The NICE guideline on surgical management of otitis media with effusion in children highlights that this condition will often resolve naturally, reports Dr John Hart

Otitis media with effusion (OME), also known as secretory otitis media and ‘glue ear’ is an extremely common problem presenting in general practice. By the age of 10 years, 80% of children will have suffered at least one episode of OME. Children typically visit their GP’s surgery with impaired hearing, which lasts for 6–10 weeks.1

As GPs are usually the first clinicians to whom concerns regarding hearing are reported, they need to be aware of current management issues. He or she must be able to provide information to parents, discuss options, and, in particular, support the policy of active observation. This requires an understanding of the normal course of OME, which usually resolves naturally, with most cases settling without any intervention within 3 months. This active observation has important implications for the cost-effective management of a common condition presenting in general practice and will avoid unnecessary outpatient referrals and surgery. The NICE guideline looked specifically at the evidence for surgical intervention in OME compared with non-surgical treatments and, in particular, ‘no treatment’.1,2 Clearly the evidence and recommendations could have a large impact on primary care referral patterns and follow up of patients.

Development of the guideline

All treatment methods were considered when developing the guideline. Although OME is usually transient and, given time, resolves by itself, in some cases intervention may be required. This may include various social interventions, such as seating the child nearer the teacher at school, provision of hearing aids, and surgical intervention, such as myringotomy and insertion of ventilation tubes (grommets), and adenoidectomy.1

Two specific childhood groups were also considered individually: children with Down’s syndrome and those with cleft palate. In both these conditions children are more prone to develop OME. It is important for GPs to be aware of this and obtain appropriate specialist assessment.1,2

Consideration was given to the risks and benefits of the intervention in all cases. Each child’s situation must be evaluated on an individual basis. Because the OME is usually temporary, the severity of the condition and the length of time it has been present, as well as how this affects the individual child socially and developmentally, are important.

Initial assessment

The NICE guideline formulated a care pathway for the assessment and treatment of children with suspected OME and this is presented in Figure 1. The guideline has further care pathways for children with Down’s syndrome and children with cleft palate who are thought to have OME.1

It is important for GPs to be able to consider the child’s overall health and development, to be able to listen to the concerns of parents and respond appropriately, and to be aware of cases of high risk where intervention is more likely. All children with either Down’s syndrome or with cleft palate should be assessed regularly for OME.

The role of the GP is key in making an initial general assessment of the child. They often have useful information from parents, school nurses, and health visitors, which helps to determine whether the child is encountering significant problems, and identifies those who may need referral.

Assessment should include taking a clinical history. This should look for evidence of:1,2

  • poor listening skills
  • indistinct speech or delayed language development
  • inattention and behaviour problems
  • hearing fluctuation
  • recurrent ear infections or upper respiratory tract infections
  • balance problems and clumsiness
  • poor educational progress.

The assessment should be accompanied by a clinical examination. This should include:1,2

  • otoscopy
  • general upper respiratory health
  • general developmental status
  • hearing testing—to be carried out by trained staff using tests suitable for the developmental stage of the child and calibrated equipment
  • tympanometry.

Hearing reports from parents were not found to be highly reliable,3 with limited sensitivity but good specificity; parents were not good at detecting a problem if there was one, but were good at accurately recognising the hearing was normal.

Figure 1: Care pathway for children with suspected OME

Care pathway for children with suspected OME

OME=otitis media with effusion; dBHL=hearing level in decibels
Adapted from National Institute for Health and Care Excellence (NICE) (2008) CG 60 Surgical management of otitis media with effusion in children.
London: NICE. Reproduced with permission. Available from www.nice.org.uk.

Hearing tests

Otoscopy, examination of the ear canal and tympanic membrane with a handheld auriscope, showed variable results, although otoscopy remains important to exclude other ear conditions that may be present.1

Tympanometry measures how readily the tympanic membrane and ossicles vibrate with sound waves while changing the air pressure in the external auditory canal. Normally there is maximal movement when pressure on each side of the tympanic membrane is equal. Reliable, portable tympanometry devices are now available. These are relatively affordable and easy to use and the number of GPs with access to this equipment in their practice is growing. In a primary care setting, the sensitivity of tympanometry is 93%, in pooled results, with a specificity of 70%.4,5,6,7 Thus tympanometry does appear to be a useful test to use in the community and is affordable for most practices.

However it will not be possible for detailed hearing assessment to be conducted in most general practices, although many will have open access to audiology services in their local hospital community/locality clinic. Thorough hearing assessment in primary care can save many unnecessary referrals to ENT outpatient departments for children with normal hearing. Practice-based commissioning could provide this if it is not available.

Interpretation of audiology results

Guidance is needed for GPs on the significance of test results and what to do after receipt.

Surgical intervention should be considered for children who have experienced persistent bilateral OME for a period of 3 months, with a hearing level in the better ear of 25–30 dB or worse, averaged at 0.5, 1.0, 2.0 and 4.0 kHz.2 Figure 2 shows an example of a typical audiology scan, which is possible in an older child. In younger children, considerable skill is required to perform an accurate audiological assessment. This may include visual reinforcement audiometry or sound field audiometry.

Tympanograms can indicate the presence of fluid in the middle ear (Figure 3), typically a flat tracing. A type C tympanogram (Figure 4) with a peak at less than -200 daPa indicates negative pressure in the middle ear in relationship to atmospheric pressure, resulting in poor movement of the tympanic membrane.

It is important to remember that some children may have a mixed hearing loss, which means there may be sensorineural loss as well as the conductive loss.

Figure 2: A typical audiology scan

A typical audiology sca

Figure 3: A flat tracing on tympanogram usually indicates there is final fluid in the middle ear

A flat tracing on tympanogram usually indicates there is final fluid in the middle ear

Figure 4: A type C tympanogram indicating negative pressure in the middle ear. Type 2 is particularly important, with a peak at less than -200 daPa

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Treatment

The NICE guideline recommends the use of ventilation tubes (grommets) once surgical intervention has been decided on. If surgery is contraindicated or is unacceptable, hearing aids should be offered to children with persistent OME in both ears.1

Insertion of ventilation tubes in children with Down’s syndrome can present technical difficulties—see further discussion below. In children with cleft palate, careful otological and audiological assessment needs to take place, and hearing aids should be offered as an alternative to ventilation tubes— see below.

Adjuvant adenoidectomy is not recommended if there are no persistent and/or frequent upper respiratory tract symptoms.

General practitioners should avoid the following treatments, which are of no proven benefit:

  • antibiotics
  • topical or systemic antihistamines
  • topical or systemic decongestants
  • topical or systemic steroids
  • homeopathy
  • cranial osteopathy
  • acupuncture
  • dietary modification, including probiotics
  • immunostimulants
  • massage.

Antibiotics

There is conflicting evidence regarding the effectiveness of antibiotics in the management of OME in children. Results from one meta-analysis showed a 23% increase in the likelihood of resolution with antibiotic usage,8 while another meta-analysis, which used a more robust methodology, found no benefit.9

Children with Down’s syndrome

The risk of OME is increased in children with Down’s syndrome, and GPs need to be aware of this. Children with Down’s syndrome who have possible OME should be cared for by a specialist multidisciplinary team, which is experienced in their care. Hearing aids are the first choice of treatment for OME with hearing loss but surgery to insert ventilation tubes may be an alternative option. The decision to use ventilation tubes should take into consideration:

  • severity of hearing loss
  • age of the child
  • practicality of insertion of the tubes
  • associated risks of ventilation tubes
  • possibility of early extrusion.

Children with cleft palate

General practitioners should take into consideration that the presence of cleft palate increases the risk of OME. Healthcare professionals in local otological and audiological services who are experienced in assessment and treatment of children with cleft palate and OME should be responsible for their care, in conjunction with the regional multidisciplinary cleft lip and palate team. Ventilation tubes should only be inserted after careful assessment, and at the same time as surgery for primary closure of the cleft palate. They can be used as an alternative to hearing aids.

Timing of treatment

The persistence of bilateral OME over a 3-month period should be confirmed before surgical intervention is considered. The resolution rates are around: 50% at 3 months; 70% at 6 months; and 80% at 9 months.1 Parents can therefore be reassured that it is appropriate to wait, at least for 3 months, to see whether the condition resolves spontaneously.

Active steps should be taken during the observation period to implement educational and behavioural strategies to minimise the effects of the hearing loss.1 General practitioners can give advice on this to parents, carers, and schools, such as seating the child near to the teacher.

Effectiveness of ventilation tubes

There is evidence that the insertion of ventilation tubes gives hearing improvement of 4–10 dB over the first 6 months.1

Possible complications of ventilation tubes are listed in Table 1. Although most were minor, occurrence levels were not low. These potential problems should be discussed with the child and his or her parent or carer when considering the risks and benefits of intervention.10

Table 1: Possible complications of ventilation tube insertion10

Complication
Occurrence (% of ears)
Otorrhoea
17.0
Blockage of the tube
7.0
Granulations
5.0
Premature extrusion
3.9
Tympanosclerosis
32.0
Atrophy/retraction
25.0
Perforation:
long-term ventilation tubes

short-term ventilation tubes


16.6

2.2

Summary

The NICE guideline on Surgical management of otitis media with effusion in children encourages active observation for at least 3 months, and GPs can offer support during this period. The guideline also considered two specific groups at risk of OME—children with Down’s syndrome or children with cleft palate—and GPs should be particularly vigilant of these patients. Parents, carers, and children should be given information on the tendency for natural resolution, opportunities to discuss the options, and they should be provided with appropriate supportive written material.

NICE implementation tools

NICE has developed the following tools to support implementation of its guideline on the surgical management of otitis media with effusion in children. They are now available to download from the NICE website: www.nice.org.uk.

Costing tools

National cost reports and local cost templates for the guideline have been produced:

  • Costing reports are estimates of the national cost impact arising from implementation based on assumptions about current practice, and predictions of how it might change following implementation of the guideline.
  • Costing templates are spreadsheets that allow individual NHS organisations and local health economies to estimate the costs of implementation taking into account local variation from the national estimates, and they quickly assess the impact the guideline may have on local budgets.

Slide set

The slides are aimed at supporting organisations to raise awareness of the guideline at a local level and can be edited to cater for local audiences. They do not cover all the recommendations from the guideline but contain key messages, and should be used in conjunction with the Quick Reference Guide.

Audit support

Audit support has been developed to assess current practice in the management of osteoarthritis compared with the guideline recommendations. Audit criteria based on key priorities for implementation in the guideline are provided, which can be adapted for use locally. Although the given standard should be aimed for, a more realistic local short-term standard can be set based on discussion with clinicians.

Click here for CPD questions on this article and the NICE guideline on the surgical management of otitis media with effusion in children

written by Dr David Jenner, NHS Alliance sPBC Lead
  • Surgical intervention for OME is not indicated unless there is bilateral OME persisting for >3 months
  • Access to audiology services with tympanometry and result interpretation in primary care would reduce expensive referrals to hospital ENT outpatient departments
  • There is no mandatory tariff for audiology assessments
  • Antibiotics and decongestant medicines are ineffective in management
  • Children with Down’s syndrome or cleft palate are best referred for specialist assessment
  • The NICE care pathway is an ideal template for local modification by PBC consortia
  • Cost of ENT outpatient appointment: new £130; follow-up £72a
  1. National Collaborating Centre for Women’s and Children’s Health. Surgical management of otitis media with effusion in children. London: Royal College of Obstetricians and Gynaecologists, 2008.
  2. National Institute for Health and Care Excellence. Surgical management of otitis media with effusion in children. Clinical Guideline 60. London: NICE, 2008.
  3. Anteunis L, Engel J, Hendriks J, Manni J. A longitudinal study of the validity of parental reporting in the detection of otitis media and related hearing impairment in infancy. Audiology 1999; 38 (2): 75–82.
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  5. Vaughan-Jones R, Mills R. The Welch Allyn Audioscope and Microtymp: their accuracy and that of pneumatic otoscopy, tympanometry and pure tone audiometry as predictors of otitis media with effusion. J Laryngol Otol 1992; 106 (7): 600–602.
  6. Fiellau-Nikolajsen M. Tympanometry and middle ear effusion: a cohort-study in three-year-old children. Int J Pediatr Otorhinolaryngol 1980; 2 (1): 39–49.
  7. Tom L, Tsao F, Marsh R et al. Effect of anesthetic gas on middle ear fluid. Laryngoscope 1994; 104 (7): 832–836.
  8. Rosenfeld R, Post J. Meta-analysis of antibiotics for the treatment of otitis media with effusion. Otolarynogol Head Neck Surg 1992; 29 (3): 219–225.
  9. Cantekin E, McGuire T. Antibiotics are not effective for otitis media with effusion: Reanalysis of meta-analyses. Oto-Rhino-Laryngologia Nova 1998; 8 (5): 214–222.
  10. Kay D, Nelson M, Rosenfeld R. Meta-analysis of tympanostomy tube sequelae. Otolaryngol Head Neck Surg 2001; 124 (4): 374–380.G