1. Management of Otitis Media with Effusion (OME) in primary care
Kifayat Ullah
Core Surgical Trainee East of England Deanery

2. Objectives 1. Background and prevalence of OME
2. Distinguishing OME from AOM
3. Risk factors of OME
4. Audit on OME management
5. Conclusion

3. Background
OME or “glue ear” commonest cause of childhood hearing impairment
Inflammation of middle ear with collection of liquid in middle ear space
Peak 2-6 years of age
85% of children experience fluid in ears following infection
50% resolve within 3 months
Otitis media with effusion- is the most appropriate term used to describe the presence of inflammation of the middle ear with a collection of liquid in the middle ear space when signs and symptoms of acute infection are absent.
PAUSE
Acute otitis media- inflammation of the middle ear that is of rapid and short onset in association with signs and symptoms indicating acute infection
There is no foolproof combination of otoscopic signs and symptoms to discriminate between acute otitis media and otitis media with effusion.

4. Prevalence of OME 1993 - 1995 (NCHS),2 OM accounted for
18% ambulatory visits (1-4 yr)
14% visits during the 1st yr of life
OME episodes diagnosed2
81% in pediatric practices
13% in hospital ED
6% in hospital outpatient departments
Data collected from the National Center for Health Statistics (NCHS) between reflects the prevalence of otitis media as one of the most common primary care clinical problems.

5. Distinguishing OME from AOM
The following published algorithm has been used in clinical trials and for instructing trainees. It provides objective and stringent diagnostic criteria to facilitate the distinction of these two conditions through careful otoscopic examination.
As illustrated, a diagnosis of otitis media with effusion requires the presence of middle ear effusion with abnormal colour of TM (white, yellow) and opacification not due to scarring and absence of otoscopic signs of acute inflammation

6. Risk factors of OME Host factors Environmental factors Age/Gender
Genetic predisposition
Cleft palate/Down syndrome
Allergy/Immunity
Environmental factors
Daycare/Siblings
Bottle (versus breast) feeding
Pacifier use
Smoking
Low socioeconomic status
Season/Upper respiratory infections
Risk factors for recurrent otitis media are host related factors and environmental factors.

7. Why do this audit? OME management not understood in community
Parents frustration why symptoms have not resolved
Unnecessary visits to ENT clinic

8. Audit
Prospective study run in ENT outpatient clinic at Tunbridge Wells Hospital, Kent
250 children aged between 2 and 10 years of age referred from primary care
Data collected prospectively in the form of a questionnaire
New referrals recruited over 12 month period
This audit of current practice in the management of OME in childhood was designed to establish current practice in a DGH

9. Main standards in audit
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 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.
Over four years of age:
To children’s 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.
Guideline commissioned and approved by the Clinical Audit and Practice Advisory Group, ENT-UK

10. Questionnaire: Initial referrals and management of OME
This is the questionnaire that was used to identify the area concerned

11. Results
Otitis media with effusion is most prevalent between 2 and 5 years of age because younger children are immunologically naïve to a variety of respiratory viruses .
In younger children there are also anatomical differences, that is, a shorter, and horizontal lying Eustachian tube, which predisposes to accumulation of secretions in the middle ear.
Both clinic and population-based investigations since 1995 have supported the findings that male gender is a risk factor for cumulative time with Otitis Media with effusion.

12. Results

13. Results No hearing test in community
All children reviewed developed conductive hearing loss
Tympanograms = type B in 90% of children
True OME in 90% of children examined
10% of children have had recent AOM
10% delay in development of speech

14. Discussion
Most children managed in community not managed according to guidelines
OME management not understood to indicate an optimal strategy
Concern regarding hearing test where none of the children had this performed prior to ENT visit
The results of this audit support the contention that most children diagnosed with OME in community were not managed in line with current accepted best practice.
It should be pointed out that it is difficult to have a consensus concerning the correct management for OME when it is not understood appropriately in the community
The findings concerning audiometric testing at the initial visit are of some concern. The evaluation of hearing is an important part of the initial assessment of this type of case especially when it comes to surgical treatment of OME. Performing hearing test in the community prior to ENT follow up according to the guidelines provides appropriate management of OME and saves ENT clinic time.

15. Discussion
OME huge impact on speech development and educational performance
30% of children had delay in speech and development
Treatment for OME should initially start with ‘watchful waiting’ – 64% children started on decongestants/antihistamines/antibiotics
OME is a common and important condition because of its impact on speech development and educational performance. Appropriate management of the condition is particularly important because of the relatively high aggregate costs of treatment to the NHS. While guidelines can be formulated for its management, based on existing data, there are still significant gaps in our knowledge and scope for individualisation of care.
30% of children had delay in speech and development – this may suggest some of the presentations in clinic may have been of a chronic nature but never investigated.
Treatment for OME should initially start with ‘watchful waiting’ – 64% children started on decongestants/antihistamines/antibiotics of those 60% started on all three. A period of active clinical monitoring is recommended for three months following initial diagnosis of OME. “Watchful waiting” (WW) has been the term for this, although in an increasingly consumer-led NHS, that term may become unacceptable to parents, and especially so unless the watching is as evident as the waiting.
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.

16. Changes made
Standards had not been met mainly due to lack of knowledge in management of OME
Following action plan:
Presentation at GP trainee teaching sessions
Leaflet and poster distribution to GP clinics
Develop a checklist for GP doctors in community when assessing children with possible OME
Currently – action plans have been implemented and re-audit is currently active

17. Conclusion
Audit indicates OME management needs appropriate decision making
Concerns raised regarding audiology services in the community
After a watchful waiting period- refer to ENT clinic if no improvement for further management

18. References Audit Commission access to care 2002
B1E F8572 Accessed 13/12/06
1  Lous J, Burton MJ, Felding JU, Oveson T, Wake M, Williamson IG. Grommets (ventilation tubes) for hearing loss associated with otitis media with effusion in children. (Cochrane Review). In: The Cochrane Library, Issue 4,2002. Oxford: Update Software.
2  Williamson I. (1999). Otitis media with effusion. Clinical Evidence: 2: BMJ Publishing, London.
3  Williamson I. (2002) Otitis media with effusion. Clinical Evidence 7: BMJ Publishing, London.
4  Cohen H, Friedman EM, Lai D, Pellicer M, Duncan N, Sulek M (1997) Balance in children with otitis media with effusion. Int J Ped Otorhinolaryngol 42,
5  Bluestone CD, Gates GA, Klein JO, Lim DJ, Mogi G, Ogra PL, Paparella MM, Paradise J, Tos M. (2002). Definitions, Terminology and Classification of otitis media. In: Lim D (ed). Recent advances in otitis media. Ann Otol Rhinol Laryngol. (supp). 111: 8-18.
6  Effective Health Care Bulletin. No. 4, (1992) The Treatment of Persistent Glue Ear in Children Effective Health Care Bulletin (4), University of Leeds, ISSN:
7  Haggard M. (2003) MRC randomised trial on surgical treatment of OME (“glue ear”) in children – 50 findings from TARGET and related HSR & epidemiological studies. March MRC- ESS in Children’s Middle Ear Disease, Cambridge. (Unpublished report).

19. Questions?