Updates in Pediatric Otolaryngology: Tympanostomy Tubes and Tonsillectomy

Educational Objectives

The goal of this program is to improve the management of common ear, nose, and throat conditions in children according to guidelines from the American Academy of Otolaryngology-Head and Neck Surgery. After hearing and assimilating this program, the clinicians will be able to:

1. Adhere to clinical practice guidelines from the American Academy of Otolaryngology-Head and Neck Surgery (AAO-HNS) guidelines on tympanostomy and tonsillectomy.
2. Appropriately address postoperative pain in children who have undergone tonsillectomy.

Summary

American Academy of Otolaryngology-Head and Neck Surgery (AAO-HNS) guidelines for tympanostomy tubes: contain 16 action statements; Key Action Statement (KAS) 1 recommends against placing tympanostomy tubes for short-duration middle ear effusions; most of these effusions resolve without treatment and cause no harm if duration is <3 mo; tube surgery should be reserved for patients with hearing loss or long-term effusions

Hearing evaluation: hearing should be assessed in children with long-term middle ear fluid and in potential candidates for tympanostomy tubes; normal hearing is now considered ≤15 db hearing level, rather than 20 db; slight hearing loss (HL), ie, hearing level 15 to 25 db, is considered relevant in many children; improved hearing is the most proven outcome for tube surgery; hearing evaluation assesses need for tube placement; hearing tests can be performed in children of all ages; on average, middle ear fluid causes HL to the 28-db level

Recurrent acute otitis media (AOM): KAS 6 recommends against placement of tubes for a child who has a history of recurrent AOM but normal bilateral ear examination when seen by the specialist; this recommendation reflects the favorable natural history of recurrent AOM and suggests that the frequency of AOM may be overdiagnosed or overstated; also, the impact of tubes on reducing recurrence of AOM is limited; Hoberman et al, 2021 found that tubes did not significantly reduce the rate of AOM; in children who have tubes in place, the typical sign of AOM is otorrhea, rather than fever or pain; otorrhea is usually treatable with ear drops rather than oral antibiotics (ABX); conclusion — tubes may provide temporary improvement in conductive HL caused by middle ear effusion but have less impact on the frequency of AOM episodes

Education of clinicians and parents: the importance of educating both about tube complications and need for follow-up was reaffirmed in the updated guidelines; educational materials are provided to assist clinicians in educating caregivers; a patient information sheet covers the indications, complications, follow-up, and tips for treating posttympanostomy otorrhea

Acute posttympanostomy otorrhea: KAS 14 recommends topical ABX drops without oral antibiotics for uncomplicated cases; ototopical drops are safe, effective, and have fewer adverse effects than oral ABX; fluoroquinolone drops are preferred as the initial treatment for new-onset drainage; oral ABX may be necessary if a tube is occluded or infection develops in an ear without a tube; however, ototopical therapy is highly effective when both ears have patent tubes in place and drainage occurs without fever or signs of systemic illness

AAO-HNS guidelines for tonsillectomy: updated guidelines (2019) define tonsillectomy as complete removal of the tonsils (subtotal or intracapsular tonsillectomy was not included because of insufficient evidence); KAS 1 recommends observation rather than surgery when the number of tonsillitis episodes is modest; tonsillectomies are now predominantly performed for sleep-related airway obstruction rather than tonsillitis; reviews of the impact of tonsillectomy for infection shows modest and short-lived effects; Paradise criteria for tonsillectomy — 7 infections in 1 yr or >5 infections in each of the preceding 2 yr, or >3 episodes in each of the preceding 3 yr; recurrent infections must be well documented, with appropriate signs and symptoms, positive Streptococcus cultures; based on a study published in 1984

Recurrent infection: KAS 2 — states physicians may recommend tonsillectomy for very frequent infections; KAS 3 — tonsillectomy may be considered for recurrent infections in the presence of modifying factors (eg, ABX allergies, periodic fevers, history of peritonsillar abscess); assess these factors rather than performing tonsillectomy solely based on the number of infections

Inpatient monitoring after tonsillectomy: the guidelines attempt to identify children who may have respiratory difficulties after surgery and may need intervention; preoperative sleep studies are not performed for many children with clinical risks; therefore, clinical criteria should be used to determine the need for admission after adenotonsillectomy (ADT); risk factors include young age (<3 yr), severe obstructive sleep apnea (OSA), craniofacial anomalies, chromosomal abnormalities, neuromuscular diseases, congenital heart disease, and history of prematurity; the same factors predict incomplete cure of OSA after surgery

Postoperative pain management: a significant issue after ADT; acetaminophen is helpful but often inadequate; the addition of ibuprofen has been found to be safe in most children and can provide pain relief comparable to narcotics, with fewer risks; the guidelines recommend combined ibuprofen and acetaminophen for analgesia, and assessment of pain, with the recognition that opioids can be dangerous in patients who have OSA or unusual opioid sensitivity; use of steroids should also be approached with caution; pain medications such as gabapentin and clonidine remain controversial

Codeine for pain management: KAS 14 strongly recommends against prescription or administration of codeine, or any medication containing codeine, to children after ADT, especially those aged <12 yr; in 2013, the Food and Drug Administration issued a black box warning for codeine use in children after ADT following a review of its use over several decade, which identified deaths at home associated with the drug; the cause of these deaths is not solely related to pharmacokinetics; rather, it is multifactorial, involving factors such as OSA, obesity, and other patient-specific characteristics that increase susceptibility to opioid-related respiratory depression; similar concerns apply to other narcotics (eg, similar warnings have been issued about adverse events associated with tramadol)

Readings

Barrette LX, Harris J, De Ravin E, et al. Clinical practice guidelines for pain management after tonsillectomy: systematic quality appraisal using the AGREE II instrument. Int J Pediatr Otorhinolaryngol. 2022;156:111091; Hoberman A, Preciado D, Paradise JL, et al. Tympanostomy tubes or medical management for recurrent acute otitis media. N Engl J Med. 2021;384:1789-1799; Mitchell RB, Archer SM, Ishman SL, et al. Clinical practice guideline: tonsillectomy in children (update). Otolaryngol Head Neck Surg. 2019;160:S1-42; Rosenfeld RM, Nnacheta LC, Corrigan MD. Clinical consensus statement development manual. Otolaryngol Head Neck Surg. 2015;153:S1-4; Rosenfeld RM, Shiffman RN, Robertson P. Clinical practice guideline development manual: a quality-driven approach for translating evidence into action. Otolaryngol Head Neck Surg. 2013;148:S1-55; Rosenfeld RM, Tunkel DE, Schwartz SR, et al. Executive summary of clinical practice guideline on tympanostomy tubes in children (Update). Otolaryngol Head Neck Surg. 2022;166:189-206.

Disclosures

For this program, the faculty and the members of the planning committee reported nothing relevant to disclose.

Acknowledgements

Dr. Tunkel was recorded at the 49th Annual Pediatric Trends, a live internet conference, held May 9-12, 2023, and presented by the John Hopkins University School of Medicine and the John Hopkins Children's Center, Baltimore, MD. For information about upcoming CME activities from this presenter, please visit https://hopkinscme.cloud-cme.com. Audio Digest thanks the speakers and presenters for their cooperation in the production of this program.

CME/CE INFO

Accreditation:

The Audio- Digest Foundation is accredited by the Accreditation Council for Continuing Medical Education to provide continuing medical education for physicians.

The Audio- Digest Foundation designates this enduring material for a maximum of 0.75 AMA PRA Category 1 Credits™. Physicians should claim only the credit commensurate with the extent of their participation in the activity.

Audio Digest Foundation is accredited as a provider of continuing nursing education by the American Nurses Credentialing Center's (ANCC's) Commission on Accreditation. Audio Digest Foundation designates this activity for 0.75 CE contact hours.

Lecture ID:

PD693502

Expiration:

This CME course qualifies for AMA PRA Category 1 Credits™ for 3 years from the date of publication.

Instructions:

To earn CME/CE credit for this course, you must complete all the following components in the order recommended: (1) Review introductory course content, including Educational Objectives and Faculty/Planner Disclosures; (2) Listen to the audio program and review accompanying learning materials; (3) Complete posttest (only after completing Step 2) and earn a passing score of at least 80%. Taking the course Pretest and completing the Evaluation Survey are strongly recommended (but not mandatory) components of completing this CME/CE course.

Estimated time to complete this CME/CE course:

Approximately 2x the length of the recorded lecture to account for time spent studying accompanying learning materials and completing tests.