Review articleDanish guidelines on management of otitis media in preschool children
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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2024, International Journal of Pediatric OtorhinolaryngologyClinical practice guidelines for the diagnosis and management of otitis media with effusion (OME) in children in Japan – 2022 update
2023, Auris Nasus LarynxCitation Excerpt :In consideration of the current status of management of OME in Japan, the JOS and the Japan Society for Pediatric Otorhinolaryngology developed evidence-based guidelines to support the diagnosis and treatment of OME in children [10,11]. After publication of the 2015 JOS Guidelines, the Danish Guidelines on management of OME [12] were issued, the US guidelines [13] were updated, and French guidelines [14] were also reported. Furthermore, an international consensus report was presented in the panel discussion during the 2017 International Federation of Oto-rhino-laryngological Societies Congress, as guidelines specialists in each area of the world met to recommend the best practices for OME management [15].
Pharmacotherapy focusing on for the management of otitis media with effusion in children: Systematic review and meta-analysis
2022, Auris Nasus LarynxCitation Excerpt :It is a leading cause of hearing impairment in children, and its early and proper management can help in avoiding hearing and speech impairment, which can cause a developmental delay in children. In severe cases that cannot be improved by conservative treatment, tympanostomy tube insertion is recommended, and the criteria are given in the guidelines of various countries [1,2,6-8]. On the contrary, watchful waiting and conservative treatment for three months from the date of effusion onset or the date of diagnosis is recommended for managing the child with OME who is not at risk, including pathological changes in the eardrum [1].
Effects of early childhood otitis media and ventilation tubes on psychosocial wellbeing – A prospective cohort study within the Danish National Birth Cohort
2020, International Journal of Pediatric OtorhinolaryngologyCitation Excerpt :Nonetheless, guidelines on treatment of OM are often based on the assumption that the associated HL does have adverse negative developmental consequences [5,16–18]. Recently published Danish National Guidelines on treatment of OM recommend ventilation tube insertion (VTI) as treatment for both COME and RAOM [19]. In fact, Denmark has one of the highest VTI rates in the world [1].
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2019, International Journal of Pediatric OtorhinolaryngologyCitation Excerpt :Secondly, the management of OME varies from one country to another and even from one ENT department to another because a validated, international, specific consensus on OME in children with CP is currently lacking. At best, the guidelines on OME issued by learned societies have a few paragraphs on children with CP [22–27]. Many aspects of the management of OME in children with CP are subject to debate [28], including the indication for TT placement, the optimum age at first TT placement, the type of TT (grommet-type or T-Tube), the impact of CP on the occurrence and recurrence of OME, the follow-up, and risk factors for OME recurrence.