Management of Otitis Media with Effusion (OME) in primary care Kifayat Ullah Core Surgical Trainee East of England Deanery

Objectives 1. Background and prevalence of OME 2. Distinguishing OME from AOM 3. Risk factors of OME 4. Audit on OME management 5. Conclusion

Background OME or “glue ear” commonest cause of childhood hearing impairment Inflammation of middle ear with collection of liquid in middle ear space Peak 2-6 years of age 85% of children experience fluid in ears following infection 50% resolve within 3 months Otitis media with effusion- is the most appropriate term used to describe the presence of inflammation of the middle ear with a collection of liquid in the middle ear space when signs and symptoms of acute infection are absent. PAUSE Acute otitis media- inflammation of the middle ear that is of rapid and short onset in association with signs and symptoms indicating acute infection There is no foolproof combination of otoscopic signs and symptoms to discriminate between acute otitis media and otitis media with effusion.

Prevalence of OME 1993 - 1995 (NCHS),2 OM accounted for 18% ambulatory visits (1-4 yr) 14% visits during the 1st yr of life OME episodes diagnosed2 81% in pediatric practices 13% in hospital ED 6% in hospital outpatient departments Data collected from the National Center for Health Statistics (NCHS) between 1993-1995 reflects the prevalence of otitis media as one of the most common primary care clinical problems.

Distinguishing OME from AOM The following published algorithm has been used in clinical trials and for instructing trainees. It provides objective and stringent diagnostic criteria to facilitate the distinction of these two conditions through careful otoscopic examination. As illustrated, a diagnosis of otitis media with effusion requires the presence of middle ear effusion with abnormal colour of TM (white, yellow) and opacification not due to scarring and absence of otoscopic signs of acute inflammation

Risk factors of OME Host factors Environmental factors Age/Gender Genetic predisposition Cleft palate/Down syndrome Allergy/Immunity Environmental factors Daycare/Siblings Bottle (versus breast) feeding Pacifier use Smoking Low socioeconomic status Season/Upper respiratory infections Risk factors for recurrent otitis media are host related factors and environmental factors.

Why do this audit? OME management not understood in community Parents frustration why symptoms have not resolved Unnecessary visits to ENT clinic

Audit Prospective study run in ENT outpatient clinic at Tunbridge Wells Hospital, Kent 250 children aged between 2 and 10 years of age referred from primary care Data collected prospectively in the form of a questionnaire New referrals recruited over 12 month period This audit of current practice in the management of OME in childhood was designed to establish current practice in a DGH

Main standards in audit Referral orientation for primary care Where OME is strongly suspected to have occurred irrespective of a known ear infection or to have continued for more than 1 month refer: Under 4 years of age: To the second tier community audiology clinic for hearing assessment. Subject to resources and efficiency of booking, this is usually the most direct route to valid audiometry. Over four years of age: To children’s ENT clinic for hearing assessment Watchful waiting is the initial management, unless there are overriding concerns about hearing, speech or language development accompanying an established history, or unless this has already occurred as set out above. Guideline commissioned and approved by the Clinical Audit and Practice Advisory Group, ENT-UK

Questionnaire: Initial referrals and management of OME This is the questionnaire that was used to identify the area concerned

Results Otitis media with effusion is most prevalent between 2 and 5 years of age because younger children are immunologically naïve to a variety of respiratory viruses . In younger children there are also anatomical differences, that is, a shorter, and horizontal lying Eustachian tube, which predisposes to accumulation of secretions in the middle ear. Both clinic and population-based investigations since 1995 have supported the findings that male gender is a risk factor for cumulative time with Otitis Media with effusion.

Results

Results No hearing test in community All children reviewed developed conductive hearing loss Tympanograms = type B in 90% of children True OME in 90% of children examined 10% of children have had recent AOM 10% delay in development of speech

Discussion Most children managed in community not managed according to guidelines OME management not understood to indicate an optimal strategy Concern regarding hearing test where none of the children had this performed prior to ENT visit The results of this audit support the contention that most children diagnosed with OME in community were not managed in line with current accepted best practice. It should be pointed out that it is difficult to have a consensus concerning the correct management for OME when it is not understood appropriately in the community The findings concerning audiometric testing at the initial visit are of some concern. The evaluation of hearing is an important part of the initial assessment of this type of case especially when it comes to surgical treatment of OME. Performing hearing test in the community prior to ENT follow up according to the guidelines provides appropriate management of OME and saves ENT clinic time.

Discussion OME huge impact on speech development and educational performance 30% of children had delay in speech and development Treatment for OME should initially start with ‘watchful waiting’ – 64% children started on decongestants/antihistamines/antibiotics OME is a common and important condition because of its impact on speech development and educational performance. Appropriate management of the condition is particularly important because of the relatively high aggregate costs of treatment to the NHS. While guidelines can be formulated for its management, based on existing data, there are still significant gaps in our knowledge and scope for individualisation of care. 30% of children had delay in speech and development – this may suggest some of the presentations in clinic may have been of a chronic nature but never investigated. Treatment for OME should initially start with ‘watchful waiting’ – 64% children started on decongestants/antihistamines/antibiotics of those 60% started on all three. A period of active clinical monitoring is recommended for three months following initial diagnosis of OME. “Watchful waiting” (WW) has been the term for this, although in an increasingly consumer-led NHS, that term may become unacceptable to parents, and especially so unless the watching is as evident as the waiting. There is no good evidence that medical treatments developed so far, including decongestants, antibiotics, antihistamines, have any clinically worthwhile effect on resolution of established middle ear effusion. A minority of cases, in whom there is an allergic component to their disease may benefit from topical (nasal) steroids.

Changes made Standards had not been met mainly due to lack of knowledge in management of OME Following action plan: Presentation at GP trainee teaching sessions Leaflet and poster distribution to GP clinics Develop a checklist for GP doctors in community when assessing children with possible OME Currently – action plans have been implemented and re-audit is currently active

Conclusion Audit indicates OME management needs appropriate decision making Concerns raised regarding audiology services in the community After a watchful waiting period- refer to ENT clinic if no improvement for further management

References Audit Commission access to care 2002 http://www.audit-commission.gov.uk/reports/accessible.asp?ProdID=D4361C80-E5CB-11d6- B1E1-0060085F8572 Accessed 13/12/06 1  Lous J, Burton MJ, Felding JU, Oveson T, Wake M, Williamson IG. Grommets (ventilation tubes) for hearing loss associated with otitis media with effusion in children. (Cochrane Review). In: The Cochrane Library, Issue 4,2002. Oxford: Update Software. 2  Williamson I. (1999). Otitis media with effusion. Clinical Evidence: 2: 206-212. BMJ Publishing, London. 3  Williamson I. (2002) Otitis media with effusion. Clinical Evidence 7: 477-480. BMJ Publishing, London. 4  Cohen H, Friedman EM, Lai D, Pellicer M, Duncan N, Sulek M (1997) Balance in children with otitis media with effusion. Int J Ped Otorhinolaryngol 42, 107-115. 5  Bluestone CD, Gates GA, Klein JO, Lim DJ, Mogi G, Ogra PL, Paparella MM, Paradise J, Tos M. (2002). Definitions, Terminology and Classification of otitis media. In: Lim D (ed). Recent advances in otitis media. Ann Otol Rhinol Laryngol. (supp). 111: 8-18. 6  Effective Health Care Bulletin. No. 4, (1992) The Treatment of Persistent Glue Ear in Children Effective Health Care Bulletin (4), University of Leeds, ISSN: 0965-0288. 7  Haggard M. (2003) MRC randomised trial on surgical treatment of OME (“glue ear”) in children – 50 findings from TARGET and related HSR & epidemiological studies. March 2003. MRC- ESS in Children’s Middle Ear Disease, Cambridge. (Unpublished report).

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