2015 HSC Section 1 Book of Articles

Rosenfeld et al

Childage 6 months to 12 years with OME

1

No

No

Is the child considered ‘at risk’?

Has the child had persistent OME for 3 months or longer?

Reevaluate child until OME resolves, persists 3 months or longer, or is associated with a type B (flat) tympanogram

Clinician may perform tympanostomy tube insertion

Yes

Yes

Obtain hearing test

Does the child have unilateral or bilateral chronic OME or a type B (flat) tympanogram?

Yes

No

Has the child had unilateral or bilateral chronic OME and symptoms that are likely attributable to OME?

No

Has the child had bilateral COME and documented hearing difficulty?

Yes

Clinician may perform tympanostomy tube insertion

Yes

No

Offer tympanostomy tube insertion

Reevaluate child every 3 to 6 months until effusion no longer present, significant hearing loss detected, or structural abnormalities suspected

Educate caregivers and proceed with tympanostomy tube placement

Does the parent or guardian agree with

No

Yes

tympanostomy tube insertion?

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Figure 9. Algorithm of guideline’s key action statements for children with otitis media with effusion.

especially P aeruginosa . One additional RCT assessed topical antibiotics with and without concurrent oral antibiotics but did not find any advantage to combination therapy. 126 Topical antibiotic therapy avoids adverse events associated with systemic antibiotics including dermatitis, 123,124 allergic reactions, gastrointestinal upset, 123,124 oral thrush, 124 and increased antibiotic resistance. 121 Only topical drops approved for use with tympanostomy tubes should be prescribed (eg, ofloxacin or ciprofloxacin-dexamethasone) to avoid potential ototoxic- ity from aminoglycoside-containing eardrops, which are often used to treat acute otitis externa. 127 Otomycosis has not been reported after topical therapy in RCTs of acute TTO, 123-125 but prolonged or frequent use of quinolone eardrops may induce fungal external otitis. 128,129 Caregivers should be advised to limit topical therapy to a single course of no more than 10 days. Last, although systemic quinolone antibiotics are not approved for children aged 14 years or younger, topical drops are approved because they do not have significant systemic absorption. Acute TTO usually improves rapidly with topical antibiotic therapy, provided that the drops can reach the middle ear space. 18 This is most likely to occur if the ear canal is cleaned of any debris or discharge before administering the drops, by

blotting the canal opening or using an infant nasal aspirator to gently suction away any visible secretions. 3 Any dry crust or adherent discharge can be cleaned using a cotton-tipped swab and hydrogen peroxide, which can be used safely when a tym- panostomy tube is present. 130 Persistent debris despite these measures can often be removed by suctioning through an open otoscope head or by using a binocular microscope for visual- ization. In addition, having the child’s caregiver “pump” the tragus several times after the drops have been instilled will aid delivery to the middle ear. 116,131 Last, caregivers should be advised to prevent water entry into the ear canal during peri- ods of active TTO. Systemic antibiotic therapy is not recommended for first- line therapy of uncomplicated, acute TTO but is appropriate, with or without concurrent topical antibiotic therapy, when: 1. Cellulitis of the pinna or adjacent skin is present 2. Concurrent bacterial infection (eg, sinusitis, pneu- monia, or streptococcal pharyngitis) is present 3. Signs of severe infection exist (high fever, severe otalgia, toxic appearance) 4. Acute TTO persists, or worsens, despite topical anti- biotic therapy

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