanostomy tube placement is tympanostomy tube otorrhea, which affects up to 26% of patients.
• Tympanostomy tubes may also be considered for children with other symptoms potentially related to chronic OME, including vestibular complaints, poor school performance, behavioral problems, ear pain, or reduced quality of life.
• Children with chronic OME who do not receive tympanostomy tubes should be monitored at 3- to 6-month intervals for complications of OME.
• The prognosis for children with recurrent AOM without effusion is generally good, and tympanostomy tubes provide questionable clinical benefit for these children. Recurrent AOM alone is insufficient as an indication for tympanostomy tubes.
• However, children with recurrent AOM who have evidence of middle ear effusion should be considered for tympanostomy tubes.
• Children who are at particularly high risk for complications of middle ear effusion or recurrent AOM, such as those with hearing aids, Down's syndrome, or cleft palate, should receive special consideration for tympanostomy tubes.
• Uncomplicated cases of tympanostomy tube otorrhea should be treated with topical, but not oral, antibiotics. Rates of clinical cure appear higher with topical vs oral antibiotics.
• Children with tympanostomy tubes do not require routine protection against water such as ear plugs or headbands. The mild benefit of ear protection against tympanostomy tube otorrhea is probably outweighed by the effort in consistently protecting the ears against water.