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REVIEW ARTICLE

Surgical Treatments for Otitis Media With Effusion:


A Systematic Review
AUTHORS: Ina F. Wallace, PhD,a Nancy D. Berkman, PhD,a
Kathleen N. Lohr, PhD,a Melody F. Harrison, PhD,b Adam J. abstract
Kimple, MD, PhD,c and Michael J. Steiner, MDd
BACKGROUND AND OBJECTIVE: The near universality of otitis media
aDivision for Health Services and Social Policy Research, RTI
with effusion (OME) in children makes a comparative review of treat-
International, Research Triangle Park, North Carolina; and
bDivision of Speech and Hearing Sciences, and Departments of ment modalities important. This study’s objective was to compare the
c
Otolaryngology/Head and Neck Surgery and dPediatrics, effectiveness of surgical strategies currently used for managing OME.
University of North Carolina, Chapel Hill, North Carolina
METHODS: We identified 3 recent systematic reviews and searched 4
KEY WORDS
adenoidectomy, comparative effectiveness, myringotomy, otitis
major electronic databases. Eligible studies included randomized con-
media with effusion, surgical treatments, systematic review, trolled trials, nonrandomized trials, and cohort studies that compared
tympanostomy tubes myringotomy, adenoidectomy, tympanostomy tubes (tubes), and watch-
ABBREVIATIONS ful waiting. Using established criteria, pairs of reviewers indepen-
AOM—acute otitis media dently selected, extracted data, rated risk of bias, and graded
CI—confidence interval
CINAHL—Cumulative Index to Nursing and Allied Health Literature strength of evidence of relevant studies. We incorporated meta-analyses
EPC—Evidence-based Practice Center from the earlier reviews and synthesized additional evidence qualitatively.
KQ—key question
OME—otitis media with effusion
RESULTS: We identified 41 unique studies through the earlier reviews
PICOTS—populations, interventions, comparators, outcomes, and our independent searches. In comparison with watchful waiting or
time frames, and settings myringotomy (or both), tubes decreased time with OME and improved
RCT—randomized controlled trial
hearing; no specific tube type was superior. Adenoidectomy alone, as
SOE—strength of evidence
an adjunct to myringotomy, or combined with tubes, reduced OME and
Dr Wallace selected articles for inclusion, extracted data, graded
the strength of evidence, and drafted and revised the improved hearing in comparison with either myringotomy or watchful
manuscript; Dr Berkman selected articles for inclusion, waiting. Tubes and watchful waiting did not differ in language, cogni-
extracted data, graded the strength of evidence, and reviewed tive, or academic outcomes. Otorrhea and tympanosclerosis were
and revised the manuscript; Dr Lohr selected articles for
inclusion and reviewed and revised the manuscript; Drs
more common in ears with tubes. Adenoidectomy increased the risk
Harrison, Kimple, and Steiner selected articles for inclusion, of postsurgical hemorrhage.
extracted data, and reviewed the manuscript; and all authors
CONCLUSIONS: Tubes and adenoidectomy reduce time with OME and
approved the final manuscript as submitted.
improve hearing in the short-term. Both treatments have associated
www.pediatrics.org/cgi/doi/10.1542/peds.2013-3228
harms. Large, well-controlled studies could help resolve the risk-
doi:10.1542/peds.2013-3228
benefit ratio by measuring acute otitis media recurrence, functional
Accepted for publication Nov 1, 2013
outcomes, quality of life, and long-term outcomes. Research is needed
Address correspondence to Ina F. Wallace, PhD, Division for to support treatment decisions in subpopulations, particularly in
Health Services and Social Policy Research, RTI International, PO
Box 12194, Research Triangle Park, NC 27709–2194. E-mail: patients with comorbidities. Pediatrics 2014;133:1–16
wallace@rti.org
PEDIATRICS (ISSN Numbers: Print, 0031-4005; Online, 1098-4275).
Copyright © 2014 by the American Academy of Pediatrics
FINANCIAL DISCLOSURE: The authors have indicated they have
no financial relationships relevant to this article to disclose.
FUNDING: Funded by the Agency for Healthcare Research and
Quality, US Department of Health and Human Services, through
contract 290-2007-10056-I awarded to RTI International for the
RTI International-University of North Carolina Evidence-based
Practice Center. In addition, Dr Wallace received funding from
RTI International to complete the manuscript.
POTENTIAL CONFLICT OF INTEREST: The authors have indicated
they have no potential conflicts of interest to disclose.

PEDIATRICS Volume 133, Number 2, February 2014 1


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Otitis media with effusion (OME) is de- the relative effectiveness of a range of outcomes, in addition to short-term
fined as a collection of fluid in the middle treatment options (tympanostomy tubes clinical outcomes and harms, and (3)
ear without signs or symptoms of acute [tubes], myringotomy, adenoidectomy, providing1 crosscuttingreview covering
ear infection.1 Fluid in the middle ear oral or topical nasal steroids, auto- all surgical strategies that clinicians use
decreases tympanic membrane and inflation, complementary and alterna- for treating OME.
middle ear function, leading to conduc- tive medicine procedures, variations
tive hearing loss, “fullness” in the ear, in surgical technique or procedures, METHODS
and occasional pain from the pressure and watchful waiting) in patients with Data Sources and Search Strategy
changes. Children with OME often have OME of any age. We first considered systematic reviews
a conductive hearing loss on pure-tone This article focuses solely on surgi- recently completed by the Cochrane
audiometry that measures at 25 dB, cal interventions (ie, myringotomy, Collaboration or commissioned by a
a level that is 10 dB worse than the level adenoidectomy, and tubes) and their national government. Three system-
for children with normal hearing. OME comparators.IntheUnitedStates,surgical atic reviews investigated tubes and
occurs commonly during childhood; as treatments are common interventions for adenoidectomy and included data from
many as 90% of children (80% of in- persistent or recurrent OME. In contrast, randomized trials and nonrandomized
dividual ears) have at least 1 episode of steroids are not recommended in current studies.10–12 Comparison treatments in-
OME by age 10.2 Many episodes of OME guidelines,7 and a recent review did not cluded watchful waiting, myringotomy,
resolve spontaneously within 3 months, find them to be effective8; autoinflation and different tube types and insertion
but 5% to 10% of episodes last more than is uncommon; and no randomized con- techniques. We then identified newer
1 year; 30% to 40% of children have re- trolled trials (RCTs) provided evidence trials and observational studies through
current episodes.1,3,4 concerning complementary and alterna- searches of Medline (via PubMed),
Despite the high prevalence of OME, its tive medicine procedures. A recent sys- Embase, the Cochrane Library, and the
long-term impact on child developmental tematic review of antibiotics did not Cumulative Index to Nursing and Allied
outcomes, such as speech, language, support routinely treating children di- Health Literature (CINAHL) for studies
intelligence, and hearing remain dis- agnosed with OME with antibiotics.9 published in English and conducted in
puted.5 A recent systematic review of any geographic location or setting. Our
We attempted to answer 5 key questions
the natural history of OME found mixed initial search (January 8, 2012) was
(KQs) concerning treatment compar-
evidence regarding the impact of OME in updated on August 13, 2012 and August
isons for patients with OME: What is the
early childhood on later developmental 5, 2013. The Supplemental Information
comparative effectiveness of surgical
outcomes.2 Lacking clear evidence that provides the initial set of search terms;
treatments and watchful waiting in (1)
OME influences children’s development, Appendix A of the full report documents
affecting clinical outcomes or health
clinicians struggle with decision-making the complete set of search terms.6
care use and (2) improving functional
for this common condition. Many chil- and health-related quality of life out-
dren with OME are actively treated; the Study Selection and Data
comes? (3) What are the harms or
annual total cost of treating OME in the Abstraction
tolerability of the different treatment
United States in 1995 was estimated at options? (4) What are the comparative We developed inclusion and exclusion
$4 billion2 and may well be higher today. benefits and harms of treatment criteria with respect to a framework
The near universality of OME in children options in subgroups of patients? (5) specifying populations, interventions,
and the high cost of its treatment make Is the comparative effectiveness of comparators, outcomes, timeframes, and
it an important topic for a comparative treatment options related to factors settings (PICOTS). Table 1 presents the
review of treatment modalities. Ac- affecting health care delivery or the PICOTS for the study. We included studies
cordingly, the Agency for Healthcare receipt of pneumococcal vaccine in- of individuals of any age or background
Research and Quality commissioned oculation? In reviewing the evidence with OME (and concurrent comorbidity);
the RTI-University of North Carolina to answer these questions, we were if other populations were included in
Evidence-based Practice Center (EPC) to particularly interested in (1) deter- a study, data had to have been analyzed
conduct a systematic review of the mining whether we could find evidence separately for those with OME.
comparative effectivenessandharmsof to examine treatments in patient We used a dual review process to review
treatments for OME. Our review was not groups not included in earlier reviews, each abstract andfull-textarticlebyusing
designed to examine whether OME suchaschildrenwithadditionaldiagnoses, the inclusion/exclusion criteria. If the
should be treated.6 Rather, we examined (2) examining a range of functional reviewers disagreed about an exclusion

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REVIEW ARTICLE

TABLE 1 Inclusion and Exclusion Criteria for Studies of OME


Domain Description
Population All individuals with OME. Subpopulations include infants; adults; individuals from different racial/ethnic backgrounds; and special
populations of any age, including individuals with craniofacial abnormalities (eg, cleft palate), Down syndrome, existing hearing loss,
delays in speech and language, or a history of AOM or OME.
Interventions • Surgical interventions: tympanostomy tubes (also referred to as pressure-equalization tubes, grommets, and ventilation tubes),
myringotomy (also referred to as paracentesis), and adenoidectomy with or without myringotomy.
Comparator • Different combinations of the above interventions and strategies. These include head-to-head comparisons of 1 or more treatments,
treatment strategies (eg, watchful waiting/delayed treatment versus early treatment), or surgical procedures and techniques
(eg, 1 type of tympanostomy tube or procedure versus another or different adjunct therapies to enhance the main intervention).
We considered head-to-head trial evidence and observational study data.
Outcomes • Clinical outcomes: changes in middle ear fluid, episodes of AOM, hearing thresholds, vestibular function (ie, balance and coordination).
• Health care utilization: number of office visits, number of surgeries, and medication use.
• Functional and quality-of-life outcomes: hearing, auditory processing, speech and language development, cognitive functioning,
academic achievement, attention and behavior, quality of life, and parental satisfaction with care.
• Harms: all reported harms for each treatment option.
Timing Shorter studies looking at outcomes 0 to ,3 mo postintervention.
Longer studies looking at outcomes past 3 mo and into adolescence or adulthood.
Setting Studies conducted in the United States or internationally.
Interventions provided in primary care offices where the patient is seen by a pediatrician, family physician, or nurse practitioner;
subspecialist physician offices where the patient is seen by an otolaryngologist; surgical settings within a hospital or outpatient clinic;
emergency departments; and craniofacial treatment centers.

decision or the primary criteria for by the earlier Cochrane Review authors, options); 776 met criteria for full-text
exclusion, they resolved conflicts by additional data from individual studies review (Fig 1). We excluded 696 full-text
consensus discussion. We abstracted in those systematic reviews, and the articles based on our inclusion criteria
detailed PICOTS data from newly included new studies from our searches. New (before the risk-of-bias assessment),
studies and summarized information studies did not lend themselves to ei- leaving 80 included articles, of which 3
from studies included in the earlier ther new pooled analyses or to modi- were systematic reviews. We recorded
systematic reviews into evidence tables. fying earlier meta-analyses. Therefore, the reason that each excluded full-text
we summarized the new evidence publication failed to satisfy the eligibility
Risk-of-Bias Assessment qualitatively. criteria and compiled a comprehensive
Two independent reviewers rated the list of such studies (Appendix B of
risk of bias for each newly identified Strength of the Body of Evidence the full report6). Of the 77 articles, 23
study by using the Cochrane Risk of Bias Two team members independently were omitted from our analyses for de-
tool for RCTs13; our EPC developed ad- graded the strength of evidence (SOE) termining benefit because of high risk of
ditional or alternative questions for to answer each KQ, for each treatment bias in their study design (see Appendix
evaluating observational studies; for comparison, following EPC guidance.15 E of the full report6). One article de-
studies from the earlier systematic The overall grade for SOE (high, mod- termined to be at high risk of bias for
reviews, we relied on the original erate, low, or insufficient) is based determining benefit was included for
authors’ ratings.10–12 We evaluated the on ratings for 4 domains: risk of bias, harms only.
risk of bias of each of the systematic consistency, directness, and precision.
reviews using AMSTAR (A Measurement In this report, we discuss the subset of
It reflects reviewers’ confidence studies providing evidence on surgical
Tool to Assess Systematic Reviews).14 in the ability of a given body of evi-
The 2 reviewers resolved disagree- interventions: 3 systematic reviews, 41
dence to answer KQs. We resolved studiesreportedin55includedarticles.Of
ments by consensus discussion. We disagreements through consensus
assigned risk-of-bias ratings of low, the 55 articles, 24 were included in an
discussions.
medium, or high; high risk-of-bias stud- earlier systematic review, 13 were
ies had at least 1 major issue with the follow-up studies, and 18 were newly
RESULTS identified.
potential to cause significant bias that
might invalidate the results. Literature Searches and Table 2 summarizes the 41 unique
Characteristics of Included Studies studies that constitute the evidence
Data Synthesis We identified 5112 unduplicated citations base for this article; we specify study
Evidence for this synthesis included in our literature searches (this included characteristics and risk of bias ratings.
results from meta-analyses conducted surgical and nonsurgical treatment Of these, 5 studies were included in

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FIGURE 1
Flow diagram of study retrieval and selection. a We accepted the risk of bias assessment conducted by the review authors for the studies included in 1 of the 3
earlier systematic reviews (37 articles). We conducted our own risk of bias assessment for 18 new articles not included in 1 of those reviews. b One article
was included for harms only.

more than 1 of the 6 main categories of Tympanostomy Tube Comparisons Tympanostomy Tubes Versus
comparisons. We assessed the 2 sys- Eleven studies (8 RCTs) provided evi- Myringotomy or Watchful Waiting
tematic reviews limited to RCTs as low dence concerning differences in clini- Twelve RCTs compared tubes with ei-
risk of bias11,12 and the third as medium cal outcomes comparing tubes (by ther myringotomy or no surgery (ie,
risk of bias.10 design, materials, size), insertion watchful waiting, delayed treatment); of
techniques, or topical prophylaxis these, 10 studies26–35 were included in
Comparative Effectiveness for therapies by comparing ears in the previous systematic reviews,10,11 and 2
Clinical Outcomes same child.16–25 Length of tube re- were new.36,37
Most studies examined some clinical tention was longer in tubes that man- Tube placement decreased the time
outcomes: most commonly, signs and ufacturers identified as “long-term with middle ear effusion by 32% in
symptoms of OME and hearing. A few tubes.” Specifically, Goode T-tubes and comparison with watchful waiting or
studies examined subsequent acute Paparella tubes were retained longer delayed treatment at 1 year after sur-
otitis media (AOM). Table 3 documents than Shah and Shepard tubes. Because gery (high SOE). Relative to a combined
findings on effectiveness in terms of of sparse data, diversity of compar- comparison group of watchful waiting
clinical outcomes separately by treat- isons, and inconsistent findings, the or myringotomy, tubes reduced effu-
ment comparisons; we give results evidence is insufficient for compar- sion by 13% through 2 years after
only when evidence was sufficient to isons of other design features or for surgery (moderate SOE). Evidence was
draw a conclusion. clinical outcomes. insufficient for longer follow-up.

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REVIEW ARTICLE

TABLE 2 Characteristics of Studies of Surgical Interventions for OME


Treatment Comparison Types of Treatments/ Study Designs, Sample Size, Patient
Comparisons Duration, Quality Rating Characteristics
Tympanostomy tube comparisons
14 studies (8 in 1 previous
systematic review)
Wielinga et al 199016 Silicone Goode TT versus RCT by ear Mean age: 79.2 mo
Teflon Armstrong TT n = 15 (30 ears) Male: 60%
Follow-up: average 6.8 y
Medium ROB
Abdullah et al 199417 Silicone Shah permavent TT NRCT by ear Mean age: 72 mo
versus Polyethylene Shah TT n = 25 (50 ears) Male: 64%
Follow-up: 29 mo
Medium ROB
Licameli et al 200818 Phophoryl-choline coated RCT by ear Mean age: 19 mo
fluroplastic Armstrong TT n = 70 (140 ears) Male: 64.3%
versus uncoated fluroplastic Follow-up: 24 mo
Armstrong TT Medium ROB
Iwaki et al 199819 Teflon Shepard TT versus Silicone RCS by ear Mean age: 72.1 mo
Goode T-tube versus Silicone n = 137 (220 ears) Male: 62%
Paraprella II TT Follow-up: 24 mo
Medium ROB
Ovensen et al 200020 TT + acetylcysteine versus RCT by person and ear Mean age: 38 mo
TT + placebo n = 75 (150 ears) Male: 64%
Follow-up: 39 mo
Medium ROB
Slack et al 198760 Shepard TT versus Shah TT RCS by ear Mean age: unknown
versus Paparella TT n = 559 ears (,16 y)
Follow-up: Until extrusion Male: unknown %
or end of study period
High ROB
Hesham et al 201263 TT + mitomycin C versus TT RCT by ear Mean age: 5.8 y
(adenoidectomy in 55% and n = 55 (110 ears) Male: 58%
adenotonsillectomy in 20% Follow-up: .6 mo
when warranted) Medium ROB
Studies in Hellstrom
et al 201110
Hampal et al 199121 Shah TT versus Mini Shah TT RCT by ear Mean age: unknown
n = 116 (3–7 y)
Dingle et al 199373 Follow-up: 1 y Male: unknown %
Medium ROB (Hellstrom)

Heaton et al 199122 Shepard TT versus Sheehy TT RCT by ear Mean age: 72 mo


n = 146 (292 ears) Male: 64%
Follow-up: 21–36 mo
Medium ROB (Hellstrom)
Hern & Jonathan, 199923 Shah TT place in anterosuperior RCT by ear Mean age: unknown
quadrant versus Shah place n = 54 (108 ears) (,12 y)
interoinferior quadrant Follow-up: 26 mo Male: unknown %
Medium ROB (Hellstrom)

Youngs & Gatland, 198824 Shah Teflon TT + aspiration before RCT by ear Mean age: 68 mo
McRae et al 198974 placement versus Shah Teflon n = 55 (110 ears) Male: 65.4%
TT (no aspiration) Follow-up: 18 mo
Medium ROB (Hellstrom)
Pearson et al 199625 Shah Teflon TT + steroid otic drops NRCT by ear Mean age: 75.6 mo
preoperative versus Shah n = 165 (330 ears) Male: 66%
Teflon TT no drops Follow-up: 29 mo
Medium ROB
Kinsella et al 199461 Shepard TT no-touch technique NRCT by ear Mean age: 51 mo
versus Shepard TT touch technique n = 60 (120 ears) Male: 43.3%
Follow-up: 7–10 d
Medium ROB (Hellstrom)

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TABLE 2 Continued
Treatment Comparison Types of Treatments/ Study Designs, Sample Size, Patient
Comparisons Duration, Quality Rating Characteristics
Salam & Cable, 199362 Sheehy TT + otic drops versus RCT by ear Mean age: 55.2 mo
Sheehy TT (no drops) n = 162 (324 ears) Male: 41.4%
Follow-up: 2 wk
Medium ROB
Hampton & Adams, 199675 Armstrong TT anterior RCT by ear Mean age: 66 mo
placement versus n = 109 (218 ears) Male: 59.6%
Armstrong TT Follow-up: 6 wk to 29 mo
posterior placement Medium ROB
Tubes versus watchful
waiting or myringotomy
12 studies (10 in 1 previous
systematic review, 6 of
which were in another
previous systematic review)
Koopman et al 200436 Unilateral TT + cold knife RCT by ear Mean age: 50.4 mo
myringotomy versus n = 208 (416 ears) Male: 51.9%
laser myringotomy Follow-up: 6 mo
Medium ROB
Mandel et al 198937 TT + myringotomy versus RCT Age: 45.7 mo
myringotomy versus n = 109 Male: 66.9%
watchful waiting Follow-up: 3 y
Medium ROB
Studies in Browning
et al 201011
Maw et al 199926,a Bilateral TT versus watchful RCT Mean age: 35.4 mo
Wilks et al 200058 waiting n = 182 Male: 48.4%
Hall et al 200955 Follow-up: 18 mo
Low ROB (Hellstrom)
MRC Multicentre Otitis Bilateral TT versus watchful RCT Mean age: 62.7 y
Media Group, 200327 waiting n = 241 Male: 50.6%
MRC Multicentre Otitis Follow-up: 2 y
Media Group, 201254 , High ROBb

Rovers et al 200028,a Bilateral TT versus watchful RCT Mean Age: unknown


Rovers et al 200159 waiting n = 187 Male: 58.8%
Follow-up: 12 mo
Medium ROB (Hellstrom)
Gates et al 198729,a Bilateral TT versus myringotomy RCT Mean Age: unknown
Gates et al 198946 n = 236 Male: 59.3%
Follow-up: 2 y
Low ROB (Hellstrom)
Mandel et al 199230 Bilateral TT versus RCT Mean age: 45.4 mo
myringotomy versus n = 111 Male: 66.7%
watchful waiting Follow-up: 3 y
, High ROBb
Paradise et al 200131,a Bilateral TT versus delayed RCT Mean age: 15 mo
Johnston et al 200464 treatment n = 429 Male: 56.9%
Paradise et al 200556 Follow-up: 3 y of age
Paradise et al 200757 Medium ROB (Hellstrom)
Black et al 199032 Unilateral TT versus RCT (by person and ears) Mean age: 72.6 mo
myringotomyc n = 74 (148 ears) Male: 64.9%
Follow-up: 24 mo
, High ROBb
Dempster et al 199333,a Unilateral TT versus no RCT (by person and ear) Mean age: 68.4 mo
surgeryc n = 35 (70 ears) Male: 65.7%
Follow-up: 12 mo
, High ROBb

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TABLE 2 Continued
Treatment Comparison Types of Treatments/ Study Designs, Sample Size, Patient
Comparisons Duration, Quality Rating Characteristics
Maw & Herod, 198634,a; Unilateral TT versus no surgeryc RCT (by person and ear) Mean age: 63.7 mo
Maw & Bawden, 199465 56 (112 ears) Male: 57.1%
Follow-up: 12 mo
Medium ROB (Hellstrom)
Rach et al 199135 Bilateral TT versus watchful waiting RCT Mean age: unknown
n = 43 (all preschoolers)
Follow-up: 6 mo Male: unknown %
, High ROBb

TT plus adenoidectomy
versus myringotomy plus
adenoidectomy or
adenoidectomy alone
11 studies (4 in 1 previous
systematic review)
Brown et al 197838 TT (Shepard) + adenoidectomy RCT by ear Mean age: unknown
versus adenoidectomy n = 55 (110 ears) (4–10 y)
Follow-up: 5 y Male: unknown %
Medium ROB

Austin, 199439 TT + adenoidectomy versus RCT by ear Mean age: unknown


adenoidectomy n = 31 (62 ears) Male: unknown %
Follow-up: 3 mo
Medium ROB
Lildholdt, 197940 TT (Donaldson) + adenoidectomy NRCT by ear Mean age: 48 mo
versus adenoidectomy n = 91 (182 ears) Male: 59.3%
Follow-up: until
extrusion or 8 mo
Medium ROB
D’Eredita & Shah, 200641 TT (Shah mini) + adenoidectomy RCT Mean age: 44.4 mo
versus CDLM + adenoidectomy n = 30 Male: 56.7%
Follow-up: 12 mo
Medium ROB
Popova et al 201042 TT (Donaldson) + adenoidectomy RCT Mean age: 60.6 mo
versus myringotomy + n = 30 Male: 53.8%
adenoidectomy Follow-up: 12 mo
Medium ROB
Shishegar & Hobhoghi, TT (Shepard) + adenoidectomy RCT by ear Mean age: unknown
200743 versus myringotomy + n = 30 (60 ears) (4–8 y)
adenoidectomy Follow-up: 6 mo Male: 63.3%
Medium ROB

Vlastos et al 201144 TT (Shepard) + adenoidectomy RCT Mean age: 54 mo


versus myringotomy + n = 52 Male: 55.8%
adenoidectomy Follow-up: 12 mo
Medium ROB
Studies in Hellstrom
et al 201110
Gates et al 198946 TT + adenoidectomy versus RCT Mean age: unknown
myringotomy + adenoidectomy n = 255 (4–8 y)
Follow-up: 2 y Male: 58.5%
Low ROB (Hellstrom)

Maw & Bawden, 199448 TT (Shepard) +adenoidectomy/ RCT by person and ear Mean age: unknown
adenotonsillectomy versus n = 139 (270 ears) (3–9 y)
adenoidectomy/adenotonsillectomy Follow-up: 10 y Male: unknown %
Medium ROB (Hellstrom)

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TABLE 2 Continued
Treatment Comparison Types of Treatments/ Study Designs, Sample Size, Patient
Comparisons Duration, Quality Rating Characteristics
Lildholdt, 198347 TT (Donaldson) + adenoidectomy RCT by ear Mean age: 46.8 mo
versus adenoidectomy n = 150 (300 ears) Male: 56.7%
Follow-up: 5 y
Medium ROB (Hellstrom)
Bonding & Tos, 198545 TT (Donaldson) + adenoidectomy NRCT by ear Mean age: unknown
Tos & Stangerup, 198966 versus myringotomy + n = 224 (448 ears) Male: unknown %
Caye-Thomasen et al 200867 adenoidectomy Follow-up: 6–7 y
Medium ROB (Hellstrom)
Myringotomy comparison
1 study
Ragab, 200549 Intervention: Radiofrequency RCT by ear Mean age: 60 mo
myringotomy + mitomycin C n = 60 Male: unknown %
Comparison: Radiofrequency Follow-up: 3 mo
myringotomy Medium ROB

Myringotomy with
adenoidectomy
comparison
1 study
Szeremeta et al 200050 Intervention: Laser myringotomy + RCT by ear Mean age: 83.9 mo
adenoidectomy n = 49 (87 ears) Male: unknown %
Comparison: Cold knife Follow-up: 6–48 mo
myringotomy + adenoidectomy Medium ROB

Adenoidectomy comparisons
8 studies (7 in 1 previous
systematic review)
MRC Multicentre Otitis Adenoidectomy + bilateral TT RCT Mean age: 63.6 mo
Media Group 201254 (Shepard) versus bilateral n = 376 Male: 48.9%
TT (Shepard) versus WW Follow-up: 24 mo
Medium ROB
In van Aardweg et al 201011
Black et al 199032,d Adenoidectomy versus no surgery RCT by person and ear Mean age: 75 mo
Adenoidectomy versus Adenoidectomy + unilateral TT n = 149 (149 ears) Male: 58.4%
Adenoidectomy versus unilateral TT Follow-up: 2 y
Adenoidectomy + unilateral TT , High ROBb
versus no surgery
Adenoidectomy + unilateral TT
versus unilateral TT
Dempster et al 199333,e Adenoidectomy + unilateral TT RCT by person and ear Mean age: 69.6 mo
versus unilateral TT n = 72 (72 ears) Male: 55.6%
Adenoidectomy versus no surgery Follow-up: 12 mo
Medium ROB (Hellstrom)

Maw & Herod, 198634,e Adenoidectomy + unilateral TT RCT by person and ear Mean age: 63 mo
(Shepard) versus unilateral n = 103 (103 ears) Male: 66%
TT (Shepard) Follow-up: 12 mo
Adenoidectomy versus no surgery Medium ROB (Hellstrom)

Filleau-Nikolajsen Adenoidectomy + RCT Mean age: unknown


et al 198051 myringotomy n = 42 (3 y old cohort)
versus myringotomy Follow-up: 6 mo Male: 50%
, High ROBb

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TABLE 2 Continued
Treatment Comparison Types of Treatments/ Study Designs, Sample Size, Patient
Comparisons Duration, Quality Rating Characteristics
Gates et al 198729,e Adenoidectomy + RCT Mean age: unknown
Myringotomy versus n = 491 (4–8 y)
Adenoidectomy + TT Follow-up: 2 y Male: 58.9%
(Shepard) versus Low ROB (Hellstrom)
Myringotomy versus
TT (Shepard)
Roydhouse, 198052 Adenoidectomy + TT RCT Mean age: 85 mo
versus TT versus n = 169 Male: 55.9%
medical treatment Follow-up: 6 y
, High ROBb
Casselbrant et al 200953 Adenoidectomy + TT RCT Mean age: 34.6 mo
(Armstrong) versus n = 98 Male: 66.4%
Adenoidectomy + Follow-up: 36 mo
myringotomy versus + , High ROBb
TT (Armstrong)
For studies with more than 1 publication, the first listed is the primary source and the others are supplementary or follow-up articles. CDLM, contact diode laser myringotomy; NRCT,
nonrandomized controlled trial; RCS, retrospective cohort study; ROB, risk of bias; TT, tympanostomy tubes; WW, watchful waiting.
a In Hellstrom et al 2011.10
b Risk of bias analyses performed by authors of systematic review; the authors only included studies that were low or medium, but they did not indicate what the risk of bias was for individual

studies.
c Included only the arm randomized to no adenoidectomy.
d In Browning et al 2010.11
e In Browning et al 201011 and Hellstrom et al 2011.10

Tubes improved hearing in the short- small studies failed to find a differ- concerning OME effusion or hearing
term: up to 9 months after surgery in ence between tubes plus adenoidectomy outcomes.
comparison with watchful waiting (3–6 and adenoidectomy alone in reducing
months: 8.8 dB; 6–9 months: 4.2 dB) OME recurrence (insufficient evidence). Myringotomy Plus Adenoidectomy
(high SOE); up to 6 months after surgery Results of 3 studies comparing tubes Comparisons
in comparison with either watchful and adenoidectomy with myringotomy One retrospective cohort study com-
waiting or myringotomy (4–6 months: plus adenoidectomy on OME recurrence pared laser myringotomy with cold
10 dB) (high SOE). Thereafter, the dif- were mixed (insufficient evidence). For knife myringotomy in children also
ferences in hearing became attenuated hearing measured at various times, receiving an adenoidectomy.50 Be-
and were not statistically significant at 7 ranging from 1 month to 6 years, 5 cause evidence was limited to 1 ob-
to 12 months compared with watchful studies failed to find a difference in servational study, we concluded that
waiting or myringotomy (low SOE) or at hearing between the addition of tubes it was insufficient for determining the
12 to 18 months compared with just versus myringotomy (low SOE for no superiority of either myringotomy
watchful waiting (low SOE). Evidence difference). We found mixed results approach in relation to OME signs and
was insufficient for longer time periods for hearing in studies that compared symptoms.
and for other clinical outcomes. the additive impact of tubes with
adenoidectomy alone (insufficient ev- Adenoidectomy Versus Other
Tympanostomy Tubes Plus idence). Interventions
Adenoidectomy Versus Myringotomy Eight RCTs (11 articles) provided evi-
Plus Adenoidectomy or Myringotomy Comparisons dence for adenoidectomy compared
Adenoidectomy Alone One RCT compared 2 different proce- with tubes, myringotomy, watchful
Seven studies that we newly identified38–44 dures for myringotomy (radiofrequency waiting, or no adenoidectomy (unilat-
and 4 studies45–48 reported in the myringotomy with and without mito- eral ear surgery with nonoperated
Hellstrom et al10 review examined out- mycin C) on both middle ear and ear as comparison) (Table 2). Seven
comes for adenoidectomy plus differ- hearing outcomes.49 Most individuals trials29,32–34,51–53 were from the van den
ent adjunctive therapies. Specifically, in each arm received adenoidectomy Aardweg et al systematic review12; the
we compared the effectiveness of (73% and 67%, respectively). Evi- eighth was the newly published Trial
tubes when added to adenoidectomy dence was insufficient for conclud- of Alternative Regimens in Glue Ear
with myringotomy or no surgery. Two ing superiority of either procedure Treatment study.54

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TABLE 3 SOE for Interventions to Improve Clinical Outcome
Intervention and Comparator No. of Studies (Sample Sizes) Outcome and Results SOE
TT versus watchful waiting, MA of 3 RCTs (n = 574) TT decreased persistent middle ear effusion at 1 y High for benefit
delayed treatment, or compared with watchful waiting or delayed
myringotomy treatment: 32% less time (95% CI 17% to 48%)
MA of 3 RCTs (n = 426) TT decreased persistent middle ear effusion at 2 y Moderate for
compared with watchful waiting or myringotomy: benefit
13% less time (95% CI 8% to 17%)
MA of 3 RCTs (n = 523) + TT had better measured hearing for up to 9 mo than High for benefit
1 RCT (n = 248) watchful waiting. MA results: –4.20dB
(95% CI –4.00 to –2.39)
MA of 3 RCTs (by ears) TT had better measured hearing for up to 6 mo than High for benefit
(n = 230) watchful waiting or myringotomy: –10.08
(95% CI –19.12 to –1.05)
MA of 3 RCTs (by ears) No difference was observed between TT and watchful Low for no
(n = 234) waiting or myringotomy in measured hearing at difference
7–12 mo: –5.18dB (95% CI –10.43 to 0.07)
MA of 2 RCTs (n = 328); No difference was observed between TT and watchful Low for no
MA of 2 RCTs (n = 283) waiting in measured hearing at 12 mo: –0.41dB difference
(95% CI –2.37 to 1.54) and 18 mo –0.02 dB
(95% CI –3.22 to 3.18)
TT + adenoidectomy versus 6 studies: 3 RCTs by No difference was observed in measured hearing Low for no
myringotomy + adenoidectomy person (n = 431) between groups at 6 and 12 mo and at more than 3 y. difference
or adenoidectomy alone 2 RCTs (by ears) (n = 338)
1 NRCT (by ears) (n = 193)
Adenoidectomy versus no MA of 2 RCTs (by ears) Adenoidectomy produced better OME resolution than no High for benefit
adenoidectomy (ears in each (n = 153); MA of 3 treatment at 6 mo. The risk difference was 0.27 (95%
group randomized to TT or no RCTs (by ears) (n = 297) CI 0.13 to 0.42) measured through otoscopy and 0.22
TT; only no TT ears examined (95% CI 0.12 to 0.32) measured through tympanometry.
in this comparison) MA of 3 RCTs (by ears) Adenoidectomy produced better OME resolution than no High for benefit
(n = 298) treatment at 12 mo. The risk difference was 0.29
(95% CI 0.19 to 0.39).
Adenoidectomy + myringotomy 1 RCT (n = 237) Adenoidectomy and myringotomy produced less mean Low for benefit
versus myringotomy time with effusion than myringotomy alone at 24 mo:
–0.76 standard mean difference (95% CI –1.02 to –0.49).
1 RCT (n = 237) Adenoidectomy and myringotomy produced better hearing Low for benefit
than with myringotomy alone at 24 mo measured as
standard mean difference time with hearing level $20:
worse ear: –0.65 (95% CI –0.91 to –0.39);
better ear: –0.66 (95% CI –0.93 to –0.40).
TT + adenoidectomy versus 1 study (n = 250) TT plus adenoidectomy improved hearing at 3 to 24 mo. Low for benefit
watchful waiting
MA, meta-analysis; NRCT, nonrandomized controlled trial; OR, odds ratio; TT, tympanostomy tube.

Adenoidectomy was superior to no (insufficient evidence for mixed find- (low SOE). Evidence was insufficient
adenoidectomy for resolution of OME ings). to determine the effectiveness of
at 6 months postsurgery measured One RCT found that adenoidectomy and adenoidectomy compared with other
through otoscopy (risk difference myringotomy were superior to myr- treatments for recurrence of AOM.
of 0.27, 95% confidence interval [CI] ingotomy alone for reducing time with
0.13–0.42) and through tympanometry effusion and for improving hearing at 24 Comparative Effectiveness for
(0.22, 95% CI 0.12–0.32) (high SOE for months (better ear standard mean Functional Outcomes or Quality of
both). It was also superior at 12 months difference of –0.66, 95% CI –0.93 to Life
postsurgery measured through tympa- –0.40) (low SOE). The evidence was in- Two treatment comparisons (tubes
nometry (risk difference of 0.29, 95% CI sufficient for determining the effec- versus watchful waiting and tubes plus
0.19–0.39) (high SOE). tiveness of adenoidectomy plus tubes adenoidectomy versus myringotomy plus
Hearing outcomes were superior with in relation to effusion or hearing be- adenoidectomy) included functional or
adenoidectomy compared with no cause outcome results were mixed. quality-of-life outcomes (Table 4).
adenoidectomy in 1 RCTat 6 months but Hearing outcomes were superior with Four trials (7 articles) reported on
not at 12 months. In a second RCT, adenoidectomy and tubes in compari- language26,28,31,35,55–57; 2 trials (5 articles)
investigators detected no differences son with watchful waiting at 24 months reported on cognitive development,

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academic achievement, or both26,31,55–57; Tympanostomy Tubes Plus waiting or myringotomy.28,30,33,36,37,46,54,64,65


and 3 trials (7 articles)26,31,36,37,55–59 Adenoidectomy Versus Myringotomy Otorrhea and tympanosclerosis occurred
reported on behavioral competence. Plus Adenoidectomy more frequently in ears with tube place-
One trial comparing adenoidectomy ment than in ears with watchful waiting
Tympanostomy Tubes Versus Watchful plus the addition of tubes versus myr- or myringotomy (low SOE). Evidence was
Waiting or Myringotomy ingotomy did not find differences in insufficient for other harms because of
Meta-analyses reported by Browning quality of life at any time point (in- either conflicting results or data reported
et al11 included trials conducted sufficient evidence); no other functional in only a single study.
by Maw and colleagues,26,55 Rovers outcomes were reported.44
and colleages,28 Paradise and col- Tubes Plus Adenoidectomy Versus
leagues,31,56,57 and Rach and col- Harms of Treatments for OME Myringotomy Plus Adenoidectomy or
leagues.35 The meta-analyses comparing Adenoidectomy Alone
Most studies examining surgical com-
tubes with watchful waiting did not find
parisons reported on harms. Table 5 We reviewed 9 trials (11 articles)
any differences in language at 6 and 9
provides the findings and SOE for thatexamined harmsof theseprocedures,
months after treatment (moderate SOE
harms by treatment comparisons. including repeat tubes, otorrhea, perfo-
for no differences). With 1 exception,
ration, and tympanosclerosis.38,40–47,66,67
trials examining children during pre-
Tympanostomy Tube Comparisons In 3 trials (4 articles) (all partic-
school and elementary school years
Eleven studies that compared tube ipants with adenoidectomy),38,45,47,66
failed to find a difference in language
length or insertion techniques reported the risk of tympanosclerosis was
skills (low SOE for no difference).55–57
on otorrhea.16–20,22,25,60–63 Longer-term higher with tubes than with myr-
In the 1 exception, the difference dis-
tubes related to a higher probability of ingotomy or no ear surgery (moder-
appeared at 8 years of age. We did
otorrhea in 3 studies16,19,60 (low SOE). ate SOE). Results for other harms
not find differences between tubes
Evidence about otorrhea was in- were mixed, reported in single stud-
and watchful waiting in any trials
sufficient for other tube comparisons. ies, or lacked precision (insufficient
reporting cognitive development, aca-
For other harms, such as perforation, evidence).
demic achievement, or quality of life at
any time point (all low SOE for no dif- cholesteatoma, occlusion, tympa-
ference). Studies reported mixed find- nosclerosis, and the presence of Adenoidectomy Versus Other
ings for behavior outcomes at ,1 year granulation tissue, the evidence was Interventions
(insufficient evidence); 3 trials reporting too limited to determine a direction of Three RCTs (4 articles)29,46,53,54 reported
behavior at 1 year or more after treat- effect (insufficient evidence). harms related to adenoidectomy. Two
ment reported no difference (low SOE). of the trials29,46,54 reported 1 case each
No studies comparing tubes with Tympanostomy Tubes Versus Watchful (among 416 subjects) of a postoperative
myringotomy reported on functional Waiting or Myringotomy hemorrhage after adenoidectomy (low
or quality-of-life outcomes (insufficient Nine trials compared side effects for SOE). Evidence was insufficient for other
evidence). tubes with side effects for watchful harms.

TABLE 4 SOE for Interventions to Improve Functional Outcomes and Health-Related Quality-of-Life Outcomes
Intervention and No. of Studies Outcome and Results SOE
Comparator (Sample Sizes)
TTs versus watchful waiting MA of 3 RCTs (n = 394) No difference was observed in language comprehension at Moderate for
or delayed treatment and 2 RCTs (n = 503) 6 to 9 mo postintervention (mean difference, 0.09; 95% CI no difference
20.21 to 0.39) or at preschool and elementary school age.
MA of 3 RCTs (n = 393) No difference was observed in language expression at
and 2 RCTs (n = 503) 6 to 9 mo postintervention (mean difference, 0.03; 95% CI
–0.41 to 0.49) or at preschool and elementary school age.
2 RCTs (n = 503) No difference was observed in cognitive development at 9 mo Low for no
postintervention or at preschool and elementary school age. difference
3 RCTs (n = 710) No difference was observed in behavior at 1 y or more Low for no
difference
2 RCTs (n = 503) No difference was observed in academic achievement at Low for no
elementary school age. difference
MA, meta-analysis; TT, tympanostomy tubes.

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TABLE 5 SOE for Harms of Interventions
Intervention and No. of Studies Outcome and Results SOE
Comparator (Sample Sizes)
TT comparisons 1 RCT (n = 30 ears), Otorrhea occurred more frequently in ears with Low for harms of
2 observational longer-term tubes than in ears with shorter-term longer-term tubes
studies (n = 779 ears) tubes after 1 y or more.
TTs versus watchful waiting 5 RCTs (n = 1129) Tympanosclerosis occurred more frequently in ears Moderate for harms
or myringotomy that had tubes, based on examinations after the of tubes
tubes had been extruded.
4 RCTs (n = 960) Otorrhea occurred more frequently in ears with tubes. Low for harms of tubes
TTs plus adenoidectomy versus 3 studies (2 RCTs; 1 NRCT) Tympanosclerosis occurred more frequently in ears Moderate for harms
adenoidectomy plus myringotomy versus (n = 485) with tubes than ears with only adenoidectomy or of tubes
adenoidectomy alone with myringotomy.
Adenoidectomy versus other 2 trials (n = 739) Although rare, adenoidectomy increased the risk of Low for harms of
treatments postsurgical hemorrhage. adenoidectomy
NRCT, nonrandomized controlled trial; TT, tympanostomy tubes.

Comparative Benefits and Harms ness and harms of various surgical development. Very recent recom-
for Patient Subgroups and nonsurgical treatments for OME. mendations, however,7 are that clini-
Although we attempted to examine This article focuses on surgical pro- cians should offer bilateral tubes to
treatment effectiveness or harms for cedures (tubes, myringotomy, and children with bilateral OME for 3
key subgroups characterized by clinical adenoidectomy and their comparators, months or longer and documented
conditions (eg, cleft palate, Down syn- including watchful waiting and delayed hearing difficulties.
drome, or sensorineural hearing loss) treatment); these are the most com- OME may lead to the development
or sociodemographic factors (eg, age), mon modalities for managing OME. of AOM; the most recent guidelines
we could not identify studies that cov- Tubes yield short-term benefits in for managing AOM69 offer tubes as a
ered most of our subgroups of interest. comparison with either watchful wait- treatment of recurrent AOM if effusion
In a single study of children with sleep ing or myringotomy. The lack of differ-
is present. Our evidence, however,
apnea and OME,44 all of whom had ences between tubes and either
was insufficient to conclude that tubes
adenoidectomy to treat that condition, myringotomy or watchful waiting be-
reduced episodes of AOM in children
tubes and myringotomy did not differ yond 1 or 2 years after surgery is not
with OME.
significantly in terms of any measured surprising given the natural history of
untreated OME and the duration of Evidence was also insufficient to con-
outcomes (insufficient evidence).
tubes. In an analysis of resolution rates clude that tubes varying in length of
of OME across prospective studies, the retention differed in OME recurrence or
Factors Affecting Health Care
Delivery or the Receipt of average resolution rate by ear was 88% in hearing outcomes; no studies com-
Pneumococcal Vaccine Inoculation at 10 to 12 months and 97% at 16 to 24 paring design features of tubes examined
months; the average resolution rate by functional or quality-of-life outcomes. Al-
No study examined issues related to
child was 95% at 7 to 12 months.68 though most studies comparing tubes
health insurance coverage, physician
Tubes did not show benefits for lan- with watchful waiting or myringotomy
specialty, type of facility of the provider,
guage, cognitive, or academic skills at used short-term tubes, we could not
geographic location of patients, pres-
any point; skills of those who received or determine whether short-term tubes
ence or absence of continuity of care,
or previous use of pneumococcal virus did not receive tubes were generally reduced time with OME, produced fewer
inoculation. Thus, evidenceis insufficient within normal limits. Thus, the con- episodes of AOM, or improved hearing.
for all such factors. ductive hearing losses that children Evidence for harms of tubes was
may have experienced did not appear to limited. In comparison with either
DISCUSSION translate to difficulties in language- watchful waiting or myringotomy,
based skills. These studies support tympanosclerosis and otorrhea oc-
Clinical Findings the findings of Roberts and colleagues5 curred more frequently in ears with
In an extensive systematic review whose meta-analyses indicated that tubes; we could not determine the se-
commissioned by the Agency for OME and its associated hearing loss verity of these complications, however.
Healthcare Research and Quality,6 we had no or very small negative associ- Otorrhea occurred more frequently in
examined the comparative effective- ations with children’s later language ears with longer-term tubes than with

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shorter-term tubes. Other harms such OME. Future research needs to fill these sizes; many researchers fail to report
as perforations, cholesteatoma, and at- gaps by examining treatments for their statistical power (the RCTs of the
rophy were inconsistently investigated children with such craniofacial anom- MRC54 and Paradise et al31 being no-
or reported. alies or developmental disorders and table exceptions). Missing data were
Adenoidectomy results in less time with for adults. often not addressed, and even if at-
effusion or better hearing (or both) Several interventions have not been trition was acknowledged, statistical
when compared with no treatment oras subjected to rigorous research meth- procedures were rarely used to cor-
an adjunct to myringotomy. Evidence ods. Inserting tubes remains a common rect for this problem.
was insufficient to determine the com- procedure, yet little evidence is avail-
parative effectiveness of adenoidectomy able about different types of tubes or CONCLUSIONS
for reducing the recurrence of AOM insertion techniques. An ongoing
Overall, we found a small and uneven
or improving functional outcomes. Swedish trial plans to enroll a large
body of evidence across treatment
Evidence for harms of adenoidectomy cohort of children in an RCT comparing
comparisons and outcomes. Com-
was limited (1 case of hemorrhage different tubes70; the results from this
pared with watchful waiting or
reported in each of 2 trials). Evidence trial may provide the needed evidence
myringotomy, we found strong and
for whether tubes confer a clinical benefit regarding which tubes are more (or
consistent evidence that tubes de-
when added to adenoidectomy is also less) beneficial. Other researchers are
creased effusion and improved hear-
limited. Adding tubes to adenoidectomy designing treatments to counteract the
ing over a short period but did not
and myringotomy did not improve hear- otological effects of gastroesophageal
affect speech, language, or other
ing but was more likely to result in reflux disease.70,71
functional outcomes. Weaker evidence
tympanosclerosis. Children who received Many cases of OME start after episodes suggested that tube placement also
bothtubesandadenoidectomyhadbetter of AOM. Vaccines to prevent pneumo- increased the rate of side effects, such
hearing outcomes than children who coccal disease can decrease the fre- as otorrhea and tympanosclerosis.
were actively monitored. quency of AOM.72 As rates of vaccination Although adenoidectomy decreases
No studies meeting our inclusion criteria increase, the character of OME may the number of children with OME in
addressed subpopulations with coexist- change because bacterial infections the short-term relative to watchful
ing conditions, so this article pertains will be less likely to play a role in the waiting, less is known about its long-
mainly to otherwise healthy, typically disease process. The use of vaccines to term outcomes, particularly with
developing children. Only 2 studies were prevent OME was outside the scope of respect to functional outcomes. Ad-
designed to examine treatments in chil- this review, but research documenting ditional research and better methods
dren 2 years or younger28,31; in other whether they decrease the rate of OME are needed to develop a compre-
studies, investigators did not provide in young children would contribute to hensive evidence base to support
sufficient information on age of the tar- understanding prevention of this con- decision-making among the various
get population or included a wide age dition. treatment options, particularly in
range of children. Thus, we could not Few studies included in this article subpopulations defined by age and
ascertain the applicability of the tested were rated as low risk of bias, and coexisting conditions.
intervention to specific age groups. We improving methods in future research
identified no studies of surgical treat- is critical. Study design heterogeneity ACKNOWLEDGMENTS
ments in adults. is a considerable barrier to synthe- The authors thank Amy Greenblatt,
sizing evidence: baseline measures Loraine G. Monroe, Karen Crotty,
Future Research Needs were not always provided; outcome Andrea Yuen, and Christiane E. Voisin
The evidence base is clearly limited for measures and time points for collect- for their assistance in conducting the
infants and adults. It is virtually non- ing outcomes differed. Moreover, systematic review. They also thank
existent for children with major coex- investigators did not routinely report Meera Viswanathan for her input on
isting or congenital conditions, such as on reoccurrence of AOM or on func- standard Agency for Healthcare Re-
those with cleft palate, Down syndrome, tional outcomes; no study measured search and Quality EPC protocols. Finally,
and sensorineural hearing loss, who discomfort from OME. Studies did not we thank Loraine G. Monroe for her as-
may be disproportionately affected by routinely provide (or document) effect sistance in preparing the manuscript.

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16 WALLACE et al
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Surgical Treatments for Otitis Media With Effusion: A Systematic Review
Ina F. Wallace, Nancy D. Berkman, Kathleen N. Lohr, Melody F. Harrison, Adam J.
Kimple and Michael J. Steiner
Pediatrics originally published online January 6, 2014;

Updated Information & including high resolution figures, can be found at:
Services http://pediatrics.aappublications.org/content/early/2014/01/01/peds.2
013-3228
Supplementary Material Supplementary material can be found at:
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013-3228.DCSupplemental
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Pediatrics is the official journal of the American Academy of Pediatrics. A monthly publication, it
has been published continuously since . Pediatrics is owned, published, and trademarked by the
American Academy of Pediatrics, 141 Northwest Point Boulevard, Elk Grove Village, Illinois,
60007. Copyright © 2014 by the American Academy of Pediatrics. All rights reserved. Print
ISSN: .

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Surgical Treatments for Otitis Media With Effusion: A Systematic Review
Ina F. Wallace, Nancy D. Berkman, Kathleen N. Lohr, Melody F. Harrison, Adam J.
Kimple and Michael J. Steiner
Pediatrics originally published online January 6, 2014;

The online version of this article, along with updated information and services, is
located on the World Wide Web at:
http://pediatrics.aappublications.org/content/early/2014/01/01/peds.2013-3228

Pediatrics is the official journal of the American Academy of Pediatrics. A monthly publication, it
has been published continuously since . Pediatrics is owned, published, and trademarked by the
American Academy of Pediatrics, 141 Northwest Point Boulevard, Elk Grove Village, Illinois,
60007. Copyright © 2014 by the American Academy of Pediatrics. All rights reserved. Print
ISSN: .

Downloaded from http://pediatrics.aappublications.org/ by guest on February 27, 2018