In 1994 a clinical practice guideli...

In 1994 a clinical practice guideline (1) forward the diagnosis and management of otitis media with effusion (OME) was expanded by the Agency for Health Care Policy and Research (now the Agency for Healthcare Research and Quality [AHRQ]). An update (2) to this clinical practice guideline, unraveled by a committee with representatives from the American Academy of Pediatricians (AAP), the American Academy of Family Physicians (AAFP), the American Academy of Otolaryngology--Head & Neck Surgery (AAO-HNS), and other organizations, not long ago was issued. This updated guideline informs clinicians of evidence-based meanss to identify, monitor, and manage OME in children ages sum of two units months through 12 years with or without developmental disabilities or underlying conditions that predispose to OME A summary of this clinical practice guideline appears in this issue of American Family Physician. (3) The 1994 guideline (1) was limited to children ages single in kind to three years with no craniofacial or neurologic abnormalities or sensory deficits.

Recommendations in this practice guideline (2) are based upon the best available published data, primarily the AHRQ report in succession OME from the Southern California Evidence-Based Practice Center (4) end April 2003. Evidence-based statements go in the rear [i]or[/i] in the wake of AAP definitions reflecting both the quality of evidence and the balance of benefit and harm. (5)

Consistent with the 1994 guideline (1) and the AHRQ evidence report, (4) this updated 2004 clinical practice guideline (2) emphasizes making an accurate diagnosis of OME Differentiating OME from acute otitis media (AOM) can avoid unnecessary antimicrobial use. (6)

* Clinicians should use pneumatic otoscopy as the primary diagnostic orderly disposition for distinguishing OME from AOM. [Strong recommendation] Tympanometry may be used to confirm diagnosis of OME [Option]

The updated guideline (2) is distinct from the 1994 guideline (1) in areas relating to risk stratification, management, and monitoring.

* Clinicians should distinguish the child with OME who is at risk for language language, or learning problems from other children with OME and should more promptly evaluate hearing, articulate utterance language, and need for intervention in these at-risk children. [Recommendation]

As defined in this updated guideline, (2) an at-risk child "is at increased risk for developmental difficulties (delay or disorder) because of sensory, physical, cognitive, or behavioral factors" that "make the child les tolerant of hearing los or vestibular question at issues secondary to middle-ear effusion." Evaluation of at-risk children with OME should include hearing testing and evaluation of tongue and language. Repeat hearing testing should be performed after OME deciphers to document improvement, because OME may mask a permanent underlying hearing los and cause a delay in detection.

* Clinicians should manage children with OME who are not at risk with watchful waiting for three month from the date of effusion charge (if known), or from the date of diagnosis (if first brunt is unknown). [Recommendation]

This recommendation is based forward the self-limited nature of mostly cases of OME as documented in cohort studies and in repress groups of randomized trials. (47) About 75 to 90 percent of residual cases of OME after an AOM episode unravel spontaneously within three months, (7) and the three-month period of observation is consistent with avoiding unnecessary intervention or surgery (1) At the discretion of the clinician, watchful waiting may include interval examinations.

* Hearing testing should be course of lifeed when OME persists for three month or longer or at any time that language delay, learning vexed questions or a significant hearing los is suspected in a child with OME [Recommendation]

Hearing testing for children aged four years or older can be done in a quiet area of the physician's office. Conventional audiometry with earphones is performed with a fail criterion of greater than 20 decibels (dB) hearing los at single in kind or more frequencies (500; 1000; 2000; 4000 Hz) in either ear. Comprehensive audiologic evaluation is indicated for children who fail office testing, are younger than four years of age, or cannot be proofed in the primary care setting. Language testing should be deportment ed for children with hearing los greater than 20 dB upon comprehensive audio-metric evaluation.

* Children with persistent OME who are not at risk should be re-examined at three- to six-month intervals until the effusion clears, significant hearing los is identified, or structural abnormalities of the eardrum or middle ear are suspected. [Recommendation]

If OME is asymptomatic and likely to unfold spontaneously, intervention is unnecessary level if OME persists for more than three month In contrast, the 1994 OME guideline (1) approveed surgery for OME persisting four to six month with hearing los greater than 20 dB The present updated guideline (2) recommends surgery if a bilateral hearing los of 40 dB or greater persists; otherwise, the decision to prosecute surgery should be individualized. As in extent as OME persists, the child should be evaluated periodically for hearing los or structural abnormality to determine the ne for intervention.