Otitis media with effusion

1
Otitis media with effusion

• Haytham Kubba
• Consultant Paediatric Otolaryngologist
• Yorkhill, Glasgow

2
Middle ear fluid for at least 3 months in the
absence of overt signs of infection
3

• Point prevalence in 2-year-olds
• 20
• Cumulative incidence by age 5
• 80

4

• Transient middle ear effusion (lt3/12)
• After URTI
• After AOM
• OME only of significance if symptomatic
• Hearing impairment
• Speech delay
• Otalgia
• Acute otitis media
• (Mild unsteadiness)

5
Eustachian tube dysfunction?

• Cleft palate?
• Age?
• Downs?

6
Ciliary function?

• PCD
• Tobacco smoke?

7
Biofilm

• Bottle feeding
• Daycare
• Siblings
• Recurrent AOM
• Age?
• Downs?

8
Take-home message 1aetiology

• Its all about bacteria

9

• Otoscopy
• Sensitivity Specificity
• 61 each
• (eg Woodson et al, Pediatrics 2003)
• Pneumatic otoscopy
• Sensitivity 74
• Specificity 79

10

• B sens 81 spec 75
• B/C2 sens 94 spec 62
• (Takata et al Pediatrics 2003 meta analysis)

11
Take-home message 2diagnosis

• (Pneumatic) Otoscopy
• Tympanometry
• Age-appropriate audiometry

12

• Discredited
• Auto-inflation
• Antihistamines
• Mucolytics
• Decongestants
• Steroids
• Antibiotics
• Level 1a evidence

Butler van der Voort, Cochrane 2001 Williams,
JAMA 1993 Rosenfeld, Oto HNS 1992 Reidpath, BMJ
1999
13
Take-home message 3medical treatments

• Waste of time

14
TARGET
controls
Baseline 376 persistent cases randomised
VTs(complete)
Hearing level
Time since randomisation (months)
15

• Hearing benefit
• Lifetime of the grommet only
• QoL benefit
• Cost effective
• Additional benefits for
• Worst hearing
• RAOM

16

• Otorrhoea
• 15-20
• Incidence halved by prophylactic antibiotic
  dropsHochman et al, meta-analysis, OtoHNS 2006

17

• Perforation
• Shepard 2
• Goode T-tube 24Strachan et al, 6yr FU, Clin
  Otol 1996

18

• Tympanosclerosis
• 59 (vs 5 OM VT-)
• Retractions
• 34 age 8 (vs 21 OM VT-)
• 7 age 18 (vs 3 OM VT-)
• de Beer et al, Otol Neurotol 2005

19
Take-home message 4grommets

• Effective in short-term for hearing
• QoL benefit and cost-effectiveness shown
• Be aware of complications
• Trade-off against duration of action

20
TARGET
controls
Baseline 376 persistent cases randomised
VTs(complete)
VTsAd(complete)
Hearing level
Time since randomisation (months)
21

• Hearing benefit
• Sustained at 2 years
• Physical health benefits
• Respiratory symptoms
• Fewer consultations, fewer ops _at_ 7-11 years
  post-op
• QoL benefit substantial
• Cost effective very
• Additional benefits for
• Weight gain in those underweight at outset
• Frequent URTI

22
When to do adenoidectomy?
Fear
23
Suction Diathermy Adenoidectomy
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Take-home message 5adenoidectomy

• Hugely beneficial
• Recurrence of OME
• Hearing at 2 years
• Respiratory health
• QoL
• New techniques can reduce complications

25
Hearing aids?

• Small uncontrolled series suggest acceptibility
• No data on efficacy
• No other evidence
• Perhaps for certain children?

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Clinical decision-making
27

• Surgery (VTs /ads)

• Other indications for surgery?
• Sore throats, OSA, RAOM

-
28

• Surgery (VTs /ads)
• Watchful waiting

• Other indications for surgery?
• Sore throats, OSA, RAOM
• Persistent OME?

-
-

29

• Surgery (VTs /ads)
• Watchful waiting
• Watchful waiting

• Other indications for surgery?
• Sore throats, OSA, RAOM
• Persistent OME?
• Hearing impairment and disability?

-
-

-

30

• Surgery (VTs /ads)
• Watchful waiting
• Watchful waiting
• Ads VTs
• VTs (or HAs?)

• Other indications for surgery?
• Sore throats, OSA, RAOM
• Persistent OME?
• Hearing impairment and disability?
• Nasal symptoms?
• Snoring, rhinorrhoea,hyponasality, URTIs

-
-

-


-
31
-

• Watchful waiting
• Surgery (VTs /ads)
• Watchful waiting
• Ads VTs
• VTs (or HAs)

• Persistent OME?
• Other indications for surgery?
• Sore throats, OSA, RAOM
• Hearing impairment and disability? OM8-30
• Nasal symptoms?
• Snoring, rhinorrhoea,hyponasality, URTIs

-
-


-
32
Treatment in special groups

• PCD
• no grommets
• hearing aids
• Cleft palate
• Selective grommet policy based on hearing
  disability
• Partial adenoidectomy?

33
Down syndrome Grommets?

• Against
• 20 persistent otorrhoea
• Risks of op (heart, c-spine)
• Fatalism

• For
• Compounds existing disabilities
• 80 no infection
• HAs difficult to fit, poorly tolerated

34
School-age children

• Search for underlying cause
• Persistent adenoids
• Allergy