“If the effusion hasn’t been present for three months and the child is otherwise healthy, tubes are probably not a good idea,” said Lawrence Kleinman, MD, MPH, associate professor of pediatrics and health evidence and policy at the Mount Sinai Medical Center, New York, N.Y. “I think this is a very important take home message for physicians and parents.”
Explore This IssueDecember 2013
Dr. Tunkel said that this action statement addresses what some have seen as the overuse of tympanostomy tubes, and provides better guidance on the use of tympanostomy tubes in children with OME of short duration.
For Craig Derkay, MD, FACS, FAAP, director of pediatric otolaryngology at Children’s Hospital of the King’s Daughters in Norfolk, Va., the recommendation illustrates a truism of guidelines: that they are helpful for making clinical decisions for the vast majority of children who present with these problems, but that clinical judgment is always necessary to take into account patient factors that may result in practicing outside the guidelines.
He cited the example of a child with persistent middle ear effusions (MEE) in both ears for nine weeks who is scheduled to undergo general anesthesia for a hernia repair operation. The child is in daycare and has a brother who has had ear tubes inserted twice. The family lives in the northeast, and it is December, with the bulk of the winter season still ahead. “Based on this child’s family history and risk factors, it is not likely that the fluid will go away in the next few weeks, and it raises the question about whether you want to have the child undergo two general anesthetics in one winter,” he said. “The guidelines suggest that we wait until the effusion lasts up to 12 weeks, but it seems that the best advice would be to place the tubes during the procedure for hernia repair.”
Action statements highlighted by the authors as likely to generate the most discussion are statements 6 and 7 on recurrent acute otitis media (AOM). “We have distinguished for the first time between recurrent AOM with and without persistent MEE, with tubes indicated only when the effusion persists,” said the authors, who went on to emphasize the importance of education to justify not recommending tubes in a child with recurrent AOM but with no MEE, who will not benefit from tubes according to the evidence.
A Move in the Right Direction, but More Research Needed
Saying that the guidelines move the field forward in extrapolating the current evidence on tympanostomy tubes into meaningful recommendations, Dr. Kleinman also emphasized the work that still needs to be done to clarify issues that remain ambiguous regarding optimal use of tubes.