Review article
Danish guidelines on management of otitis media in preschool children

https://doi.org/10.1016/j.ijporl.2016.06.003Get rights and content

Abstract

Introduction

Otitis media is one of the most common diseases in small children. This underlines the importance of optimizing diagnostics and treatment of the condition. Recent literature points toward a stricter approach to diagnosing acute otitis media (AOM). Moreover, ventilating tube treatment for recurrent AOM (RAOM) and chronic otitis media with effusion (COME) has become the most frequently performed surgical procedure in pre-school children. Therefore, the Danish Health and Medicines Authority and the Danish Society of Otorhinolaryngology, Head and Neck Surgery deemed it necessary to update the Danish guidelines regarding the diagnostic criteria for acute otitis media and surgical treatment of RAOM and COME.

Methods

The GRADE system (The Grading of Recommendations Assessment, Development and Evaluation) was used in order to comply with current standards of evidence assessment in formulation of recommendations. An extensive literature search was conducted between July and December 2014. The quality of the existing literature was assessed using AGREE II (Appraisal of Guidelines for Research & Evaluation), AMSTAR (assessing the Methodological Quality of Systematic Reviews), QUADAS-2 (Quality of Diagnostic Accuracy Studies), Cochrane Risk of Bias Tool for randomized trials and ACROBAT-NRSI (A Cochrane Risk of Bias Assessment Tool for Non-Randomized Studies). The working group consisted of otolaryngologists, general practitioners, pediatricians, microbiologists and epidemiologists.

Conclusion

Recommendations for AOM diagnosis, surgical management for RAOM and COME, including the role of adenoidectomy and treatment of ventilating tube otorrhea, are proposed in the guideline.

Introduction

Otitis media (OM) is a very common childhood condition and despite it's often self-limiting nature, it is the leading cause of doctor consultations for pre-school children [1]. Results of a recently published study show that more than 60% of Danish children experience episodes of OM [2]. This underlines the importance of optimizing diagnosis and treatment.

OM is often divided in two major diagnostic subgroups; acute otitis media (AOM) and otitis media with effusion (OME). AOM is characterized by middle ear effusion (MEE) and acute onset of signs and symptoms of middle ear inflammation such as fever, otalgia, possible otorrhea and discomfort that may result in interference with or precludes normal activity or sleep [3]. The prevalence of AOM peaks among children aged 6–18 months [2]. Some children will experience recurrent episodes of AOM (RAOM). RAOM is defined by three or more episodes of AOM in six months or four or more episodes of AOM in 12 months. Many children may experience symptoms of AOM without the presence of MEE. This condition is often referred to as otitis simplex (OS) and is often self-limiting, but may also be a precursor to AOM or OME. OME on the other hand, is defined as MEE without signs or symptoms of acute ear infection. Disease severity of OME ranges from no symptoms to lowered activity level and sleep disturbances or even significant hearing loss and speech impairment. OME that persists for a minimum of three months is referred to as chronic OME (COME) [4]. These diseases are recognized as continuums.

In order to limit false positive diagnosis and unnecessary treatment, recently published international guidelines point toward a stricter diagnosis of AOM. In Denmark the total use of antibiotics has increased by 20% from 2004 to 2013. At the same time, Denmark is experiencing an increase in resistant bacteria (DANMAP reports - www.danmap.org). In the same period ventilating tube treatment (VT) for RAOM and/or COME has become the most common surgical procedure in the western world. With a VT frequency of 250 pr. 10.000 children, Denmark has one of the highest frequencies in the world [2]. Moreover, some regional differences are present [5]. The Danish guideline for VT in children with COME has not been updated since 1987, and until now no Danish guideline on surgical management for children with RAOM has existed. Therefore, the Danish Health and Medicines Authority (DHMA) and the Danish Society of Otorhinolaryngology, Head and Neck Surgery deemed it necessary to update the Danish guidelines regarding the diagnostic criteria for acute otitis media and surgical treatment of RAOM and COME.

Otherwise healthy children aged 0–5 years with AOM/RAOM or COME were defined as our target population. Children with e.g. syndrome diseases (e.g. Downs syndrome or cleft-lip-palate), neurological diseases, diseases of the immune system or diseases of the cardio-pulmonary system are not covered by this guideline.

The primary purpose of this guideline is to provide clinicians, especially in primary health care, with recommendations on selected focus areas within diagnosis of AOM and surgical treatment of RAOM and COME, and to provide clinicians with an overview of the current scientific evidence these recommendations are based upon. Furthermore, the guideline may also be relevant to caregivers of children with OM that seek more information on diagnosis and treatment. The focus areas were chosen based on consensus on the most important elements within diagnosis and management of OM. Many aspects of OM deserve attention. However, a limit of ten focus questions was set by the DHMA. The working group would like to emphasize that antibiotic treatment in children with AOM is another important aspect that should be included in future guidelines.

Section snippets

Methods

The GRADE system (The Grading of Recommendations Assessment, Development and Evaluation) was used in order to comply with current international standards of evidence assessment [6], [7]. The GRADE approach, assessing both the quality of evidence and strength of recommendations, provides a comprehensive and transparent approach for developing clinical guidelines (http://www.gradeworkinggroup.org). Fig. 1 provides an overview of the process.

Recommendations

Ten focused clinical questions formed the basis of the systematic literature reviews (Appendix A). The working group formulated nine recommendations based on these reviews (see Table 2).

Implementation and update

The working group aims to review and update the guideline after three years from the publication date. We aim to follow if the guideline recommendations will change treatment practice in Denmark by following the frequency of VT insertions and VT insertions with adjuvant adenoidectomy and additionally the use of antibiotics.

Conflict of interest

None declared. Declarations of interests are available at https://sundhedsstyrelsen.dk/da/udgivelser/2015/mellemoerebetaendelse-og-oeredraen.

Funding

The Danish Health and Medicines Authority funded the entire process.

Acknowledgements

We would like to acknowledge the reference group for valuable feedback during the process. The reference group consisted of Associate Professor Michael Gaihede, Associate Professor Henrik Glad, Associate Professor Margit Nørgård-Edmund, Professor Therese Ovesen, Administrative Officer Tue Schou Pedersen and Associate Professor Jens Højberg Wanscher. We would also like to thank the peer reviewers Professor Sten Hellström and ENT Specialist Torben Lildholdt.

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