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Audit Glue Ear
Audit Glue Ear
Although the diagnosis with which this guideline is concerned is OME, super-added
RAOM with the OME occurs, and is one of the main co-morbidities to consider. Many
of the seriously affected children also have other contributing health or
developmental problems, for both biological and social reasons. Down syndrome and
cleft palate are two well-known ones, but the potential list is long. The difficulties of
research on conjunctions of conditions, because some of the conjunctions are very
rare, means that there could not be detailed evidence on the implications of comorbidity. Nevertheless, the impact of co-morbidity is a general argument for making
an overall clinical assessment. In those with confirmed co-morbidity, such impact has
usually been accepted as clinical reason for a stronger tendency to intervene.
effective way, there then has to be prompt access to secondary care outpatient and
surgical services. This is needed if the treatments that can improve physical health
and development are to be effective throughout a significant part of the remaining
natural history.
In recent years intervention rates have reduced and their variation from place to
place has narrowed. Therefore, any proposal for greater selectivity than in the past in
a particular commissioner/provider environment should be made in the light of local
standardised intervention rates in relation to national averages, and should start from
clinical criteria for intervention, not from arbitrary numbers or the blind imposition of
yet further formal waiting (e.g. 6 rather than 3 months).
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 after one,
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. Many community services have local arrangements for direct
access to ENT if the OME persists after watchful waiting at this level.
Over four years of age:
To childrens 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.
Management orientation for secondary care, on exit from formal watchful
waiting (wherever it may occur)
IF RESOLUTION DOES NOT OCCUR DURING A THREE-MONTH PERIOD OF
WATCHFUL WAITING, DISCUSS SURGICAL MANAGEMENT AND THE
ALTERNATIVES
Under three years of age:
General advice on family support and behavioural management of the condition and
provision of explanatory and rehabilitative information
Insertion of bilateral ventilation tubes (grommets) and advice on parental vigilance
and action in the event of infection or early extrusion etc
Over three years of age:
General advice on family accommodation to the condition and provision of
explanatory and rehabilitative information
Treatment alternatives
There is no good evidence that medical treatments developed so far, including
decongestants, antibiotics, antihistamines, have any clinically worthwhile effect on
resolution of established middle ear effusion. A minority of cases, in whom there is an
allergic component to their disease may benefit from topical (nasal) steroids. Various
complementary remedies, (e.g. cranial osteopathy), are no more effective than the
same period of watchful waiting.
Vaccines with meningitis as their main target are emerging, efficacious against the
main Pneumococcus serotypes and, more recently, against these together with nontypable Haemophilus influenzae, another major pathogen for otitis media. The new
population vaccination schedule now includes the former, and this is likely to
influence the pattern of childrens middle-ear disease seen in the near future.
Individual case vaccination (i.e. in 2-3 year olds with continuing histories) has not
been subjected to appropriate trials yet, and the scope for it may be limited by
reduced immunocompetence being the source of the problem. In the foreseeable
future there may also be effective mucolytics but there is as yet not an adequate
evidence base for use in practice.
The physical therapy of Eustachian auto-inflation may be helpful in some cases, but
difficulties over adherence (i.e. regular performance by the child as achievable in
most families) do not make it a generally useful treatment, or an alternative regimen
in the usual sense.
Hearing aids have a place in the management of OME, due to the lack of clear
medical alternatives. The issues in aiding are also far from clear-cut, due to lack of
good trials on their overall cost-effectiveness, and. Many departments will offer this
option after two or three sets of ventilation tubes where parents may not wish further
operations, or where there is reason to be concerned about long-term effects on the
eardrum. Use of amplification in this long-term history group is not very contentious,
as the group is not large, and it may become smaller with an increasing use of
adenoidectomy. In contrast, the range of opinion in ORL on aiding in OME while
waiting for or as an alternative to surgery is very wide. Where hearing aids are
provided in early history OME, there needs to be a clear understanding with the
sensory support/educational audiology service about the further support that can be
provided or otherwise; where it can be provided, there has to be an efficient
mechanism for notification of individual cases. Counselling of parents should confirm
that they are happy about the possibilities of stigmatisation, and possible future
dependency on an aid, when it may no longer be required to manage a hearing loss
that has resolved.
Parents should be asked about the presence of sound-field amplification systems in
the childs school or nursery. Where these are reliably present and physical health
problems do not predominate in the childs presentation, this may tip the balance to
watchful waiting rather than surgery. Where an overall local NHS policy is being
developed for children with OME, the educational authority needs to be brought into
discussions about classroom amplification as an option. Its widespread benefits have
been demonstrated. These benefits may be expected to be slightly greater in OME,
or in permanent hearing-impairment, but their relevance does not require specifically
large benefits to be demonstrated.
OME in adults
In adults, OME may be due to neoplasm in the nasopharynx. Referral falls within the
two-week rule protocol. Outpatient assessment, nasendoscopy and audiology are
carried out at the first clinic visit. EUA/biopsy of the nasopharynx is required urgently
if there is clinical suspicion of neoplasm. Insertion of ventilation tube(s) is performed
at the same time. If there is an obvious preceding cause for the OME such as URTI
after a flight, and if outpatient examination of the nasopharynx is normal, many
specialists would offer medical management: vasoconstrictors, steroids or antibiotics
as initial treatment. Although the effectiveness of these is unlikely to be high, the
incidence is low.
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