NICE has published Referral Advice - A guide to appropriate referral from general to specialist services, which deals with 11 common complaints. Last month we covered osteoarthritis of the knee. In this issue we reproduce the advice on persistent otitis media with effusion (glue ear) in children.

The referral advice is set out in consensus statements based on the best available evidence. It is designed to help clinicians determine how urgently particular patients need to be referred.

Glue ear

Otitis media with effusion is the commonest cause of hearing loss in childhood. The effusion usually follows acute otitis media and resolves spontaneously.

In half of those affected resolution occurs within 3 months, and in 95% within a year.

When fluid persists there may be further episodes of acute otitis media. The condition occurs more frequently in winter.

Hearing loss is not always the presenting complaint and consultation may occur because of problems with speech and language development (this applies particularly to children aged under 4 years), or because of learning or behavioural problems and compromised levels of social function. Sometimes hearing loss is first detected by child health surveillance. When hearing loss is mild, it can only be detected reliably by age-appropriate hearing assessment.

The effusion is usually accompanied by otoscopic findings, of which the salient features are a drum that appears dull, retracted, and poorly mobile. Such changes, which are usually bilateral, are best seen using a pneumatic otoscope with halogen lighting.

Tympanometry can be used to confirm the presence of effusion. In those in whom effusion and hearing loss persist, treatment may involve surgical intervention (grommet insertion with or without adenoidectomy).

Primary care

The role of primary care is to detect, diagnose, observe (watchful waiting), counsel and advise.

Parents, carers and teachers may be helped with advice on communication and coping strategies. In children with persistent effusion, nothing worthwhile is gained by prescribing an antibiotic, decongestant or antihistamine.

Parents should be informed that exposure to cigarette smoke worsens the outlook.

Specialist services

These are in a position to:

  • clarify the diagnosis and advise on management alternatives
  • undertake hearing assessment
  • assess the need for, and undertake, surgical intervention
  • provide speech and language assessment and therapy
  • coordinate care for children with additional problems, such as cleft palate.
Referral Advice
In the majority of children, the effusion and hearing loss will resolve spontaneously and management will remain within primary care. Specialist services (e.g. hearing assessment, tympanometry) may be required to clarify the diagnosis. Referral for an ENT opinion should take into account concerns raised by the child?s parent, school or health visitor. Children awaiting a routine outpatient appointment may need to be reassessed to check for clinical changes, and so the possible revision of the referral time. For those with persistent effusion, referral for an ENT opinion is advised if:
the otoscopic features are atypical and accompanied by a foul-smelling discharge suggestive of cholesteatoma
they have excessive hearing loss suggestive of additional sensorineural deafness
they have proven hearing loss plus difficulties with speech, language, cognition or behaviour
they have proven hearing loss plus a second disability, such as Down?s syndrome
they have proven hearing loss together with frequent episodes of acute otitis media

they have proven persistent hearing loss detected on two occasions separated by 3 months or more (results of formal testing should be included in the referral letter)

The starring system developed by NICE to identify referral priorities
Arrangements should be made so that the patient:
is seen immediately1
is seen urgently2
is seen soon2
has a routine appointment2
is seen within an appropriate time depending on his or her clinical circumstances (discretionary)

1 within a day
2 health authorities, trusts and primary care organisations should work to local definitions of maximum waiting times in each of these categories. The multidisciplinary advisory groups considered a maximum waiting time of 2 weeks to be appropriate for the urgent category.

Reproduced with kind permission from: Referral Advice - A Guide to Appropriate Referral from General to Specialist Services. London: NICE, December 2001.

The complete document can be downloaded from the NICE website

Guidelines in Practice, July 2002, Volume 5(7)
© 2002 MGP Ltd
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