2015 HSC Section 1 Book of Articles

Otolaryngology–Head and Neck Surgery 149(1S)

• • Policy level: Option • • Differences of opinion: None. Supporting Text

STATEMENT 4. CHRONIC OME WITH SYMPTOMS: Clinicians may perform tympanostomy tube insertion in children with unilateral or bilateral OME for 3 months or longer (chronic OME) AND symptoms that are likely attrib- utable to OME that include, but are not limited to, balance (vestibular) problems, poor school performance, behavioral problems, ear discomfort, or reduced quality of life. Option based on randomized controlled trials and before-and-after stud- ies with a balance between benefit and harm. Action Statement Profile • • Aggregate evidence quality: Grade C, based on before-and-after studies on vestibular function and QOL, RCTs on reduced MEE after tubes for chronic OME, and observational studies regarding the impact of MEE on children as related, but not limited to, school performance, behavioral issues, and speech delay • • Level of confidence in evidence: High for vestibular problems and QOL; medium for poor school per- formance, behavioral problems, and ear discomfort, because of study limitations and the multifactorial nature of these issues • • Benefits: Reduced prevalence of MEE, possible relief of symptoms attributed to chronic OME, elimi- nation of MEE as a confounding factor from efforts to understand the reason or cause of a vestibular problem, poor school performance, behavioral prob- lem, or ear discomfort • • Risks, harms, costs: None related to offering sur- gery, but if performed, tympanostomy tube inser- tion includes risks from anesthesia, sequelae of the indwelling tympanostomy tubes (otorrhea, granula- tion tissue, obstruction), complications after tube extrusion (myringosclerosis, retraction pocket, per- sistent perforation), premature tympanostomy tube extrusion, retained tympanostomy tube, tympanos- tomy tube medialization, procedural anxiety and dis- comfort, and direct procedural costs • • Benefit-harm assessment: Equilibrium • • Value judgments: Chronic MEE has been associated with problems other than hearing loss; intervening when MEE is identified can reduce symptoms. The group’s confidence in the evidence of a child benefit- ting from intervention was insufficient to conclude a preponderance of benefit over harm and instead found at equilibrium • • Intentional vagueness: The words likely attributable are used to reflect the understanding that the symp- toms listed may have multifactorial causes, of which OME may be only one factor, and resolution of OME may not necessarily resolve the problem • • Role of patient (caregiver) preferences: Substantial role for shared decision making regarding the deci- sion to proceed with, or to decline, tympanostomy tube insertion • • Exceptions: None

The purpose of this statement is to facilitate intervention for children with chronic OME and associated symptoms that are likely attributable to OME, when the child does not meet cri- teria for intervention in the preceding action statement (eg, bilateral OME with documented hearing difficulty). This is consistent with current guidelines from the United Kingdom that state “exceptionally, healthcare professionals should con- sider surgical intervention in children with chronic bilateral OME with a hearing loss less than 25–30 dB HL where the impact of the hearing loss on a child’s developmental, social or educational status is judged to be significant.” 58 In contrast, the guideline development group for this document also con- sidered chronic unilateral OME as a surgical indication if they also presented with symptoms likely attributable to OME. OME has a direct and reversible impact on the vestibular system. 69-73 Children with chronic OME have significantly poorer vestibular function and gross motor proficiency when compared with non-OME controls. Moreover, these deficien- cies tend to resolve promptly following tympanostomy tube insertion, although 1 case-control study did not show vestibu- lar benefits with rotational chair testing. 74 In aggregate, how- ever, evidence suggests tympanostomy tube insertion is a reasonable option for children with chronic OME who have unexplained clumsiness, balance problems, or delayed motor development. Since most parents/caregivers do not appreciate the potential relation of these symptoms with OME, clinicians must often ask specific and targeted questions about clumsi- ness, balance (eg, frequent falls), or motor development (eg, delays in walking) to elucidate symptoms. Certain behavioral problems occur disproportionately with OME, including distractibility, withdrawal, frustration, and aggressiveness. 75 In a large cohort study, for example, OME severity from age 5 to 9 years correlated with a lower intelli- gence quotient to age 13 years and with hyperactive and inat- tentive behavior until age 15 years. 76 The largest effects were observed for defects in reading ability between 11 and 18 years. An RCT of children treated with tympanostomy tubes for chronic OME had fewer documented behavioral problems compared with nonsurgical controls. 46 Children with OME have also been found to have more attention disorders and anxiety/depression-related disorders when compared with children without OME. 77 Two prospective cohort studies evaluated QOL outcomes among children undergoing tympanostomy tube placement for otitis media using a disease-specific QOL measure, the OM-6 survey. 8,67 Rosenfeld and colleagues 8 found physical symptoms, caregiver concerns, emotional distress, hearing loss, and speech impairment significantly improved after tym- panostomy tube placement. Timmerman and colleagues 67 also noted improved QOL among children after tympanostomy tube placement and concluded further that caregivers tend to underestimate their child’s degree of baseline hearing impair- ment; when asked to reassess their preoperative rating of their

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