1. Chronic otitis media A scoping review and evidence map for a suite of Cochrane reviews
Mahmood Bhutta
TWJ & Colledge Family Memorial Otology Fellow
Systematic review team
Dr Chris Brennan-Jones, Prof Anne Schilder, Prof Martin Burton,
Dr Lee-Yee Chong, Karen Head
Lead Patient Representative
Courtney McMahen
Clinical expert team
Dr Mahmood Bhutta, Prof Shyan Vijayasekaran, Prof Peter Richmond,
Prof Peter Morris, Dr Tom Snelling, Dr Nathan Tu

2. Background Chronic suppurative otitis media is a major global disease
Disproportionately affects poor & under-resourced populations
Regional prevalence of CSOM per thousand population (2005)
Two Cochrane reviews completed over 10 years ago. Need to examine evidence from new trials and provide relevant guidance based on those findings.
Also an opportunity to examine emerging treatments like Betadine ear washes, which are currently the subject of trials.
Original plan was for 2-3 reviews of pragmatic treatments such as topical antiseptics (i.e. Betadine ear wash) – but decided this was a good opportunity to pursue the full suite of non-surgical interventions for CSOM
Our searches identified one major international guideline: the current World Health Organization (WHO) guideline, published in 2004 (CSOM – burden of illness and management options). Part of the evidence base that was used to support this guideline was published as two Cochrane systematic reviews on the use of antibiotics. CD005608: Systemic antibiotics versus topical treatments for chronically discharging ears with underlying eardrum perforations; CD004618: Topical antibiotics without steroids for chronically discharging ears with underlying eardrum perforations

3. Treatments Primary ear care Medical care Surgical care Aural toileting
Topical antiseptics
Topical antibiotics +/- steroids
Systemic antibiotics
Tympanoplasty
Surgical care
Medical care
Primary ear care
Two Cochrane reviews completed over 10 years ago. Need to examine evidence from new trials and provide relevant guidance based on those findings.
Also an opportunity to examine emerging treatments like Betadine ear washes, which are currently the subject of trials.
Original plan was for 2-3 reviews of pragmatic treatments such as topical antiseptics (i.e. Betadine ear wash) – but decided this was a good opportunity to pursue the full suite of non-surgical interventions for CSOM
Our searches identified one major international guideline: the current World Health Organization (WHO) guideline, published in 2004 (CSOM – burden of illness and management options). Part of the evidence base that was used to support this guideline was published as two Cochrane systematic reviews on the use of antibiotics. CD005608: Systemic antibiotics versus topical treatments for chronically discharging ears with underlying eardrum perforations; CD004618: Topical antibiotics without steroids for chronically discharging ears with underlying eardrum perforations

4. Aims Initial scoping exercise to identify existing gaps in evidence
& to define important outcome measures for interventions for COM
External stakeholder engagement
Conduct a suite of high-priority Cochrane reviews on COM
Incorporate findings into local, national (CRE_ICHEAR TAG) and international (WHO) clinical guidelines
Two Cochrane reviews completed over 10 years ago. Need to examine evidence from new trials and provide relevant guidance based on those findings.
Also an opportunity to examine emerging treatments like Betadine ear washes, which are currently the subject of trials.
Original plan was for 2-3 reviews of pragmatic treatments such as topical antiseptics (i.e. Betadine ear wash) – but decided this was a good opportunity to pursue the full suite of non-surgical interventions for CSOM
Our searches identified one major international guideline: the current World Health Organization (WHO) guideline, published in 2004 (CSOM – burden of illness and management options). Part of the evidence base that was used to support this guideline was published as two Cochrane systematic reviews on the use of antibiotics. CD005608: Systemic antibiotics versus topical treatments for chronically discharging ears with underlying eardrum perforations; CD004618: Topical antibiotics without steroids for chronically discharging ears with underlying eardrum perforations

5. Evidence base Last Cochrane review conducted in 2005
Many potential trials published since then (1859 hits)
Details blinded……

6. Stakeholder engagement
Known experts identified and asked to identify others (snowball effect)
10 Stakeholders recruited (7 Australia, 2 Asia, 1 Africa)
Stakeholder opinions elicited (Jan 2017)
Which treatments they use & how these are administered
Prioritise (rank) review topics
Confirm / refute outcome measures
Confirm / refute subgroups for analysis
Findings and details discussed within research team
Finalised protocol

7. Review topics
Topical antibiotics vs placebo (subgroup by antibiotic class)
Systemic antibiotics vs placebo (subgroup by antibiotic class)
Topical antibiotics vs systemic antibiotics
Topical antibiotics vs topical antiseptic
Topical antiseptic vs placebo (subgroup by chemical class)
Aural toileting vs placebo
Topical corticosteroid (+/- antibiotic) vs no corticosteroid
Public health measures or preventative therapies
Decongestants, antihistamines
Surgery

8. Outcomes Resolution of ear discharge Health related quality of life
at 2 weeks, 2-4 weeks, >4 weeks
Health related quality of life
questionnaires such as COMOT-12, COMOT-15, CES
Hearing
Pure tone average
Adverse effects
Pain / discomfort
Ototoxicity (hearing loss, dizziness and tinnitus)
Secondary fungal infection
Primary outcome measures
Secondary outcome measures

9. Analysis controversies
Duration of discharge for diagnosis (6 weeks?)
Include studies with chronic ear discharge and diagnosis unknown (if proportion is <20%)
Exclude cholesteatoma / tympanic membrane retraction
Analysis by patient (by ear analysis also)
Adjunctive aural toileting ignored for topical therapies
Subgroup by
Young children (age < 4)
High risk groups (grommets, indigenous groups, cleft palate, Down syndrome)
Pure tone average is an incomplete evaluation of hearing

10. Completion timeline Protocols nearing completion
Complete analysis by end of 2017
Publish suite of reviews in 2018

11. Acknowledgments Funding Participants in the stakeholder exercise
CRE ICHEAR,
Western Australia Department of Health
Colledge Family Memorial Fellowship / TWJ Fellowship
Participants in the stakeholder exercise
Traditional owners of this land and their elders
Contacts