One might think that the best treatment
for a condition as prevalent as otitis media would have
been settled upon long ago. Not so, says a study in
the January 18 New England Journal of Medicine,
which finds that children are being heavily over-treated
while guidelines are widely ignored.
Only half of 682 children who received
tympanostomy tubes in five New York hospitals in 2002
met the criteria of the guidelines endorsed by pediatric,
family physician and otolaryngology groups.
These guidelines stipulate that
otitis media with effusion is only indicated in children
whose effusions have lasted for at least three months.
The mean average duration of the current episode of
effusion in the children who underwent tympanostomy
was just 29 days, while the median was a mere 16 days.
QUICK
FIX
Only a quarter of these children were experiencing a
current episode of effusion that had lasted longer than
42 days. Most, however, had suffered multiple episodes,
with an average of three in the past year. But even
when the cumulative days of effusion over the past year
were added up, only half of these children met the three-month
criteria.
"One of our key findings is that
more than three quarters of the children in our study
who got ear tubes had fluid for less than a month and
a half," said lead researcher Dr Salomeh Keyhani in
a press release.
"Ear infection is the most common
illness with which children present to the doctor,"
she added. "We found that many children are getting
surgeries for minor disease and the typical child who
gets ear tube surgery does not have disease severe enough
to warrant the operation. If the study findings could
be applied to rest of the country, it would be particularly
troubling."
There's every reason to believe
the findings can be applied to the rest of the US, because
this is far from being the first study to document overuse
of tympanostomy, which has been a recognized problem
since 1991.
CANADIAN
SITUATION
As for Canada, we have no data on the patient characteristics
of children who undergo the procedure here, but we do
have a 2000 CMAJ survey inspired by the uneven geographical
distribution of tympanostomy rates in Ontario. All 227
otolaryngologists in Ontario were asked what symptoms
would typically lead them to recommend such a procedure.
There was a good deal of disagreement
about the best course of action in three borderline
hypothetical cases that these physicians were presented
with. Most agreed that less than three months' effusion
was a contraindication for surgery. But then, US otolaryngologists,
when surveyed, also hew to the guidelines in theory.
It's practice that's the problem.
Presented with the hypothetical
case of a two-and-a-half year old girl with no otorrhea,
no hearing loss, and normal tympanic membranes, but
who had suffered ten episodes of otitis media in the
past year, 30% of the Canadian specialists said they
would recommend tympanostomy, clearly going against
the guidelines.
PARENT
TRAP
Specialists agree that tympanostomy is not a dangerous
procedure. The polled Canadian otolaryngologists agreed
that serious adverse anesthetic events occur in fewer
than one in 10,000 cases. Scarring, however, is expected
in one case in ten, usually without a major impact on
hearing. The treatment fails to resolve otorrhea in
one case in 20.
If physicians are finding the guidelines
harder to follow in practice than in theory, the likeliest
explanation by far is parental pressure. Nobody wants
to be told to wait three months when they have a two-year-old
with an earache. Beyond that, there have been persistent
concerns that temporary hearing loss in these crucial
early years might delay a child's development.
Those concerns have been largely
laid to rest, however, by a pair of landmark studies
in the NEJM, led by Dr Jack Paradise of Pittsburgh
Children's Hospital. Following a prospective cohort
of 6,350 newborns through the earache years, Dr Paradise
found that those who had received rapid tympanostomy
showed no developmental advantage over the delayed treatment
group.
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