“I think the guidelines present a nice, organized presentation of both certainty and uncertainty, but what often comes through in the guidelines is the illusion of certainty, and that would be a false precision to think that we know enough,” he said, adding that he thinks the guidelines are a bit more aggressive than if they had been developed by pediatricians, who tend to be more cautious in their treatment approach.
Explore This IssueDecember 2013
For example, he cited statement 7, which recommends that children with unilateral or bilateral AOM and MEE at the time of assessment be offered tubes, as providing a stronger recommendation than he feels is warranted by the evidence. “This is a recommendation in the face of weak evidence, particularly since it doesn’t require that middle ear effusions have been present for any length of time at the moment of assessment,” he said, “and we know that middle ear effusions come and go.”
Another action statement or recommendation that he thinks is more aggressive than many pediatricians would prefer is statement 3, which recommends that physicians offer bilateral tube insertion in children with bilateral OME for three months or longer who have documented hearing difficulties. Implicit in this statement, he said, is the assumption, acknowledged by the authors as a value judgment, that optimizing auditory access will improve speech and language outcomes despite inconclusive evidence on the impact of OME on speech and language development. “There is actually pretty good evidence that the use of tympanostomy tubes does not improve developmental outcomes, at least in healthy children,” he said.
Emphasizing that the guidelines are not meant to be comprehensive but offer a good start to providing a more systematic approach to the use of tubes in children, Dr. Derkay mentioned several issues not discussed in the guidelines that are important for the practicing clinician to consider. These include the questions of when to insert a second set of tubes in the many children (one out of five) who will need them, whether an adenoidectomy should be done on all children who need a second set of tubes and how to choose among the many types of tubes available.
“The guidelines are a reasonably good first effort to establish some guidance, but they shouldn’t be interpreted as being the final word on tympanostomy tubes,” he emphasized.