Transcript Management of Otitis Media with Effusion (OME) in primary care

Management of Otitis Media with
Effusion (OME) in primary care
Kifayat Ullah
Core Surgical Trainee East of England
Deanery
Objectives
1. Background and prevalence of OME
2. Distinguishing OME from AOM
3. Risk factors of OME
4. Audit on OME management
5. Conclusion
Background
• OME or “glue ear” commonest cause of
childhood hearing impairment
• Inflammation of middle ear with collection of
liquid in middle ear space
• Peak 2-6 years of age
• 85% of children experience fluid in ears
following infection
• 50% resolve within 3 months
Prevalence of OME
• 1993 - 1995 (NCHS),2 OM accounted for
 18% ambulatory visits (1-4 yr)
 14% visits during the 1st yr of life
• OME episodes diagnosed2
 81% in pediatric practices
 13% in hospital ED
 6% in hospital outpatient departments
Distinguishing OME from AOM
At least two of :
1. Abnormal color: white, yellow,
amber, blue
2. Opacification not due to scarring
3. Decreased or absent mobility
Yes
Or
Bubbles or air-fluid interfaces
behind the TM
Acute purulent otorrhea
not due to otitis externa
Yes
Middle Ear Effusion
(MEE)
No Acute
Inflammation
Acute
Inflammation
1. Distinct fullness or bulging of the TM
2. Substantial ear pain, including
unaccustomed tugging or rubbing of
the ear
3. Distinct erythema of the TM
Yes
Otitis Media with Effusion
(OME)
Acute Otitis Media
(AOM)
Yes
Risk factors of OME
• Host factors




Age/Gender
Genetic predisposition
Cleft palate/Down syndrome
Allergy/Immunity
• Environmental factors






Daycare/Siblings
Bottle (versus breast) feeding
Pacifier use
Smoking
Low socioeconomic status
Season/Upper respiratory infections
Why do this audit?
Unnecessary
visits to ENT
clinic
Parents
frustration
why symptoms
have not
resolved
OME management not
understood in
community
Audit
• Prospective study run in ENT outpatient clinic
at Tunbridge Wells Hospital, Kent
• 250 children aged between 2 and 10 years of
age referred from primary care
• Data collected prospectively in the form of a
questionnaire
• New referrals recruited over 12 month period
Main standards in audit
Referral orientation for primary care
Where OME is strongly suspected to have occurred irrespective of a known
ear infection or to have continued for more than 1 month refer:
•
Under 4 years of age:
To the second tier community audiology clinic for hearing assessment.
Subject to resources and efficiency of booking, this is usually the
most direct route to valid audiometry.
•
Over four years of age:
To children’s ENT clinic for hearing assessment
Watchful waiting is the initial management, unless there are overriding
concerns about hearing, speech or language development accompanying
an established history, or unless this has already occurred as set out
above.
Questionnaire: Initial referrals and management of
OME
Results
Age
Female
24%
6-10
16%
Gender
Male
76%
2-5
84%
Results
> 4 weeks
14%
Duration of symptoms
86%
< 4 weeks
0% 20% 40% 60% 80% 100%
8%
Recent ear infection
92%
0%
20%
40%
60%
80%
8%
OME episode
92%
0%
20%
40%
60%
80% 100%
Yes
No
100%
> 1episode
1 episode
Results
• No hearing test in community
• All children reviewed developed conductive
hearing loss
• Tympanograms = type B in 90% of children
• True OME in 90% of children examined
• 10% of children have had recent AOM
• 10% delay in development of speech
Discussion
• Most children managed in community not
managed according to guidelines
• OME management not understood to indicate
an optimal strategy
• Concern regarding hearing test where none of
the children had this performed prior to ENT
visit
Discussion
• OME huge impact on speech development
and educational performance
• 30% of children had delay in speech and
development
• Treatment for OME should initially start with
‘watchful waiting’ – 64% children started on
decongestants/antihistamines/antibiotics
Changes made
• Standards had not been met mainly due to
lack of knowledge in management of OME
• Following action plan:
Presentation at GP trainee teaching sessions
 Leaflet and poster distribution to GP clinics
 Develop a checklist for GP doctors in community when
assessing children with possible OME
• Currently – action plans have been
implemented and re-audit is currently active
Conclusion
• Audit indicates OME management needs
appropriate decision making
• Concerns raised regarding audiology services
in the community
• After a watchful waiting period- refer to ENT
clinic if no improvement for further
management
References
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Audit Commission access to care 2002
http://www.audit-commission.gov.uk/reports/accessible.asp?ProdID=D4361C80-E5CB-11d6- B1E10060085F8572
Accessed 13/12/06
1 Lous J, Burton MJ, Felding JU, Oveson T, Wake M, Williamson IG. Grommets (ventilation tubes)
for hearing loss associated with otitis media with effusion in children. (Cochrane Review). In: The
Cochrane Library, Issue 4,2002. Oxford: Update Software.
2 Williamson I. (1999). Otitis media with effusion. Clinical Evidence: 2: 206-212. BMJ Publishing,
London.
3 Williamson I. (2002) Otitis media with effusion. Clinical Evidence 7: 477-480. BMJ Publishing,
London.
4 Cohen H, Friedman EM, Lai D, Pellicer M, Duncan N, Sulek M (1997)
Balance in children with otitis media with effusion. Int J Ped Otorhinolaryngol 42, 107-115.
5 Bluestone CD, Gates GA, Klein JO, Lim DJ, Mogi G, Ogra PL, Paparella MM, Paradise J, Tos M.
(2002). Definitions, Terminology and Classification of otitis media. In: Lim D (ed). Recent advances
in otitis media. Ann Otol Rhinol Laryngol. (supp). 111: 8-18.
6 Effective Health Care Bulletin. No. 4, (1992)
The Treatment of Persistent Glue Ear in Children Effective Health Care Bulletin (4), University of
Leeds, ISSN: 0965-0288.
7 Haggard M. (2003) MRC randomised trial on surgical treatment of OME (“glue ear”) in children –
50 findings from TARGET and related HSR & epidemiological studies. March 2003. MRC- ESS in
Children’s Middle Ear Disease, Cambridge. (Unpublished report).
Questions?