This is the current release of the guideline.

American Academy of Pediatrics (AAP) Policies are reviewed every 3 years by the authoring body, at which time a recommendation is made that the policy be retired, revised, or reaffirmed without change. Until the Board of Directors approves a revision or reaffirmation, or retires a statement, the current policy remains in effect.

The evidence grades (A-D) and evidence-based statements (Strong Recommendation, Recommendation, Option, and No Recommendation) are repeated at the end of the "Major Recommendations" field.

1A. Pneumatic Otoscopy: Clinicians should use pneumatic otoscopy as the primary diagnostic method for otitis media with effusion (OME), and OME should be distinguished from acute otitis media (AOM).
(This is a strong recommendation based on systematic review of cohort studies and the preponderance of benefit over harm).

Aggregate evidence quality: A, diagnostic studies in relevant populations
Policy level: strong recommendation

1B. Tympanometry: Tympanometry can be used to confirm the diagnosis of OME.
(This option is based on cohort studies and a balance of benefit and harm.)

Aggregate evidence quality: B, diagnostic studies with minor limitations
Policy level: option

1C. Screening: Population-based screening programs for OME are not recommended in healthy, asymptomatic children.
(This recommendation is based on randomized, controlled trials and cohort studies, with a preponderance of harm over benefit.)

Aggregate evidence quality: B, randomized, controlled trials with minor limitations and consistent evidence from observational studies
Policy level: recommendation against

2. Documentation: Clinicians should document the laterality, duration of effusion, and presence and severity of associated symptoms at each assessment of the child with OME.
   (This recommendation is based on observational studies and strong preponderance of benefit over harm.)

   Aggregate evidence quality: C, observational studies
   Policy level: recommendation

3. Child at Risk: Clinicians should distinguish the child with OME who is at risk for speech, language, or learning problems from other children with OME and should evaluate hearing, speech, language, and need for intervention more promptly.
   (This recommendation is based on case series, the preponderance of benefit over harm, and ethical limitations in studying children with OME who are at risk.)

   Aggregate evidence quality: C, observational studies of children at risk; D, expert opinion on the ability of prompt assessment and management to alter outcomes
   Policy level: recommendation

4. Watchful Waiting: Clinicians should manage the child with OME who is not at risk with watchful waiting for 3 months from the date of effusion onset (if known) or diagnosis (if onset is unknown).
   (This recommendation is based on systematic review of cohort studies and the preponderance of benefit over harm.)

   Aggregate evidence quality: B, systematic review of cohort studies
   Policy level: recommendation

5. Medication: Antihistamines and decongestants are ineffective for OME and are not recommended for treatment; antimicrobials and corticosteroids do not have long-term efficacy and are not recommended for routine management.
   (This recommendation is based on systematic review of randomized, controlled trials and the preponderance of harm over benefit.)

   Aggregate evidence quality: A, systematic review of well-designed, randomized, controlled trials
   Policy level: recommendation against

6. Hearing and Language: Hearing testing is recommended when OME persists for 3 months or longer or at any time that language delay, learning problems, or a significant hearing loss is suspected in a child with OME; language testing should be conducted for children with hearing loss.
   (This recommendation is based on cohort studies and the preponderance of benefit over risk.)

   Aggregate evidence quality: B, diagnostic studies with minor limitations; C, observational studies
   Policy level: recommendation

7. Surveillance: Children with persistent OME who are not at risk should be reexamined at 3- to 6-month intervals until the effusion is no longer present, significant hearing loss is identified, or structural abnormalities of the eardrum or middle ear are suspected.
   (This recommendation is based on randomized, controlled trials and observational studies with a preponderance of benefit over harm.)

   Aggregate evidence quality: C, observational studies and some randomized trials
   Policy level: recommendation

8. Referral: When children with OME are referred by the primary care clinician for evaluation by an otolaryngologist, audiologist, or speech-language pathologist, the referring clinician should document the effusion duration and specific reason for referral (evaluation, surgery) and provide additional relevant information such as history of acute otitis media (AOM) and developmental status of the child.
   (This option is based on panel consensus and a preponderance of benefit over harm.)

   Aggregate evidence quality: C, observational studies
   Policy level: option

9. Surgery: When a child becomes a surgical candidate, tympanostomy tube insertion is the preferred initial procedure; adenoidectomy should not be performed unless a distinct indication exists (nasal obstruction, chronic adenoiditis). Repeat surgery consists of adenoidectomy plus myringotomy, with or without tube insertion. Tonsillectomy alone or myringotomy alone should not be used to treat OME.
   (This recommendation is based on randomized, controlled trials with a preponderance of benefit over harm.)

   Aggregate evidence quality: B, randomized, controlled trials with minor limitations
   Policy level: recommendation

10. Complementary and Alternative Medicine (CAM): No recommendation is made regarding complementary and alternative medicine (CAM) as a treatment for OME.
    (There is no recommendation based on lack of scientific evidence documenting efficacy and an uncertain balance of harm and benefit.)

    Aggregate evidence quality: D, case series without controls
    Policy level: no recommendation

11. Allergy Management: No recommendation is made regarding allergy management as a treatment for OME.
    (There is no recommendation based on insufficient evidence of therapeutic efficacy or a causal relationship between allergy and OME.)

    Aggregate evidence quality: D, case series without controls
    Policy level: no recommendation

Definitions:

Evidence-Based Statements

Strong Recommendation: A strong recommendation means that the subcommittee believes that the benefits of the recommended approach clearly exceed the harms (or that the harms clearly exceed the benefits in the case of a strong negative recommendation) and that the quality of the supporting evidence is excellent (grade A or B)*. In some clearly identified circumstances, strong recommendations may be made based on lesser evidence when high-quality evidence is impossible to obtain and the anticipated benefits strongly outweigh the harms. Implication: Clinicians should follow a strong recommendation unless a clear and compelling rationale for an alternative approach is present.

Recommendation: A recommendation means that the subcommittee believes that the benefits exceed the harms (or that the harms exceed the benefits in the case of a negative recommendation), but the quality of evidence is not as strong (grade B or C)*. In some clearly identified circumstances, recommendations may be made based on lesser evidence when high-quality evidence is impossible to obtain and the anticipated benefits outweigh the harms. Implication: Clinicians also should generally follow a recommendation but should remain alert to new information and sensitive to patient preferences.

Option: An option means that either the quality of evidence that exists is suspect (grade D)* or that well-done studies (grade A, B, or C)* show little clear advantage to one approach versus another. Implication: Clinicians should be flexible in their decision-making regarding appropriate practice, although they may set boundaries on alternatives; patient preference should have a substantial influencing role.

No Recommendation: No recommendation means that there is both a lack of pertinent evidence (grade D)* and an unclear balance between benefits and harms. Implication: Clinicians should feel little constraint in their decision-making and be alert to new published evidence that clarifies the balance of benefit versus harm; patient preference should have a substantial influencing role.

* Refer to "Rating Scheme for the Strength of the Evidence" field above for the definitions of evidence grades.

Evidence Quality for Grades of Evidence

Grade A: Well-designed, randomized, controlled trials or diagnostic studies performed on a population similar to the guideline’s target population

Grade B: Randomized, controlled trials or diagnostic studies with minor limitations; overwhelmingly consistent evidence from observational studies

Grade C: Observational studies (case-control and cohort design)

Grade D: Expert opinion, case reports, or reasoning from first principles (bench research or animal studies)

None provided

The recommendations contained in the practice guideline are based on the best available published data through April 2003. Where data are lacking, a combination of clinical experience and expert consensus was used. The type of supporting evidence is identified and graded for each recommendation (see "Major Recommendations").

Not applicable: The guideline was not adapted from another source.

2004 May

American Academy of Family Physicians - Medical Specialty Society
American Academy of Otolaryngology - Head and Neck Surgery Foundation - Medical Specialty Society
American Academy of Pediatrics - Medical Specialty Society

American Academy of Pediatrics
American Academy of Family Physicians
American Academy of Otolaryngology-Head and Neck Surgery

Subcommittee on Otitis Media with Effusion

Subcommittee on Otitis Media with Effusion: Richard M. Rosenfeld, MD, MPH, American Academy of Pediatrics (AAP), American Academy of Otolaryngology-Head and Neck Surgery (AAO-HNS), Co-chairperson; Larry Culpepper, MD, MPH, American Academy of Family Physicians (AAFP), Co-chairperson; Karen J. Doyle, MD, PhD, AAO-HNS; Kenneth M. Grundfast, MD, AAO-HNS; Alejandro Hoberman, MD, AAP; Margaret A. Kenna, MD, AAO-HNS; Allan S. Lieberthal, MD, AAP; Martin Mahoney, MD, PhD, AAFP; Richard A. Wahl, MD, AAP; Charles R. Woods, Jr., MD, MS, AAP; Barbara Yawn, MD, MSc, AAFP

Consultants: S. Michael Marcy, MD; Richard N. Shiffman, MD

Liaisons: Linda Carlson, MS, CPNP, National Association of Pediatric Nurse Practitioners; Judith Gravel, PhD, American Academy of Audiology; Joanne Roberts, PhD, American Speech-Language-Hearing Association

Staff: Maureen Hannley, PhD, AAO-HNS; Carla T. Herrerias, MPH, AAP; Bellinda K. Schoof, MHA, CPHQ, AAFP

Dr Marcy serves as a consultant to Abbott Laboratories GlaxoSmithKline (vaccines).

This is the current release of the guideline.

American Academy of Pediatrics (AAP) Policies are reviewed every 3 years by the authoring body, at which time a recommendation is made that the policy be retired, revised, or reaffirmed without change. Until the Board of Directors approves a revision or reaffirmation, or retires a statement, the current policy remains in effect.

None available

None available

This NGC summary was completed by ECRI on July 2, 2004. The information was verified by the guideline developer on August 4, 2004.

This NGC summary is based on the original guideline, which is subject to the guideline developer's copyright restrictions. Please contact the Permissions Editor, American Academy of Pediatrics (AAP), 141 Northwest Point Blvd, Elk Grove Village, IL 60007.