Executive Summary of Clinical Practice Guideline on Tympanostomy Tubes in Children (Update)

Abstract

Objective This executive summary of the guideline update provides evidence-based recommendations for patient selection and surgical indications for managing tympanostomy tubes in children. The summary and guideline are intended for any clinician involved in managing children aged 6 months to 12 years with tympanostomy tubes or children being considered for tympanostomy tubes in any care setting as an intervention for otitis media of any type. The target audience includes specialists, primary care clinicians, and allied health professionals. Purpose The purpose of this executive summary is to provide a succinct overview for clinicians of the key action statements (recommendations), summary tables, and patient decision aids from the update of the American Academy of Otolaryngology–Head and Neck Surgery Foundation’s “Clinical Practice Guideline: Tympanostomy Tubes in Children (Update).” The new guideline updates recommendations in the prior guideline from 2013 and provides clinicians with trustworthy, evidence-based recommendations on patient selection and surgical indications for managing tympanostomy tubes in children. This summary is not intended to substitute for the full guideline, and clinicians are encouraged to read the full guideline before implementing the recommended actions. Methods The guideline on which this summary is based was developed using methods outlined in the American Academy of Otolaryngology–Head and Neck Surgery Foundation’s “Clinical Practice Guideline Development Manual, Third Edition: A Quality-Driven Approach for Translating Evidence Into Action,” which were followed explicitly. The guideline update group represented the disciplines of otolaryngology–head and neck surgery, otology, pediatrics, audiology, anesthesiology, family medicine, advanced practice nursing, speech-language pathology, and consumer advocacy. Action Statements Strong recommendations were made for the following key action statements: (14) Clinicians should prescribe topical antibiotic ear drops only, without oral antibiotics, for children with uncomplicated acute tympanostomy tube otorrhea. (16) The surgeon or designee should examine the ears of a child within 3 months of tympanostomy tube insertion AND should educate families regarding the need for routine, periodic follow-up to examine the ears until the tubes extrude. Recommendations were made for the following key action statements: (1) Clinicians should not perform tympanostomy tube insertion in children with a single episode of otitis media with effusion (OME) of less than 3 months’ duration, from the date of onset (if known) or from the date of diagnosis (if onset is unknown). (2) Clinicians should obtain a hearing evaluation if OME persists for 3 months or longer OR prior to surgery when a child becomes a candidate for tympanostomy tube insertion. (3) Clinicians should offer bilateral tympanostomy tube insertion to children with bilateral OME for 3 months or longer AND documented hearing difficulties. (5) Clinicians should reevaluate, at 3- to 6-month intervals, children with chronic OME who do not receive tympanostomy tubes, until the effusion is no longer present, significant hearing loss is detected, or structural abnormalities of the tympanic membrane or middle ear are suspected. (6) Clinicians should not perform tympanostomy tube insertion in children with recurrent acute otitis media (AOM) who do not have middle ear effusion (MEE) in either ear at the time of assessment for tube candidacy. (7) Clinicians should offer bilateral tympanostomy tube insertion in children with recurrent AOM who have unilateral or bilateral MEE at the time of assessment for tube candidacy. (8) Clinicians should determine if a child with recurrent AOM or with OME of any duration is at increased risk for speech, language, or learning problems from otitis media because of baseline sensory, physical, cognitive, or behavioral factors. (10) The clinician should not place long-term tubes as initial surgery for children who meet criteria for tube insertion unless there is a specific reason based on an anticipated need for prolonged middle ear ventilation beyond that of a short-term tube. (12) In the perioperative period, clinicians should educate caregivers of children with tympanostomy tubes regarding the expected duration of tube function, recommended follow-up schedule, and detection of complications. (13) Clinicians should not routinely prescribe postoperative antibiotic ear drops after tympanostomy tube placement. (15) Clinicians should not encourage routine, prophylactic water precautions (use of earplugs or headbands, avoidance of swimming or water sports) for children with tympanostomy tubes. Options were offered from the following key action statements: (4) 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 attributable, all or in part, to OME that include, but are not limited to, balance (vestibular) problems, poor school performance, behavioral problems, ear discomfort, or reduced quality of life. (9) Clinicians may perform tympanostomy tube insertion in at-risk children with unilateral or bilateral OME that is likely to persist as reflected by a type B (flat) tympanogram or a documented effusion for 3 months or longer. (11) Clinicians may perform adenoidectomy as an adjunct to tympanostomy tube insertion for children with symptoms directly related to the adenoids (adenoid infection or nasal obstruction) OR in children aged 4 years or older to potentially reduce future incidence of recurrent otitis media or the need for repeat tube insertion.

Task force Guideline of Brazilian Society of Otology – hearing loss in children – Part II — Treatment

“…TTP should not be performed in children with recurrent AOM without middle ear effusion. However, the American Academy of Otolaryngology-Head and Neck Surgery (AAO-HNS) guidelines include the following exceptions: 103 (1) children with a history of a severe episode or persistent AOM. (2) Presence of immunosuppression.…”

“… 104 It may occur as a result of Eustachian tube dysfunction, during upper respiratory tract infection, or after the inflammatory process of AOM. 103 Although OME resolves spontaneously in most cases, up to 40% of patients have repeated episodes, and 10% of episodes last 1-year or longer. 105 The prevalence of OME is higher in children with Down syndrome or cleft palate.…”

“…Children younger than 6-months are excluded from almost all guidelines and randomized trials because evidence is extremely limited and their treatment requires individualized decision-making based on specific clinical circumstances. 103 Children considered at risk for language developmental difficulties are those with a diagnosis such as ASD, blindness or hearing impairment regardless of OME, and syndromic hearing loss, and those with cleft palate or delayed neuropsychomotor development. 103 , 104 …”

“… 103 Children considered at risk for language developmental difficulties are those with a diagnosis such as ASD, blindness or hearing impairment regardless of OME, and syndromic hearing loss, and those with cleft palate or delayed neuropsychomotor development. 103 , 104 …”

“…If the diagnosis remains uncertain after pneumatic otoscopy, tympanometry should be performed (strong recommendation). 103 , 108 At-risk children should be identified and evaluated for the presence of OME. This evaluation should be repeated at 12 and 18 months of age.…”