Otitis Media Guidelines Leave Door Open for Chiropractic

Federally-Funded Practice Guidelines Encourage Parents to "Discuss All Treatments with Your Child's Health Care Provider"

By Editorial Staff

The long-awaited clinical practice guidelines on otitis media with effusion (OME) have finally been published. The effort was funded by the Agency for Health Care Policy and Research (AHCPR) and carried out by a consortium of the American Academy of Pediatrics, the American Academy of Family Physicians, and the American Academy of Otolaryngology-Head and Neck Surgery.

The Parent Guide

The consumer version for OME is not provider specific. In all cases, the term "health care provider" is used. It begins with a discussion of OME and how it can be prevented (keep kids away from cigarette smoke and sick playmates). It continues with a description of the types of tests used for determining OME.

While this pamphlet does make specific suggestions regarding treatment, it first stresses that there are many alternatives, and that what works for one child may not work for another. They urge parents to discuss with their provider the treatment options and the pros and cons of each.

The three specific suggestions made for the treatment of OME are: observation, antibiotic drug treatment, and surgery (tubes in the ears). Parents are warned about potential undesirable effects of the antibiotic and surgery alternatives and the cost of such treatment.

The final portion of the parent pamphlet discusses what treatments are not recommended for children. While this is where one might expect the pediatric community to place chiropractic care, the list was restricted to certain drugs and surgery:

decongestants and antihistamines
steroids
adenoidectomy
tonsillectomy

The Parent Guide, in summation, explains OME, makes some suggestions and discourages those surgeries and drugs that are not proven or have been shown to be ineffective. It doesn't mention spinal manipulation/adjustments but leaves the opportunity for chiropractors to discuss other "treatments" with concerned parents.

Quick Reference Guide for Clinicians

This 16-page pamphlet gives the reader some insight into just how widespread the problem of otitis media really is and why it's a concern to so many parents. Chiropractic doesn't receive a recommendation, nor is it listed as "not recommended." The Quick Reference Guide has only this to say:

"Evidence regarding other therapies for the treatment of otitis media with effusion was sought, but no reports of chiropractic, holistic, naturopathic, traditional/indigenous, homeopathic, or other treatments contained information obtained in randomized controlled studies. Therefore, no recommendation was made regarding such other therapies for the treatment of otitis media with effusion in children."

Clinical Practice Guideline

There are however several ways to reduce the risks and increase the recovery rate of OME. The panel reviewed studies where "breast-feeding versus bottle-feeding showed a several-fold increase of otitis media in bottle-fed compared to breast-fed infants." Other studies showed that the risk of otitis media was 2.8 times higher for a child in a household with smokers. The most consistent research demonstrated a definite "relationship between otitis media with effusion and child care in group facilities."

Antibiotics and Tympanostomy Tubes

The clinician guidelines give a greater discussion of the adverse effects of antibiotics and the potential harm of tympanostomy tubes. These are important to know:

"Nevertheless, potentially serious adverse effects--especially allergic reactions--do occur with this therapy in young children. The most common adverse effects of antibiotic drug therapy are gastrointestinal, with diarrhea occurring in about 9 percent of children treated with 20-40 mg/kg/day of amoxicillin with clavulanic acid.
"Dermatologic reactions can occur in 3 to 5 percent of cases; severe anaphylactic reactions occur much less frequently; severe hematologic, cardiovascular, central nervous system, endocrine, renal, hepatic, and respiratory adverse effects are more rare still.
"Finally, there is concern that unnecessary use of antibiotics might lead to antimicrobial drug resistance and potentially more serious illness with later episodes of infection.
"Morbidity associated with myringotomy and insertion of tympanostomy tubes can include external auditory canal wall laceration, persistent otorrhea, granuloma formation at the myringotomy site, cholesteatoma, and permanent tympanic membrane perforation ...
"Structural changes in the tympanic membrane, such as flaccidity, retraction, and/or tympanosclerosis, can occur, especially in cases repeated tube insertions ...
"As high a proportion as 30 percent of children can need to undergo repeat tympanostomy tube insertion within 5 years after the initial surgery (Maw, 1991).
"The literature review allowed the Panel to assess the frequency of two specific complications of myringotomy with tympanostomy tube insertion--tympanosclerosis and postoperative otorrhea. Meta-analysis of data from two studies showed a risk of tympanosclerosis of 51 percent...
"The possible effects of tympanosclerosis on long-term hearing are not known, but the Panel estimated from experience that they would be small. The risk of postoperative otorrhea was calculated by meta-analysis of data from three studies to be 13 percent ...
"Other disadvantages of tympanostomy tubes include the risks associated with the general anesthesia or substantial sedation required for the procedure ... and possible limitations on the child's activity while tubes are in place. Another problem complicating tube placement is persistent eardrum perforation. Finally, intrusion of the tube into the middle ear cleft instead of normal extrusion into the external ear canal can occur. Because records are not kept of the fate of every tympanostomy tube, the incidence of this complication is not known. It could, however, result in increased risk of further episodes of otitis media, as well as tympanomastoiditis, cholesteatoma, or infection due to the foreign body."

While the clinical practice guidelines made no recommendation regarding chiropractic, the panel did make this comment:

"The Panel found the process of the Open Meeting, during which many individuals provided interesting testimony on the other therapies, both enlightening and disappointing. The Panel was impressed by the variety and apparent safety of many of the proposed therapies, but was disappointed that none had been submitted to scientific study. The Panel suggests that research begin with those other therapies commonly provided that appear the least likely to have adverse effects. Study designs should be similar to those proposed for evaluation of drugs and surgery."

The opportunities for chiropractic research are very apparent. While the profession has missed the opportunity to conduct research prior to the convening of this panel, these guidelines will be updated.

Editor's note: Please see Dr. Claudia Anrig Howe's in-depth analysis of the AHCPR guidelines on OME beginning on the front page.

The AHCPR guidelines are available free-of-charge by calling toll-free 800-358-9295.