Surveillance decision

Surveillance decision

We will update the whole guideline on otitis media with effusion in under 12s.

The following table gives an overview of how evidence identified in surveillance might affect each area of the guideline, including any proposed new areas.

Section of the guideline

New evidence identified

Impact

1.1 Clinical presentation

No

No

1.2 Diagnosis of otitis media with effusion (OME)

No

No

1.3 Appropriate time for intervention

No

No

1.4 Children who will benefit from surgical intervention

Yes

No

1.5 Surgical interventions

Yes

Yes

1.6 Non-surgical interventions

Yes

Yes

1.7 Management of OME in children with Down's syndrome

No

No

1.8 Management of OME in children with cleft palate

No

No

1.9 Information for children, parents and carers

Yes

Yes

Proposed new areas

Intraoperative care

Yes

Yes

Post-operative care

Yes

Yes

Reasons for the decision

This section provides a summary of the areas that will be updated and the reasons for the decision to update.

For some sections of the guideline there was either no new evidence identified or the evidence supported current recommendations. However, because new evidence impacts on a high proportion of the guideline and it has not been updated for over 10 years, we are proposing a full update.

Surgical interventions

New evidence was identified that is relevant to recommendation 1.5.1 which states 'Once a decision has been taken to offer surgical intervention for OME in children, the insertion of ventilation tubes is recommended. Adjuvant adenoidectomy is not recommended in the absence of persistent and/or frequent upper respiratory tract symptoms.' The new evidence shows a significant benefit of adenoidectomy in combination with a unilateral ventilation tube on the resolution of OME in children aged 4 years and older who have recurrent OME, although the effect on hearing may be small (van den Aardweg et al. 2010 and Simon et al. 2018). The evidence does not therefore support the recommendation that adenoidectomy should only be undertaken in children with OME who also have frequent upper respiratory tract symptoms. This new evidence should be considered for a potential impact on recommendation 1.5.1.

Non-surgical interventions

Recommendation 1.6.1 recommends that antibiotics should not be used in the management of OME. While this viewpoint is supported by the International consensus (ICON) on management of OME in children (Simon et al. 2018), a Cochrane review which assessed the benefits and harms of oral antibiotics in children, reported that oral antibiotics significantly increased the chance of complete resolution of OME when compared with any control treatment, which included placebo, no treatment or 'therapy of unproven effectiveness' (Venekamp et al. 2016). The impact of antibiotics on hearing was uncertain and antibiotic use was associated with significantly more incidents of diarrhoea, vomiting or skin rash. While OME often clears up on its own within 3 months and there are concerns about side-effects from antibiotic use and the emergence of antimicrobial resistance, this new evidence should be considered for a potential impact on recommendation 1.6.1.

Recommendation 1.6.2 advises that, 'Autoinflation may be considered during the active observation period for children with OME who are likely to cooperate with the procedure.' New evidence indicates that autoinflation is effective at resolving OME, low cost, not associated with adverse events and may be used in children as young as 2 years old (Perera et al. 2013 and Simon et al. 2018). Therefore, there appears to be evidence to support the use of autoinflation which suggests that the recommendation for its use could be strengthened to 'offer autoinflation'.

Information for children, parents and carers

Recommendations 1.9 provides a general recommendation that parents, children and carers should be given information on OME and have opportunity to discuss the condition. However there is no advice on the specific content and details of this information. All the evidence identified in the surveillance review should be considered for how it impacts on parents'/carers' decisions and therefore what information they should receive about different non-surgical and surgical options' appropriateness, risks, benefits and expected outcomes. For example, while the guideline recommends that ventilation tubes should be offered once a decision has been taken to offer surgical intervention for OME in children (recommendation 1.5.1), recommendations do not reflect the evidence identified in the surveillance review that ventilation tubes benefit hearing loss when they are in place, but do not appear to have a long-term beneficial effect on hearing following ventilation tube extrusion (Browning et al. 2010 and Simon et al. 2018). Children who present with recurrent hearing loss after a first tube extrusion may therefore require further surgical intervention (Simon et al. 2018). This is information that parents and carers may want to consider prior to any surgical intervention.

New areas

Intraoperative care

Although the current guideline makes recommendations around surgery, it does not advise on intraoperative care. Evidence suggests that a number of approaches are effective at reducing the rate of otorrhoea (ear discharge) up to 2 weeks following surgery. These include multiple saline washouts at surgery, a single application of topical antibiotic and/or corticosteroid drops at surgery, a prolonged application of topical antibiotic eardrops, antibiotic and/or corticosteroid eardrops or aminoglycoside and/or corticosteroid eardrops, or a prolonged application of oral antibacterial agents and/or corticosteroids (Syed et al. 2013). Recommendations in this area would support healthcare professionals and should be considered in the update of the guideline.

Post-operative care

Similarly, the current guideline does not advise on post-operative care. For children with ear discharge occurring at least 2 weeks after ventilation tube insertion, there is evidence that antibiotic eardrops (with or without corticosteroid) are more effective than oral antibiotics, corticosteroid eardrops and no treatment (Venekamp et al. 2016). There was also some limited, inconclusive evidence that antibiotic eardrops are more effective than saline rinsing; and there was uncertainty concerning whether antibiotic-corticosteroid eardrops are more effective than eardrops containing antibiotics only. Another Cochrane review assessed the effectiveness of water precautions (actions to ensure ears are kept dry) for the prevention of ear infections in children with ventilation tubes at any time while the tubes are in place (Moualed et al. 2016). It reported that while there was 'some evidence to suggest that wearing ear plugs (when swimming or bathing) reduces the rate of otorrhoea in children with ventilation tubes, clinicians and parents should understand that the absolute reduction in the number of episodes of otorrhoea appears to be very small and is unlikely to be clinically significant.' They also noted that consensus guidelines 'recommend against the routine use of water precautions on the basis that the limited clinical benefit is outweighed by the associated cost, inconvenience and anxiety'. Recommendations in this area should be considered in the update of the guideline as they would support healthcare professionals, parents, carers and children.


This page was last updated: 12 December 2018