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Evidence Profile: Hearing and Language





Aggregate evidence quality: B, diagnostic studies with minor limitations; C, observational studies.

Benefit: to detect hearing loss and language delay and identify strategies or interventions to improve developmental outcomes.

Harm: parental anxiety, direct and indirect costs of assessment, and/or false-positive results.

Balance of benefit and harm: preponderance of benefit over harm.

Policy level: recommendation.

SURVEILLANCE: CHILDREN WITH PERSISTENT OME WHO ARE NOT AT RISK SHOULD BE REEXAMINED AT 3- TO 6-MONTH INTERVALS UNTIL THE EFFUSION IS NO LONGER PRESENT, SIGNIFICANT HEARING LOSS IS IDENTIFIED, OR STRUCTURAL ABNORMALITIES OF THE EARDRUM OR MIDDLE EAR ARE SUSPECTED

This recommendation is based on randomized, controlled trials and observational studies with a preponderance of benefit over harm.

If OME is asymptomatic and is likely to resolve spontaneously, intervention is unnecessary even if OME persists for more than 3 months. The clinician should determine whether risk factors exist that would predispose the child to undesirable sequelae or predict nonresolution of the effusion. As long as OME persists, the child is at risk for sequelae and must be reevaluated periodically for factors that would prompt intervention.

The 2000 OME guideline recommended surgery for OME persisting 4 to 6 months with hearing loss but requires reconsideration because of later data on tubes and developmental sequelae. For example, selecting surgical candidates using duration-based criteria (eg, OME >3 months or exceeding a cumulative threshold) does not improve developmental outcomes in infants and toddlers who are not at risk. Additionally, the 2000 OME guideline did not specifically address managing effusion without significant hearing loss persisting more than 6 months.

Asymptomatic OME usually resolves spontaneously, but resolution rates decrease the longer the effusion has been present, and relapse is common. Risk factors that make spontaneous resolution less likely include:

- Onset of OME in the summer or fall season

- Hearing loss more than 30-dB HL in the better-hearing ear

- History of prior tympanostomy tubes

- Not having had an adenoidectomy

Children with chronic OME are at risk for structural damage of the tympanic membrane because the effusion contains leukotrienes, prostaglandins, and arachidonic acid metabolites that invoke a local inflammatory response. Reactive changes may occur in the adjacent tympanic membrane and mucosal linings. A relative underventilation of the middle ear produces a negative pressure that predisposes to focal retraction pockets, generalized atelectasis of the tympanic membrane, and cholesteatoma.

Structural integrity is assessed by carefully examining the entire tympanic membrane, which, in many cases, can be accomplished by the primary care clinician using a handheld pneumatic otoscope. A search should be made for retraction pockets, ossicular erosion, and areas of atelectasis or atrophy. If there is any uncertainty that all observed structures are normal, the patient should be examined by using an otomicroscope. All children with these tympanic membrane conditions, regardless of OME duration, should have a comprehensive audiologic evaluation.

Conditions of the tympanic membrane that generally mandate inserting a tympanostomy tube are posterosuperior retraction pockets, ossicular erosion, adhesive atelectasis, and retraction pockets that accumulate keratin debris. Ongoing surveillance is mandatory, because the incidence of structural damage increases with effusion duration.

As noted in recommendation 6, children with persistent OME for 3 months or longer should have their hearing tested. Based on these results, clinicians can identify 3 levels of action based on HLs obtained for the better-hearing ear using earphones or in sound field using speakers if the child is too young for ear-specific testing.

1) HLs of ≥40 dB (at least a moderate hearing loss): A comprehensive audiologic evaluation is indicated if not previously performed. If moderate hearing loss is documented and persists at this level, surgery is recommended, because persistent hearing loss of this magnitude that is permanent in nature has been shown to impact speech, language, and academic performance.

2) HLs of 21 to 39 dB (mild hearing loss): A comprehensive audiologic evaluation is indicated if not previously performed. Mild sensorineural hearing loss has been associated with difficulties in speech, language, and academic performance in school, and persistent mild conductive hearing loss from OME may have a similar impact. Further management should be individualized based on effusion duration, severity of hearing loss, and parent or caregiver preference and may include strategies to optimize the listening and learning environment or surgery. Repeat hearing testing should be performed in 3 to 6 months if OME persists at follow-up evaluation or tympanostomy tubes have not been placed.

3) HLs of ≥20 dB (normal hearing): A repeat hearing test should be performed in 3 to 6 months if OME persists at follow-up evaluation.

In addition to hearing loss and speech or language delay, other factors may influence the decision to intervene for persistent OME. Roberts showed that the caregiving environment is more strongly related to school outcome than was OME or hearing loss. Risk factors for delays in speech and language development caused by a poor caregiving environment included low maternal educational level, unfavorable child care environment, and low socioeconomic status. In such cases, these factors may be additive to the hearing loss in affecting lower school performance and classroom behavior problems.

Persistent OME may be associated with physical or behavioral symptoms including hyperactivity, poor attention, and behavioral problems in some studies and reduced child quality of life. Conversely, young children randomized to early versus late tube insertion for persistent OME showed no behavioral benefits from early surgery. Children with chronic OME also have significantly poorer vestibular function and gross motor proficiency when compared with non-OME controls. Moreover, vestibular function, behavior, and quality of life can improve after tympanostomy tube insertion. Other physical symptoms of OME that, if present and persistent, may warrant surgery include otalgia, unexplained sleep disturbance, and coexisting recurrent AOM. Tubes reduce the absolute incidence of recurrent AOM by ~1 episode per child per year, but the relative risk reduction is 56%.

The risks of continued observation of children with OME must be balanced against the risks of surgery. Children with persistent OME examined regularly at 3- to 6-month intervals, or sooner if OME-related symptoms develop, are most likely at low risk for physical, behavioral, or developmental sequelae of OME. Conversely, prolonged watchful waiting of OME is not appropriate when regular surveillance is impossible or when the child is at risk for developmental sequelae of OME because of comorbidities. For these children, the risks of anesthesia and surgery (see recommendation 9) may be less than those of continued observation.

Date: 2015-09-27; view: 314; Нарушение авторских прав; Помощь в написании работы --> СЮДА...



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