4.1 Initial follow up

4.1.1 FOLLOW UP FOR AOM

The natural history of AOM is for spontaneous resolution in most cases. The possibility exists for incomplete resolution and the development of a longstanding effusion, or a chronic perforation with or without discharge. It is difficult to visualise the tympanic membrane of a discharging ear, so these patients should be re-examined after two weeks. If a perforated drum is visible at this stage further GP review is required. Patients with persisting problems should be referred to an otolaryngologist (see section 4.2.1).

4.1.2 FOLLOW UP FOR OME

As OME is a condition which is well recognised to relapse and remit during its natural history until resolution occurs, commonly around the age of seven to eight years, the observation that the effusion has cleared and the hearing has reverted to normal does not necessarily imply that the child will have no further problems. The strategy of watchful waiting has been developed before taking a decision about surgical intervention. Underpinning this is the concept that a single observation of the child does not permit an assessment of the severity of the condition which varies with time.⁶⁹ A child diagnosed with OME should be observed for a period in order to assess severity and disability and evaluate the need for referral for an opinion within the secondary care services. This can be done in the primary care setting by regular review of history of symptoms from parents, teachers and speech and language therapist if appropriate. Otoscopy and, if facilities for accurate testing are available, audiometry and tympanometry, may be needed. A regular review within the primary care setting is advisable. Two or three monthly visits may be necessary before the picture becomes clear and the need for referral established.

4.2 Referral

4.2.1 REFERRAL FOR AOM PATIENTS

No studies were identified concerning when AOM patients should be referred. The pilot National Institute for Clinical Excellence (NICE) referral advice recommends referral for frequent episodes of AOM, which is defined as more than four episodes in six months.⁷⁰ An American guideline recommends referral for more than three episodes in six months, or more than four episodes in 12 months.⁷¹ Neither the PRODIGY guideline (www.prodigy.nhs.uk) nor New Zealand Guideline Group (www.nzgg.org.nz) make any recommendation on referral for AOM. Evidence level 4

Given the absence of evidence better than expert opinion and the minor differences between previous guidelines, the NICE recommendation has been adopted.

Complications of AOM such as mastoiditis or facial nerve paresis require referral.

Children with frequent episodes (more than four in six months) of acute otitis media, or complications, should be referred to an otolaryngologist.

4.2.2 REFERRAL FOR OME PATIENTS

No studies on the referral of OME patients were identified. The evidence from three trials comparing early grommet insertion with delayed surgery/watchful waiting may be helpful in making referral decisions. Evidence level 1++,1+

One American RCT (429 patients) of early versus delayed grommet insertion in children under three with mild to moderate hearing loss and OME showed that early surgery gave no benefit in terms of language development, speech sound production, cognition or behaviour.⁷² Evidence level 1++,1+

Another RCT conducted in the Netherlands studied 182 children, under three years of age, who had failed a hearing test but were otherwise asymptomatic.⁷³ Again no benefit with early surgery was demonstrated. Evidence level 1++,1+

A UK study looking at behaviour and language development showed that early surgery gave marginally significant benefits in language development at nine months. Early surgical intervention significantly reduced behavioural problems by 17%. This difference was largely mediated by concurrent hearing loss. After 18 months, there was no longer a significant difference. However, the majority (85%) of the watchful waiting group had required surgery and 22% of all children still had behavioural problems.^{74, 75} The conclusion was that there is some benefit from ventilation-tube insertion for expressive language and verbal comprehension but that the timing of surgery is not critical. Evidence level 1++,1+

For children under three with OME and mild to moderate hearing loss (=<25 dB) and no other problems, there is consistent evidence that watchful waiting is as good as early surgery.^{72, 73} It should be noted that the children in these trials all underwent audiometry to exclude a more serious degree of hearing loss.

The trial showing benefits from early surgery included children over three and those with behavioural or language problems.^{74, 75} Accordingly, children with persistent OME over the age of three years, or with language, behavioural or developmental problems should be referred.

Children under three years of age with persistent bilateral otitis media with effusion and hearing loss of =<25 dB, but no speech and language, development or behavioural problems, can be safely managed with watchful waiting. If watchful waiting is being considered, the child should undergo audiometry to exclude a more serious degree of hearing loss.

Children with persistent bilateral otitis media with effusion who are over three years of age or who have speech and language, developmental or behavioural problems should be referred to an otolaryngologist.