2015 HSC Section 1 Book of Articles

Rosenfeld et al

Table 3. Topics and issues considered in tympanostomy tube guideline development. a Indications for Tube Placement Perioperative Management

Care of Children with Tubes

Outcomes

Otitis media with effusion Recurrent acute otitis media

Baseline hearing assessment Optimal conditions for general anesthesia (impact of upper respiratory infections)

Early extrusion of tubes Dry ear (water) precautions

Quality of life (child and caregiver) School performance, attendance

Persistent acute otitis media

Assessment for surgery

Tube otorrhea

Long-term sequelae (perforation, retraction pocket, hearing loss)

Hearing loss caused by middle ear effusion

Assessment of anesthetic complications including laryngospasm, hypoxemia, bronchospasm Need for intravenous access during surgery

Tube granuloma or granulation tissue

Vestibular function

Unacceptable antibiotic burden for treating acute otitis media

Obstructed tube lumen

Hearing levels and outcomes during life of tube and after tube extrusion

Situations in which tube insertion would be recommended Situations in which tube insertion would be an option Situations in which tube insertion would not be recommended

Need to sterilize ear canal prior to tube placement

Postoperative hearing assessment Physical suffering (pain, sleep disturbance)

Tube duration: short-term, intermediate, long-term

Frequency of follow-up for indwelling tubes

Speech and language development

Tube composition

Setting for follow-up; which clinician is responsible or best suited Frequency of hearing assessment (postoperative and for surveillance)

Listening in complex environments

Tube location in the tympanic membrane

Prevalence of middle ear effusion

Need to irrigate middle ear with saline Use of perioperative topical otic preparations Adenoidectomy as an alternative or adjunct to tubes Pain management after surgery Alternatives to general anesthesia Recovery room issues: emergent delirium, nausea/vomiting, parental/caregiver anxiety Learning curve for tube surgery

Need for additional tube surgery

Need for oral antibiotics

Incidence of acute otitis media

Incidence of otorrhea

Chronic suppurative otitis media

Retained tube

Medialized tube

a This list was created by the guideline development group to refine content and prioritize action statements; not all items listed were ultimately included or discussed in the guideline.

with chronic OME, tube insertion reduces the prevalence of MEE by 32% in the first year and improves average hearing levels (HLs) by 5 to 12 dB. 7,13 Although RCTs have, in gen- eral, not found a significant impact of tympanostomy tube insertion on speech, language, or cognitive outcomes, 7,13,18 the trials typically included only healthy children without devel- opmental delays at entry. A nonrandomized study, however, did show improved caregiver perception of speech and lan- guage after tympanostomy tube placement, especially for chil- dren with developmental delays. 21 The efficacy of tympanostomy tubes for preventing recur- rent AOM is unclear, with systematic reviews reporting insuf- ficient evidence, 18 small short-term benefits, 22,23 or moderate benefits of similar magnitude to antibiotic prophylaxis. 24 Part of this debate relates to inclusion criteria for RCTs in the reviews, some of which excluded children with chronic OME between AOM episodes and others that did not. When limited

Benefits of Tympanostomy Tubes Tympanostomy tube insertion is associated with short-term QOL improvements. 18 Otitis media can affect QOL for the child and caregiver. In one study of children with chronic OME or recurrent AOM, 88% of caregivers were worried or concerned about their child’s ear infections or middle ear fluid at least some of the time, with 42% spending most or all of their time preoccupied with their child’s condition. 19 Physical suffering was a problem for 85% of children, emotional dis- tress for 76%, and activity limitations for 57%. Another inves- tigation of children with otitis media noted that 31% of caregivers had to cancel family activities, 29% reported lack of sleep, and 12% missed work or school. 20 The efficacy of tympanostomy tubes in managing chronic OME, recurrent AOM, or both has been studied in randomized controlled trials (RCTs) and systematic reviews. For children

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