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Bad medicine: paediatric ear, nose, and throat surgery

BMJ 2010; 341 doi: https://doi.org/10.1136/bmj.c6560 (Published 17 November 2010) Cite this as: BMJ 2010;341:c6560

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Otitis media with effusion: aiming the right therapy at the right patient

J.A.deRu@umcutrecht.nl

Considering the 'storms of outrage' caused by the article: 'pediatric
ENT, bad medicine', it seems that the discussion on the preferred therapy
for otitis media with effusion (OME) is far from closed. It was suggested
before that OME could function in defence of the body during the first
childhood years and that usually no treatment is needed. Promoting this
point of view can be helpful in the current state-of-war.

Our first statement is that OME is not a singular 'disease', but
merely a symptom. The second suggestion is that resolving the glue itself
is not a prerequisite, yet the cause for the necessity of glue formation
should be taken care of.

We think that the glue is formed in order to protect the middle ear
from further damage when other components of the human defence system have
failed. Various levels of resistance could be implicated, such as
inadequate antibody formation, craniofacial deformities, or Kartagener
syndrome, but it can also develop during a more common (viral) upper
respiratory tract infection. All of these are completely different causes
that consequentially would require different treatment options. The need
for this symptom to develop might theoretically be enhanced due to other
local factors that cause damage to the mucosa such as allergy and reflux.

Ventilation tubes improve the annoying hearing loss and can be
considered in patients with a definite need of improving it. In the past,
groups of patients that might benefit from grommets have been
'identified'. These mostly consist of patients with language and learning
problems. We do agree that a short-term benefit, theoretically, can be
desirable. However, even in these special groups only a marginal benefit
has been established.
Furthermore, over time grommets cause more hearing loss than an
observational policy, and although most eardrum pathology associated with
OME is selflimiting, myringosclerosis which is associated with the
insertion of grommets, shows the least tendency towards recovery. And, we
must not forget that grommet insertion is associated with the development
of otorrhoea. So, perhaps hearing aids might be preferable.

It was postulated that a long-term therapy of antibiotics might be
appropriate for specific patient populations. However, the benefits appear
to be limited, leaving the question whether the slight advantage outweighs
the risk of developing resistance to antibiotics? Furthermore, prescribing
antibiotics leads to more visits to the doctor's office. In light of the
above, we propose a significant decrease in antibiotic therapy, especially
because for most children 'watchful waiting' appears to be justified.

Bio-films are mentioned to explain why active bacteria are found in a
middle ear secretion that otherwise yields a negative culture. However,
the existence of a bio-film isn't of much significance in itself,
especially not, when we consider that this bio-film is not capable of
causing serious infections. This may reverse our thinking: it could be
that the body is capable of building such a strong defence, that bacteria
can only survive in a 'bio-film'.
Recently, it was mentioned that Alloiococcus otitidis might play a part in
OME. Yet, this in no way diminishes the conclusion that it is not possible
to establish any clinically important infection caused by these bacteria.

Reflux may be a contributing factor, based on the presence of bile
salts in the middle ear. This finding does lend more credence to the
premise that once children start spending more time in an upright
position, OME is self-limiting. One wonders whether treatment with acid
inhibitors is an option. Positive results with this kind of treatment are
scarce.

What do we suggest as treatment? There might be valid reasons to take
action against OME, see also the NICE-guidelines on this subject. If so,
adenoidectomy is in many cases probably the best form of treatment to
start with. This will reduce the number of infections as well as its
source.

Corticosteroids in nasal spray were successfully administered in one
study, however these results could not be duplicated in others. This could
be due to differences in the inclusion criteria. Patients in the study
that reported successful treatment were scheduled for grommets and
adenoidectomy, which suggests that these patients had more rhinological
(allergic?) symptoms and were more likely to benefit from said treatment.
The patients in the study with a negative result were a small subgroup
with non-resolving, bilateral OME.

Including every patient with OME in every study does not make sense.
Sub-groups possibly benefiting from the different treatment modalities
need to be defined.

In a recent study a nasal spray with Streptococcus sanguinis
constitutes an interesting new therapy. This therapy offers a boost to the
immune system. Its effectiveness needs further confirmation, but we like
the thought of improving the immune system.

In conclusion, the current surgical or medical therapy of OME often
is a form of 'over' treatment. When confronted with OME in children the
focus, more than ever, is a matter of aiming the right therapy at each
individual child.

Competing interests: No competing interests

16 September 2011
Jacob A. de Ru
otorhinolaryngologist
Paul A.A. Struyvenberg
Central Military Hospital, Utrecht, the Netherlands