IMPLEMENTATION OF GUIDELINES FOR TYMPANOSTOMY TUBES IN CHILDREN CYNTHIA HAYES, PGY-5 SEPTEMBER 13, 2015

Transcription

1 IMPLEMENTATION OF GUIDELINES FOR TYMPANOSTOMY TUBES IN CHILDREN CYNTHIA HAYES, PGY-5 SEPTEMBER 13, 2015

2 TYMPANOSTOMY TUBES IN CHILDREN 20% of all ambulatory surgeries. Approximately 667,000 children receive tympanostomy tubes each year. 1.8 billon in healthcare dollars. Children have a higher incidence of otitis media due to poor functioning Eustachian tubes. 40% of children have experience at least three episodes of acute otitis media (AOM) by age 2. At any one time 20% of school-aged children are afflicted by middle ear effusion (MEE). One study demonstrated that tympanostomy tubes Reduce incidence of MEE by 32%. Improved average hearing levels by 5-12dB.

3 AAO-HNS GUIDELINES July 2013 Evidence-based guidelines- indications and care of tympanostomy tubes. Strong Recommendations (1) Recommendations (9) Optional (2) Prior to this no clinical guidelines in the US. Patients aged 6 months to 12 years. Exclusion Retraction-type ear disease. Complications of AOM. Medication administered to middle ear (ie-snhl).

4 STUDY Fourteen question survey created using Survey Monkey. Demographics. Gender, focus of practice, and years of clinical practice. Strong Recommendation and Recommendation. Approved by the Institutional Review Board (IRB) May 2014-Survey created and distributed at AOCOO-HNS annual meeting in Scottsdale, AZ. Thirty-eight of the fifty surveys were collected. Completion rate 78% Data analyzed in Excel spreadsheet. No p-values were calculated due to the small sample size.

5 RESULTS Characterisitcs of Osteopathic ENT Physicains Surveyed Gender Years of practice Focus of practice

6 Referenc e Number Survey Questions 4 If a child presents with acute uncomplicated tympanostomy tube otorrhea how often do you only prescribe topical antibiotics? (Strong Recommendation) 5 How often do you obtain an ageappropriate hearing test if otitis media with effusion (OME) persists for 3 months of longer? 6 How often do you obtain an ageappropriate hearing test prior to surgery when a child becomes a candidate for tympanostomy tube? 7 How often do you recommend bilateral tympanostomy tube insertion if a child has OME for 3 months of longer and documented hearing difficulties? Survey Responses (Response #/38) Never Somet imes Most of the time Alway s 5.3% 2.8% 23.7% 68.4% 2.6% 15.8% 15.8% 65.8% 2.6% 23.7% 18.4% 55.3% 0% 0% 47.4% 52.6%

7 Referenc e Number Survey Questions 8 How often do you reevaluate a child with OME at 3 to 6 months intervals until the effusion has resolved, significant hearing loss is detected or structural abnormalities of tympanic membrane or middle ear is suspected? 9 How often do you counsel against tympanostomy tube insertion in children with recurrent acute otitis media who do not have middle ear effusion at time of assessment? 10 How often do you recommend tympanostomy tube insertion in children with recurrent acute otitis media who have middle ear effusion at the time of assessment? Survey Responses (Response #/38) Never Somet imes Most of the time Alway s 0% 7.9% 42.1% 50% 5.3% 52.6% 26.3% 15.8% 0% 28.9% 44.7% 26.3%

8 Referenc e Number Survey Questions 11 How often do you recommend tympanostomy tube insertion in at-risk children with OME that is unlikely to resolve documented by a type B tympanogram or effusion greater than 3 months? 12 How often do you counsel caregivers on the duration of tube function, recommended follow up schedule and detection of complications? 13 How often do you counsel caregivers on prophylactic water precautions for children with tympanostomy tubes? Survey Responses (Response #/38) Never Somet imes Most of the time Alway s 0% 2.6% 34.2% 63.2% 0% 0% 7.9% 92.1% 2.6% 13.2% 10.5% 73.7%

9 DISCUSSION Frequencies were calculated if focus of practice or years practicing has any effect on guidelines. Neither factors played a difference in results. Overwhelmingly physicians surveyed are following AAO-HNS tympanostomy tube guidelines. However, 60.5% of physicians responded that the guidelines have not changed how they practice of manage their patients.

10 DISCUSSION However, according to this study there are two recommendations physicians are not following. Advise against tympanostomy tubes in the setting of AOM without evidence of OME. AOM can be difficult to diagnosis. Majority of parents describe nonspecific symptoms such as fever and otalgia. Physical exam can be hampered by crying child or cerumen leading a false sense of erythematous tympanic membrane. Residual middle ear effusion aids in diagnosis or confirmation of AOM and Eustachian tube dysfunction. Predispose a child to further infections.

11 DISCUSSION Against counseling on water precautions. Goldenstein NA, Mandel EM, Kurs-Lasky M, Rockette HE, Casselbrant ML. Water precautions and tympanostomy tubes: a randomized, controlled trial. Laryngoscope. 2005; 115(2): Wilcox L, Darrow D. Should Water Precautions Be Recommended for Children With Tympanostomy Tubes. Laryngoscope. 2013; 124: Showed little clinical benefit for use of plugs. No significant data to show enough pressure is present to allow water into the middle ear space in swimming at the surface. Considerable effort by caregivers to limit water exposure. Exception is children with persistent tube otorrhea from P. aeruginosa or immune dysfunction.

12 IN SUMMARY Physicians surveyed are following the guidelines. Two recommendations that physicians are not following. Recommend against tympanostomy tube insertion in children with recurrent acute otitis media who do not have middle ear effusion at the time of assessment. Recommend against counseling caregivers on prophylactic water precautions for children with tympanostomy tubes.

13 THANK YOU. Any questions?

14 REFERENCES Rosenfeld RM, Shwartz SR, Pynnonen MA. Clinical Practice Guideline: Tympanostomy Tubes in Children. Otolaryngology-Head and Neck Surgery. 2013; 149(IS)S1-S35. Cullen KA, Hall MJ, Golosinskiy A. Ambulatory surgery in the United States, Natl Health Stat Report. 2009; (11):1-25. Rosenfeld RM, Jang DW, Tarashansky K. Tympanostomy tube outcomes in children at-risk and not at-risk for developemental delays. Int J Pediatr Otorhinolaryngol. 2011;75(2): Rovers MM, Black N, Browning GG, Maw R, Zielhuis GA, Haggard MP. Grommets in otitis media with effusions: an individual patient date meta-analysis. Arch Dis Child. 2005; 90(5): Weigel MT, Parker MY, Goldsmith MM, Postma DS, Pillsbury HC. A prospective randomized study of four commonly used tympanostomy tubes. Laryngoscope. 1989; 99(3): Kay DJ. Nelson M, Rosenfeld RM. Meta-analysis of tympanostomy tube sequelae. Otoaryngol. Head Neck Surg. 2001; 124(4): Dohar J, Giles W, Roland P. Topical ciprofloxacin/dexamethasone superior to oral amoxicillin/clavulanic acid in acute otitis media with otorrhea through tympanostomy tube. Pediatrics. 2006; 118(3):e561-e569. Goldblatt EL, Dohar J, Nozza RJ. Topical ofloxacin versus systemic amoxicillin/clavulanate in purulent otorrhea in children with tympanostomy tubes. Int J Pediatr Otorhinolaryngol. 1998; 46(1-2): Heslop A, Lildholdt T, Gammelgaard N, Ovesen T. Topical ciprofloxacin is superior to topical saline and systemic antibiotics in the treatment of tympanostomy tube otorrhea in children: the results of a randomized clinical trial. Laryngoscope. 2010; 120(12): Gravel JS. Hearing and auditory function. In: Rosenfeld RM, Bluestone CD, eds. Evidence-based Otitis Media. 2 nd ed. Hamilton, Ontario, Canda: BC Decker; 2003: Fria TJ, Canetkin El. Eichler JA. Hearing acuity of children with otitis media with effusion in young children: guideline overview. Agency for Health Care Policy and Research, Rockville, Maryland. J Natl Med Assoc. 1994; 86 (10): , Timmerman AA, Meesters CM, Anteunis LJ, Chenault MN, Haggard MP. Psychometric evaluation of the OM8-30 questionaire in Dutch children with otitis media. Eur Arch Otorhinoloaryngol. 2008; 265(9): Rosenfeld RM, Culpepper L, Doyle KJ, et al. Clinical practice guideline: otitis media with effusion. Otolaryngol Head and Neck Surg. 2004; 130(5suppl):S9- S118. Pichichero ME. Acute otitis media: part I. Improving diagnostic accuracy. Am Fam Physician. 2000; 61(7): Gebhart DE. Tympanostomy tubes in the otitis media prone child. Laryngoscope. 1981; 91(6): Rosenfeld RM, Kay D. Natural history of untreated otitis media. Laryngoscope. 2003; 113(10): Goldenstein NA, Mandel EM, Kurs-Lasky M, Rockette HE, Casselbrant ML. Water precautions and tympanostomy tubes: a randomized, controlled trial. Laryngoscope. 2005; 115(2): Giannoni C. Swimming with tympanostomy tubes. Arch Otolaryngol Head and Neck Surg. 2000; 126(12): Wilcox L, Darrow D. Should Water Precautions Be Recommended for Children With Tympanostomy Tubes. Laryngoscope. 2013; 124: