Otitis Media guidelines

The clinical practice guidelines for otitis media (the medical term for ear infections) have just been published. Nothing could be more exciting to the field of otolaryngology (the ear specialists) than these new guidelines. What is the big deal about new practice guidelines?

About 15 years ago the government formed a group of specialists to hash out the current knowledge in several major fields. They reviewed the medical literature about what worked and what didn't. Otitis was high on the government's list. Ear infections represent one of the most common disorders of childhood. About 2.2 million cases are diagnosed each year in the United States. The cost of treating these ear infections is estimated at $4 billion. By first grade, 90% of all children have had at least one ear infection. Ear infections are the most common reason that a child has surgery. The experts put together recommendations about the diagnosis and treatment of uncomplicated ear infections. The idea was to give doctors an idea of where current knowledge was in treating ear infections. The end product is not an easy document to read. It has lots of flow diagrams with, if this then that and so on. As an ear doctor, I couldn't put it down, but most readers might doze into a coma.

Most practicing physicians really don't follow the guidelines. They're a complicated set of rules and recommendations which dictate what to do and when to do it but you have to remember a lot of arcane stuff. This is a relatively new kind of document summarizing our current knowledge about a particular issue and unlike almost anything else you have read, this is long and complicated from the first paragraph. Physicians know that each individual patient has a complex medical history and unique set of needs associated with a given disease process. A physician may be aware of several conditions that the patient has that have not been studied and therefore the ear infection needs to be treated in a manner different from the guidelines. An example is that a child might have a history of a congenital heart condition and a new ear infection. An ear infection could lead to serious heart problems and this is not part of the guidelines. The doctor might decide that the treatment should be more aggressive than the guidelines suggest.

Insurance companies, on the other hand, want to pay only for the care that is absolutely necessary. They want to know how they can cut their cost and still provide relatively high-quality care. These guidelines are often used by insurance companies to ensure patients receive adequate and appropriate treatment. They don't want to pay for something that might be unnecessary. Several insurance companies use these guidelines to determine if surgery is 'really' necessary.

Before the Second World War, otitis media or its complications resulted in 2% of all hospital deaths. After the advent of penicillin, ear infections were minor inconveniences. The field of otolaryngology was turned upside down. In recent years, ear infections have been returning. There are several factors that are playing into this new epidemic. 1) Children who live with smokers are more likely to have ear infections. 2) Children who are in day-care centers are more likely to give each other an infection. 3) Because we've used our antibiotics for a number of years, the bacteria have developed an 'immunity to the drugs.' The frequently used antibiotics are becoming useless against certain types of bacteria. This process is called antibiotic resistance. The three most common bacterial causes of ear infections are now increasingly resistant to penicillin-based drugs.

So how do the guidelines handle these problems? The guidelines have recommendations about how to diagnose ear infections. Many ear infections are caused by a virus and there is no good treatment for viral illnesses. Get a cold, the best treatment is still chicken soup. (I checked this one with my mom. The guidelines make no specific recommendations about treating viral infections.) They recommended abandoning older forms of treatment. Antihistamines and decongestants have never been shown to be effective and therefore the new guidelines recommend against their use. Because speech and language delays can sometimes occur, the new recommendation suggests that hearing testing should be performed when a child has three months or more of infected fluid in the ear. The use of antibiotics for treatment is recommended when strict criterion are met. In children who have persisting or recurring problems, they may require surgical intervention with the placement of PE tubes. While doctors have recommended tonsillectomy for many years, there is no scientific evidence to suggest that tonsillectomy alone has any influence on the rate of infections. Adenoidectomy, however, has been shown to be an effective treatment.

The authors of the guidelines also have identified a real need for better research in this area. Some issues could not be clearly addressed. Many people feel that allergy plays a role in the development of otitis but the evidence has been conflicting. There is a need for better tools to identify which child can be watched and which one requires more aggressive antibiotic therapy or even surgery. The authors recognize that bacterial resistance is an increasing problem. Careful monitoring will be necessary to determine which antibiotics can and should be used in the near future.

The guidelines represent 30 pages of fairly small type and complicated reading. They will dramatically influence what insurance companies will pay for in the very near future. They may change how your family doctor approaches the treatment of an ear infection. Hopefully, we in the medical community will get this right so we don't return to an era where ear infections are a serious problem.