otitis media with effusion steven feinberg sept 23 ,2004

Otitis Media With EffusionOtitis Media With Effusion

Steven Feinberg MDSteven Feinberg MD

What is OME?What is OME?

Presence of fluid without signs or symptoms Presence of fluid without signs or symptoms of ear infectionof ear infection

Decreased TM mobility and barrier to sound Decreased TM mobility and barrier to sound conduction conduction

2.2 million yearly diagnoses2.2 million yearly diagnoses $4.0 Billion (direct and indirect)$4.0 Billion (direct and indirect)

Etiology and EpidemiologyEtiology and Epidemiology

Epidemiology:Epidemiology:– 90% of children suffer from OME before school 90% of children suffer from OME before school

age (usually 6 months to 4 years)age (usually 6 months to 4 years)

– 30-40% of children with recurrent OME30-40% of children with recurrent OME– 5-10% last greater than 1 year5-10% last greater than 1 year

Etiology: Etiology: – Poor Eustachian Tube FunctionPoor Eustachian Tube Function– Inflammatory response following AOMInflammatory response following AOM

Clinical Practice GuidelinesClinical Practice Guidelines

Applicable to all children ages 2 months to Applicable to all children ages 2 months to 12 years with or without disability12 years with or without disability

Expert panel (AAP,AAFP, AAONS)Expert panel (AAP,AAFP, AAONS) Primary outcomes:Primary outcomes:

– Speech, language, learningSpeech, language, learning– Physiologic sequelaePhysiologic sequelae

– Health care utilizationHealth care utilization– Quality of life Quality of life

Recommendation LevelsRecommendation Levels

Strong Recommendation – clinicians should Strong Recommendation – clinicians should follow unless clear rational follow unless clear rational

Recommendation – clinicians should follow, Recommendation – clinicians should follow, but remain alert to new informationbut remain alert to new information

Option – flexible, clinicians may set bounds Option – flexible, clinicians may set bounds on alternatives.on alternatives.

No recommendation – little constraint in No recommendation – little constraint in decision, be aware of new datadecision, be aware of new data

Diagnosis of OMEDiagnosis of OME

Strong Recommendation – Pneumatic Strong Recommendation – Pneumatic otoscopy should be used as the primary otoscopy should be used as the primary diagnostic method for OME.diagnostic method for OME.

Option – tympanometry should be used to Option – tympanometry should be used to confirm diagnosisconfirm diagnosis

Important to distinguish from AOM – Important to distinguish from AOM – redness of TM should not be indication for redness of TM should not be indication for antibioticsantibiotics

ScreeningScreening

Recommendation – population based Recommendation – population based screening programs are not recommended screening programs are not recommended in healthy, asymptomatic childrenin healthy, asymptomatic children– Has not been found to influence short-term Has not been found to influence short-term

language outcomeslanguage outcomes– Long-term effects have not been evaluated in Long-term effects have not been evaluated in

randomized controlled trialrandomized controlled trial

Potential risks of screeningPotential risks of screening Criteria of population based criteriaCriteria of population based criteria

DocumentationDocumentation

Recommendation: physicians should Recommendation: physicians should document laterality, duration, presence and document laterality, duration, presence and severity of associated symptoms at each severity of associated symptoms at each assessmentassessment

Difficulty: 40-50% of children have no Difficulty: 40-50% of children have no complaints referable to MEE.complaints referable to MEE.

DocumentationDocumentation

Associated signs and symptoms:Associated signs and symptoms:– Ear pain, popping, fullnessEar pain, popping, fullness– Ear rubbing, irritability, sleep disturbancesEar rubbing, irritability, sleep disturbances– Failure to respond appropriately to voices or soundsFailure to respond appropriately to voices or sounds

– Hearing lossHearing loss– Recurrent AOM Recurrent AOM – Problems with school performanceProblems with school performance– Balance problems, motor delayBalance problems, motor delay– Delayed speech, languageDelayed speech, language

Child at RiskChild at Risk

Recommendation – clinicians should Recommendation – clinicians should distinguish the child with OME who is at risk distinguish the child with OME who is at risk for speech, language, or learning problems for speech, language, or learning problems from other children with OME, and should from other children with OME, and should more promptly evaluate hearing, speech, more promptly evaluate hearing, speech, language, and need for interventionlanguage, and need for intervention

Who is at risk?Who is at risk? Few studies evaluate those at riskFew studies evaluate those at risk

Watchful WaitingWatchful Waiting

What to do?What to do? Recommendation – Clinicians should Recommendation – Clinicians should

manage the child with OME who is not manage the child with OME who is not at risk with watchful waiting for 3 at risk with watchful waiting for 3 months from the date of effusion onset months from the date of effusion onset (if known) or from the date of diagnosis (if known) or from the date of diagnosis (if onset is unknown)(if onset is unknown)

Watchful WaitingWatchful Waiting

Self limited nature – well documented in Self limited nature – well documented in cohort and randomized trialscohort and randomized trials

Likelihood of resolution determined by Likelihood of resolution determined by cause and duration of effusioncause and duration of effusion– 75-90% of episodes following AOM resolve by 3 75-90% of episodes following AOM resolve by 3

monthsmonths– 55% of children newly diagnosed with OME with 55% of children newly diagnosed with OME with

a flat tympanogram will change to a non-type B a flat tympanogram will change to a non-type B tympanogram within 3 months of onset. One tympanogram within 3 months of onset. One third relapse in next 3 months.third relapse in next 3 months.

Watchful waitingWatchful waiting

25% of newly detected OME of unknown duration 25% of newly detected OME of unknown duration in children age 2-4 years resolves by 3 months in children age 2-4 years resolves by 3 months based on tympanogram based on tympanogram

Resolution rates may be higher for infant and Resolution rates may be higher for infant and young children in whom the preexisting duration of young children in whom the preexisting duration of effusion is shortereffusion is shorter

Documented bilateral OME of 3 months duration Documented bilateral OME of 3 months duration or longer resolves in 30% of children 2 or older or longer resolves in 30% of children 2 or older after 6-12 months observatoinafter 6-12 months observatoin

MedicationMedication

Recommendation: Antihistamines and Recommendation: Antihistamines and decongestants are ineffective for OME and decongestants are ineffective for OME and are not recommended for treatment. are not recommended for treatment. Antimicrobials and corticosteroids do not Antimicrobials and corticosteroids do not have long-term efficacy and are not have long-term efficacy and are not recommended for routine managementrecommended for routine management


No benefit for antihistamines and decongestants No benefit for antihistamines and decongestants vs. placebovs. placebo

Long-term benefits of antimicrobials unproven Long-term benefits of antimicrobials unproven despite modest short-term benefit for 2-8 weeks in despite modest short-term benefit for 2-8 weeks in randomized trials.randomized trials.

Oral steroids and antimicrobial combinationOral steroids and antimicrobial combination– Short term benefit compared to antibiotics alone in 1/3 Short term benefit compared to antibiotics alone in 1/3

children treatedchildren treated– Not sustained after several weeksNot sustained after several weeks

Intranasal steroids – no benefit over antimicrobials Intranasal steroids – no benefit over antimicrobials alonealone


Antimicrobials with or without steroids may Antimicrobials with or without steroids may be considered in some cases of parental be considered in some cases of parental aversion to surgeryaversion to surgery– 10-14 day course10-14 day course– Unlikely to provide long term benefitUnlikely to provide long term benefit– Multiple courses not recommendedMultiple courses not recommended


Insufficient data regarding:Insufficient data regarding:– MucolyticsMucolytics– AutoinflationAutoinflation– Systemic use of other medications other than Systemic use of other medications other than

antimicrobials, antihistamine-congestants, or antimicrobials, antihistamine-congestants, or steroidssteroids

Hearing and LanguageHearing and Language

Recommendation: hearing testing is Recommendation: hearing testing is recommended when OME is present for 3 recommended when OME is present for 3 months or longer, or at any time that months or longer, or at any time that language delay, learning problems, or a language delay, learning problems, or a significant hearing loss is suspected in a significant hearing loss is suspected in a child with OME. Language testing should child with OME. Language testing should be conducted for children with hearing loss.be conducted for children with hearing loss.


OME may impair dinaural processing, sound OME may impair dinaural processing, sound localization, speech perception in noiselocalization, speech perception in noise

Home environment criticalHome environment critical Studies suggest no impact on children with Studies suggest no impact on children with

OME who are not at risk by screening or OME who are not at risk by screening or surveillancesurveillance


Average pure tone hearing loss at 4 Average pure tone hearing loss at 4 frequencies ranges from normal to frequencies ranges from normal to moderate hearing loss with OME (0-55dB)moderate hearing loss with OME (0-55dB)

25dB is 5025dB is 50thth percentile percentile Evidence that children with greatest hearing Evidence that children with greatest hearing

loss for longest period of time more likely to loss for longest period of time more likely to develop sequelaedevelop sequelae


Initial testing for children older than 4 can be Initial testing for children older than 4 can be done in the primary care settingdone in the primary care setting

Fail criteria >20 dB loss at 1 or more Fail criteria >20 dB loss at 1 or more frequencyfrequency

Formal audio recommended for children Formal audio recommended for children that:that:– Fail primary care testingFail primary care testing– Younger than age 4Younger than age 4– Primary care testing cannot be performedPrimary care testing cannot be performed


Language testing – indicated if hearing loss Language testing – indicated if hearing loss present.present.

Children with repeated and persistent OME Children with repeated and persistent OME and hearing loss may be at disadvantage and hearing loss may be at disadvantage for learning speech and languagefor learning speech and language

Conflicting dataConflicting data

SurveillanceSurveillance

Recommendation: children with persistent Recommendation: children with persistent OME who are not at risk should be OME who are not at risk should be reexamined at 3- to 6-month intervals until reexamined at 3- to 6-month intervals until the effusion is no longer present, significant the effusion is no longer present, significant hearing loss is identified, or structural hearing loss is identified, or structural abnormalities of the eardrum or middle ear abnormalities of the eardrum or middle ear are suspectedare suspected


Significant change in recommendation from Significant change in recommendation from 1994 guidelines.1994 guidelines.– Previous recommendations included surgery if Previous recommendations included surgery if

effusion persisted 4-6 months with hearing loss. effusion persisted 4-6 months with hearing loss.

– New data indicates developmental outcomes New data indicates developmental outcomes are not improved for children not at risk with are not improved for children not at risk with early tube placementearly tube placement


Likelihood of effusion resolutionLikelihood of effusion resolution– Decreases with time for asymptomatic effusionsDecreases with time for asymptomatic effusions– Risk factors making spontaneous resolution less likelyRisk factors making spontaneous resolution less likely

Onset of OME in summer or fallOnset of OME in summer or fall Hearing loss greater than 30 dB in the better-hearing earHearing loss greater than 30 dB in the better-hearing ear History of prior tympanostomy tubesHistory of prior tympanostomy tubes Not having had an adenoidectomyNot having had an adenoidectomy

Sequelae of chronic OME – Tympanic membrane Sequelae of chronic OME – Tympanic membrane damage and inflammation, retraction pockets, damage and inflammation, retraction pockets, atalectasis, and cholesteatoma. Comprehensive atalectasis, and cholesteatoma. Comprehensive audiologic evaluation indicated.audiologic evaluation indicated.


Conditions mandating tube insertion:Conditions mandating tube insertion:– Posteriorsuperior retraction pockets, ossicular Posteriorsuperior retraction pockets, ossicular

erosion, adhesive atalectasis, retraction pockets erosion, adhesive atalectasis, retraction pockets that accumulate debristhat accumulate debris

– Increased incidence with prolonged effusion.Increased incidence with prolonged effusion.


Treatment algorithm for children with Treatment algorithm for children with persistent OME greatr than 3 monthspersistent OME greatr than 3 months– Hearing loss >40 dB for better hearing ear – Hearing loss >40 dB for better hearing ear –

surgery recommended.surgery recommended.– Hearing loss 21-39 dB – individualized Hearing loss 21-39 dB – individualized

management. Repeat audio in 3-6 months if management. Repeat audio in 3-6 months if tubes not placed and effusion persists at tubes not placed and effusion persists at followupfollowup

– Normal hearing – repeat audio in 3-6 months if Normal hearing – repeat audio in 3-6 months if OME persists at followupOME persists at followup


Other factors influencing decision to intervene:Other factors influencing decision to intervene:– Poor caregiving environmentPoor caregiving environment– Low socioeconomic statusLow socioeconomic status– Poor maternal education levelPoor maternal education level– Physical and behavioral symptoms associated with Physical and behavioral symptoms associated with

OMEOME ADHDADHD Behavioral problemsBehavioral problems Poor vestibular function and motor proficiencyPoor vestibular function and motor proficiency OtalgiaOtalgia Sleep disturbanceSleep disturbance Recurrent AOMRecurrent AOM

ReferralReferral

Option: When children with OME are referred by Option: When children with OME are referred by the primary care physician for evaluation by an the primary care physician for evaluation by an otolaryngologist, audiologist, or speech-language otolaryngologist, audiologist, or speech-language pathologist, the referring clinician should pathologist, the referring clinician should document the effusion duration and specific document the effusion duration and specific reason for referral (evaluation, surgery), and reason for referral (evaluation, surgery), and provide additional relevant information such as provide additional relevant information such as history of AOM and developmental status of the history of AOM and developmental status of the childchild

SurgerySurgery

Recommendation: when a child becomes a Recommendation: when a child becomes a surgical candidate, tympanostomy tube insertion is surgical candidate, tympanostomy tube insertion is the preferred initial procedure; adenoidectomy the preferred initial procedure; adenoidectomy should not be performed unless a distinct should not be performed unless a distinct indication exists (nasal obstruction, chronic indication exists (nasal obstruction, chronic adenoiditis). Repeat surgery consists of adenoiditis). Repeat surgery consists of adenoidectomy plus myringotomy, with or without adenoidectomy plus myringotomy, with or without tube insertion. Tonsillectomy alone or tube insertion. Tonsillectomy alone or myringotomy alone should not be used to treat myringotomy alone should not be used to treat OMEOME

SurgerySurgery

Tubes recommended as initial surgery because:Tubes recommended as initial surgery because:– 62% decrease in effusion prevalence 62% decrease in effusion prevalence – Absolute decrease of 128 effusion days per child during Absolute decrease of 128 effusion days per child during

the next yearthe next year– Hearing levels improve by mean 6-12 dB while tubes Hearing levels improve by mean 6-12 dB while tubes

patentpatent

– Adenoidectomy and tubes – similar efficacy in children Adenoidectomy and tubes – similar efficacy in children >4 years, greater risks>4 years, greater risks

– Benefit of adenoidectomy in addition to tubes is limited Benefit of adenoidectomy in addition to tubes is limited and short term in children >3 with no prior tubesand short term in children >3 with no prior tubes

SurgerySurgery

OME relapseOME relapse– 20-50% of children with prior tubes relapse after 20-50% of children with prior tubes relapse after

extrusion.extrusion.

– Adenoidectomy confers 50% reduction in need Adenoidectomy confers 50% reduction in need for future operations.for future operations.

– Benefit of adenoidectomy apparent at age 2 Benefit of adenoidectomy apparent at age 2 years, greatest for children >3 years, years, greatest for children >3 years, independent of adenoid size.independent of adenoid size.

Surgical ComplicationsSurgical Complications

Anesthesia – mortality reported as 1:50,000 for Anesthesia – mortality reported as 1:50,000 for ambulatory surgeryambulatory surgery

Tympanostomy tube sequelaeTympanostomy tube sequelae– Perforations in 2% after short-term tubes, 17% after Perforations in 2% after short-term tubes, 17% after

long-term tubeslong-term tubes– Usually transient (otorrhea) or do not affect function Usually transient (otorrhea) or do not affect function

(tympanosclerosis, atrophy, shallow retraction)(tympanosclerosis, atrophy, shallow retraction)

AdenoidectomyAdenoidectomy– 0.2-0.5% incidence hemorrhage0.2-0.5% incidence hemorrhage– 2% incidence of transient VPI2% incidence of transient VPI

Complementary and Alternative Complementary and Alternative MedicineMedicine

No recommendation regarding CAM as a No recommendation regarding CAM as a treatment for OMEtreatment for OME

No randomized trials demonstrating efficacyNo randomized trials demonstrating efficacy Proposed interventions include:Proposed interventions include:

– Chiropractic manipulationChiropractic manipulation– Dietary exclusionDietary exclusion– AccupunctureAccupuncture– Traditional Chinese medicineTraditional Chinese medicine– HomeopathyHomeopathy

Allergy ManagementAllergy Management

No recommendation is made regarding No recommendation is made regarding allergy management as a treatment for allergy management as a treatment for OMEOME

No controlled studiesNo controlled studies Prevalence of allergy in children with OME Prevalence of allergy in children with OME

ranges from 10-80%.ranges from 10-80%. Postulated to contribute to OME through Postulated to contribute to OME through

eustacian tube dysfunctioneustacian tube dysfunction

otitis media with effusion steven feinberg sept 23 ,2004

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