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CME

Chronic Otitis Media Outcomes May Be Better With Medical Vs Surgical Treatment

  • Authors: News Author: Laurie Barclay, MD
    CME Author: Penny Murata, MD
  • CME Released: 12/16/2005
  • THIS ACTIVITY HAS EXPIRED
  • Valid for credit through: 12/16/2006
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Target Audience and Goal Statement

This article is intended for primary care clinicians, pediatricians, otolaryngologists, pediatric infectious disease physicians, and other specialists who treat children with OME.

The goal of this activity is to provide medical news to primary care clinicians and other healthcare professionals in order to enhance patient care.

Upon completion of this activity, participants will be able to:

  • Describe the long-term effects of VT insertion on TM pathologic abnormalities in children with OME.
  • Describe the long-term effects of VT insertion on hearing thresholds in children with OME.


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Medscape encourages Authors to identify investigational products or off-label uses of products regulated by the US Food and Drug Administration, at first mention and where appropriate in the content.


Author(s)

  • Laurie Barclay, MD

    Laurie Barclay is a freelance reviewer and writer for Medscape.

    Disclosures

    Disclosure: Laurie Barclay, MD, has disclosed no relevant financial relationships.

Reviewer(s)

  • Gary Vogin, MD

    Senior Medical Editor, Medscape

    Disclosures

    Disclosure: Gary Vogin, MD, has disclosed no relevant financial relationships.

CME Author(s)

  • Penny Murata, MD

     

    Penny Murata, MD
    is a freelancer for Medscape.

    Disclosures

    Disclosure: Penny Murata, MD, has disclosed no relevant financial relationships.


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CME

Chronic Otitis Media Outcomes May Be Better With Medical Vs Surgical Treatment

Authors: News Author: Laurie Barclay, MD CME Author: Penny Murata, MDFaculty and Disclosures
THIS ACTIVITY HAS EXPIRED

CME Released: 12/16/2005

Valid for credit through: 12/16/2006

processing....

Dec. 16, 2005 — In healthy children with chronic otitis media with effusion (OME) who were candidates for ventilation tube (VT) insertion, long-term outcomes were better with medical treatment than with VT insertion, according to the results of a randomized study reported in the December issue of the Archives of Pediatrics & Adolescent Medicine. The editorialist agrees and suggests that current guidelines are confusing, but that medical treatment is appropriate for mild hearing loss (HL) associated with chronic OME.

"As many as 700,000 children undergo myringotomy and insertion of VTs for the treatment of chronic and recurrent OME annually in the United States," write Robert Stenstrom, MD, PhD, from St. Paul's Hospital in Vancouver, British Columbia, and colleagues. "Controversy surrounds VT utility for treatment of recurrent and chronic OME with regard to effectiveness and long-term sequelae. Studies have reported a several-fold increase in long-term risk of tympanic membrane (TM) pathologic abnormalities (scarring, perforation, and atelectasis) in children treated with VTs compared with medical management for OME."

In this prospective cohort study at the otorhinolaryngology and audiology service of a tertiary care children's hospital, 125 patients participated in a randomized controlled trial (RCT) of medical vs VT treatment for recurrent OME at ages 2.5 to 7 years.

Of these 125 children, 113 (90.4%) underwent blinded audiometric, tympanometric, otomicroscopic, and parental questionnaire evaluation 6 to 10 years after the trial, when they were aged 8 to 16 years. Of 56 subjects randomized to medical treatment, 30 (54%) ultimately received VTs and 18 (32%) of 57 children in the VT group received more than 1 set of tubes. To evaluate the risk for sequelae associated with VTs independent of disease severity, the investigators compared 27 medical subjects who never received VTs and 38 subjects randomized to VT who only received 1 set of tubes.

Pathologic abnormalities of the TM were detected in 81% of VT subjects and in 19% of medical subjects (relative risk [RR], 4.4; 95% confidence interval [CI], 2.2 - 9.9). Compared with the medically treated subjects, those treated with VT had hearing thresholds 2.1 to 8.1 dB higher (P = .005).

"In children who were candidates for VT insertion randomly assigned to receive medical or VT treatment for OME, elevated hearing thresholds and TM pathologic abnormalities were more common in VT subjects 6 to 10 years after insertion," the authors write. "We did not identify any other risk factors for the development of TM pathologic abnormalities other than treatment with VTs."

Study limitations include possible postrandomization selection bias; limited number of subjects included in the analyses; questionable generalizability; some VTs removed 10 to 14 months after insertion; 12 subjects lost to follow-up; and failure to assess the reliability and validity of parental reports of school performance.

"More rigorous criteria for the selection of children receiving VTs for the treatment of chronic OME should be adopted," the authors conclude.

One of the authors has disclosed that he or she was supported by a doctoral research fellowship from Health Canada, Ottawa, Ontario.

In an accompanying editorial, Stephen Berman, MD, from the Children's Hospital in Denver, Colo, suggest that these sequelae of VT insertion are additive to age-related sensorineural HL and noise-induced HL, and that they can have an adverse effect in later life. Dr. Berman also suggests that the American Academy of Pediatrics revised clinical practice guideline on OME published in May 2004 is somewhat confusing.

The surgery section of the practice guideline recommends surgical VT placement for "'OME lasting 4 months or longer with persistent HL or other signs and symptoms, recurrent or persistent OME in children at risk regardless of hearing status, and OME and structural damage to the tympanic membrane.'" The surveillance section states that "For otherwise normal, asymptomatic children with OME associated with hearing thresholds of less than 40 dB, ... 'watchful waiting' without surgical procedures, with 3- to 6-month reassessments to check for symptoms, hearing, and the development of TM pathologic abnormalities." Dr. Berman writes, "I wonder how many other pediatricians were as confused by the guideline's surgery section as I was and will continue to refer otherwise normal, asymptomatic children with 4 months of OME associated with mild hearing loss with thresholds less than 40 dB for VT surgical procedures? Perhaps the next revision of the OME guideline will be clearer — the third time may be the charm to make the guideline clear to everyone."

Arch Pediatr Adolesc Med. 2005;159:1151-1156, 1183-1185