C Y N T H I A H A Y E S , P G Y - 5S E P T E M B E R 1 3 , 2 0 1 5

IMPLEMENTATION OF GUIDELINES FOR

TYMPANOSTOMY TUBES IN CHILDREN

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.

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).

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.

RESULTS

0102030405060708090

100

Gender Years of practice Focus of practice

Characterisitcs of Osteopathic ENT Physicains Surveyed

Reference Number

Survey Questions Survey Responses (Response #/38)

Never Sometimes

Most of the time

Always

4 If a child presents with acute uncomplicated tympanostomy tube otorrhea how often do you only prescribe topical antibiotics? (Strong Recommendation)

5.3% 2.8% 23.7% 68.4%

5 How often do you obtain an age-appropriate hearing test if otitis media with effusion (OME) persists for 3 months of longer?

2.6% 15.8% 15.8% 65.8%

6 How often do you obtain an age-appropriate hearing test prior to surgery when a child becomes a candidate for tympanostomy tube?

2.6% 23.7% 18.4% 55.3%

7 How often do you recommend bilateral tympanostomy tube insertion if a child has OME for 3 months of longer and documented hearing difficulties?

0% 0% 47.4% 52.6%

Reference Number

Survey Questions Survey Responses (Response #/38)Never Somet

imesMost of the time

Always

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?

0% 7.9% 42.1% 50%

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?

5.3% 52.6% 26.3% 15.8%

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?

0% 28.9% 44.7% 26.3%

Reference Number

Survey Questions Survey Responses (Response #/38)

Never Sometimes

Most of the time

Always

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?

0% 2.6% 34.2% 63.2%

12 How often do you counsel caregivers on the duration of tube function, recommended follow up schedule and detection of complications?

0% 0% 7.9% 92.1%

13 How often do you counsel caregivers on prophylactic water precautions for children with tympanostomy tubes?

2.6% 13.2% 10.5% 73.7%

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.

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.

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):324-330.

• Wilcox L, Darrow D. Should Water Precautions Be Recommended for Children With Tympanostomy Tubes. Laryngoscope. 2013; 124: 10-11.

• 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.

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.

THANK YOU.

• Any questions?

REFERENCES

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S118.• Pichichero ME. Acute otitis media: part I. Improving diagnostic accuracy. Am Fam Physician. 2000; 61(7):2051-2056.• Gebhart DE. Tympanostomy tubes in the otitis media prone child. Laryngoscope. 1981; 91(6):849-866.• Rosenfeld RM, Kay D. Natural history of untreated otitis media. Laryngoscope. 2003; 113(10):1645-1657.• Goldenstein NA, Mandel EM, Kurs-Lasky M, Rockette HE, Casselbrant ML. Water precautions and tympanostomy tubes: a randomized, controlled trial.

Laryngoscope. 2005; 115(2):324-330.• Giannoni C. Swimming with tympanostomy tubes. Arch Otolaryngol Head and Neck Surg. 2000; 126(12):1507-1508.• Wilcox L, Darrow D. Should Water Precautions Be Recommended for Children With Tympanostomy Tubes. Laryngoscope. 2013; 124: 10-11.