International perspectives on management of acute otitis media: a qualitative review

doi:10.1016/j.ijporl.2003.09.002

International Journal of Pediatric Otorhinolaryngology

Volume 68, Issue 1, January 2004, Pages 29-36

https://doi.org/10.1016/j.ijporl.2003.09.002 Get rights and content

Abstract

Background: Current opinions regarding the management of acute otitis media (AOM) in children vary across Western countries. With antibiotic resistance rising and more evidence regarding the limited clinical efficacy of antibiotics becoming available, interest in managing AOM other than with antibiotics is renewed. Objectives: To compare international rates of antibiotic prescription and surgery for AOM. To provide current evidence regarding the efficacy of various treatment options for AOM and their potential complications. Methods: Qualitative (narrative) review. Results: The percentage of patients given antibiotics for AOM varies from 31% in The Netherlands to more than 90% in most other Western countries. The 1998 prevalence of penicillin-resistant S. pneumoniae strains, on the other hand, ranges from 3% in The Netherlands to 53% in France. The surgical rate for tympanostomy tubes varies from 2 per 1000 children per year in the United Kingdom to 20 per 1000 in The Netherlands. The benefit of both antibiotic and surgical therapy in AOM appears to be limited, with numbers needed to treat ranging from 8 to 25 for antibiotic therapy, depending on the definition of outcome. Conclusions: International rates of antibiotic prescription and surgery for AOM vary strongly, which can be explained largely by the lack of uniform evidence-based guidelines. International debates with the aim of overcoming cultural differences regarding the management of otitis media, and of reaching agreement on guidelines on the basis of current evidence are necessary.

Introduction

Otitis media (OM) continues to be one of the most common childhood infections and is the leading cause of doctors’ visits by children [1]. The incidence of acute otitis media (AOM) is highest in children aged less than 2 years of age. Up to 62% of the children experience at least one attack of AOM during the first year of life and over 70% have contracted AOM before their second birthday [2], [3].

Although current opinions regarding the management of acute otitis media (AOM) in children vary across Western countries, AOM is one of the most common indications for both antibiotic treatment [4] and surgery [5] in children in most countries. The evidence regarding the effectiveness of these therapies, however, is marginal. Consequently, the international rates of antibiotic prescription and surgery for AOM show a large variation.

With antibiotic resistance of bacteria rising, the issue whether AOM should be managed aggressively or conservatively is renewed. To decide upon the best alternative, knowledge is needed, not only of the efficacy of various treatment options, but also of its potential complications. In this paper we will (1) compare international rates of antibiotic prescription and surgery for AOM, and (2) provide evidence regarding the efficacy of these treatment options and their complications.

Section snippets

Methods

A systematic search was performed with MEDLINE from 1966 to January 2003 with the subject headings “otitis media”, “randomised controlled trial”, “antibiotics”, “ventilation tubes”, “grommets”, “adenoidectomy”, “practice management”, “antibiotic resistance”, and “complications”.

In addition, the four-yearly published Research Conference Reports on Recent Advances in Otitis Media as well as the proceedings of major international otitis media conferences were included. A review of identified

Antibiotic therapy

Cars et al. [6] recently reported data on outpatient antibiotic sales for 1997 in 15 countries of the European Union (Fig. 1). They showed that the daily-defined dose of antibiotics per 1000 people—irrespective of the condition for which they were prescribed—varied more than fourfold between European countries, from 9 in The Netherlands to 37 in France. It is obvious that this large variation cannot be explained by differences in frequency of bacterial infections.

In 1986 Froom et al. [7]

Discussion

In this paper, we have demonstrated that there are large differences in antibiotic prescription and surgical rates for AOM across the Western world, and that a restrictive policy regarding antibiotics might go together with a more liberal policy regarding surgery for AOM. These international differences regarding management of AOM are possible because there is little evidence about the efficacy of antibiotics and surgery, and uniform management guidelines for AOM in children are missing.

Other

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To investigate postoperative morbidity and mortality after paediatric adenoidectomy.
This was a retrospective national population-based cohort study of data from the Swedish National Patient Register (NPR) and The Swedish Cause of Death Register (CDR).
All patients aged 0–18 years who underwent adenoidectomy from 2007 to 2017 (without concomitant tonsil surgery) were included in this study. To evaluate postoperative morbidity and mortality, all diagnostic and surgical codes registered in the NPR for health care contacts within 30 days of surgery were analysed. The patients retrieved from the NPR were matched with the CDR to identify any deaths occurring within 30 days of the surgery.
A total of 51 746 adenoidectomies were included in this study. No deaths related to adenoidectomy were identified. All types of haemorrhagic complications were rare. Only 0.1% of the surgeries resulted in an outpatient contact due to postoperative haemorrhage and only 0.1% of the adenoidectomies resulted in a readmission due to haemorrhage. The rarest haemorrhagic complication was RTT (return to theatre), with only 4 events (0.01%). Postoperative haemorrhage was most frequent on the first day after surgery. Other complications were rare as well, requiring a total of 922 (2.6%) outpatient visits and 75 (0.2%) readmissions in the adenoidectomy group, with postoperative infection being the most commonly reported.
Overall, adenoidectomy should be considered a safe surgical procedure associated with few postoperative complications. No deaths related to adenoidectomy were found. Severe complications, such as late postoperative haemorrhage after adenoidectomy, were rare, and haemorrhage resulting in RTT was even rarer. The highest rate of postoperative haemorrhage was observed the first day after surgery, and most haemorrhagic complications occurred within a week. Comparisons with studies on tonsil surgery show that adenoidectomy is associated with substantially lower postoperative morbidity.
Effects of early childhood otitis media and ventilation tubes on psychosocial wellbeing – A prospective cohort study within the Danish National Birth Cohort
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Otitis Media (OM) is one of the most common infections among children in developed countries and may result in temporary conductive hearing loss (HL) if accompanied by middle ear effusion (MEE). Ventilation tube insertion (VTI) is recommended as treatment for recurrent acute OM or chronic MEE with HL. HL may lead to impaired development of psychosocial skills. However, evidence for the developmental consequences of OM and the effect of VTI is inconsistent. The objectives of this study were to investigate 1) whether OM in early childhood is associated with long-term consequences of psychosocial development and 2) if VTI prevents the possible negative consequences of OM.
This study examined prospectively collected data from 52.877 children registered in the Danish National Birth Cohort (DNBC). Information about previous OM-episodes and VTI was obtained through systematic follow-up interviews at seven years, and The Strength and Difficulties Questionnaire (SDQ) containing questions about psychological wellbeing was completed. Five groups were defined based on OM-exposure and the presence of VTI. Baseline characteristics were analysed, and comparison of mean SDQ-scores for the five exposure groups was conducted. Means were adjusted for à priori defined confounding factors.
Data from 52,877 children in the DNBC showed an association between OM and poorer SDQ-scores. VTI was associated with an additional increase, i.e. worsening, of the SDQ-score for boys, and only a slight beneficial effect on the girls' outcome. The groups differed in their baseline characteristics in e.g. maternal education, socio-economic status, breastfeeding, and prematurity.
Significant associations between parent-reported OM in early childhood and later psychosocial health difficulties were found. VTI did not resolve this association.
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Observed rates of tympanostomy tube placement varied >30-fold across English PCT (N = 150) and >3-fold across NNE PSA (N = 30). At a 25 dB hearing threshold, the overall difference in observed to expected tympanostomy tubes provided was −3.41 per 1000 child-years in England and −0.01 per 1000 child-years in NNE. Observed incidence of insertion was less than expected in 143 of 151 PCT, and was higher than expected in one-half of the PSA. Using a 20 dB hearing threshold, there were fewer tube insertions than expected in all but 2 England and 7 NNE areas. There was an inverse relationship between estimated need and observed tube insertion rates.
Regional variations in observed tympanostomy tube insertion rates are unlikely to be due to differences in need and suggest overall underuse in England and both overuse and underuse in NNE.
Pediatric adenoid surgery in Sweden 2004-2013: Incidence, indications and concomitant surgical procedures
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A retrospective study based on data from the National patient registry in Sweden. All children born from 1st of January 2004 to December 31st, 2013 who underwent adenoidectomy for the first time in Sweden during 2004–2013 were included in the study. Patient characteristics (age and gender), indications for surgery and performed ENT surgery were evaluated.
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View full text

International perspectives on management of acute otitis media: a qualitative review

Abstract

Introduction

Section snippets

Methods

Antibiotic therapy

Discussion

Int. J. Pediatr. Otorhinolaryngol.

Lancet

Vaccine

Int. J. Pediatr. Otorhinolaryngol.

Otolaryngol. Head Neck Surg.

Otolaryngol. Head Neck Surg.

Lancet

Int. J. Pediatr. Otorhinolaryngol.

Int. J. Pediatr. Otorhinolaryngol.

Ambulatory health care visits by children: principal diagnosis and place of visit

Vital Health Stat.

Epidemiology of otitis media during the first seven years of life in children in Greater Boston: a prospective, cohort study

J. Infect Dis.

Trends in antimicrobial drug prescribing among office-based physicians in the United States

JAMA

Ambulatory and inpatient procedures in the United States, 1996

Vital. Health Stat.

Diagnosis and antibiotic treatment of acute otitis media: report from International Primary Care Network

BMJ

Impact of effective health care bulletin on treatment of persistent glue ear in children: time series analysis

BMJ

Physician and population determinants of rates of middle-ear surgery in Ontario

JAMA