Evidence Profile: Surveillance

Aggregate evidence quality: C, observational studies and some randomized trials.

Benefit: avoiding interventions that do not improve outcomes.

Harm: allowing structural abnormalities to develop in the tympanic membrane, underestimating the impact of hearing loss on a child, and/or failing to detect significant signs or symptoms that require intervention.

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

Policy level: recommendation.

REFERRAL: WHEN CHILDREN WITH OME ARE REFERRED BY THE PRIMARY CARE CLINICIAN FOR EVALUATION BY AN OTOLARYNGOLOGIST, AUDIOLOGIST, OR SPEECH-LANGUAGE PATHOLOGIST, THE REFERRING CLINICIAN SHOULD DOCUMENT THE EFFUSION DURATION AND SPECIFIC REASON FOR REFERRAL (EVALUATION, SURGERY) AND PROVIDE ADDITIONAL RELEVANT INFORMATION SUCH AS HISTORY OF AOM AND DEVELOPMENTAL STATUS OF THE CHILD

This option is based on panel consensus and a preponderance of benefit over harm.

This recommendation emphasizes the importance of communication between the referring primary care clinician and the otolaryngologist, audiologist, and speech-language pathologist. Parents and caregivers may be confused and frustrated when a recommendation for surgery is made for their child because of conflicting information about alternative management strategies. Choosing among management options is facilitated when primary care physicians and advanced-practice nurses who best know the patient's history of ear problems and general medical status provide the specialist with accurate information. Although there are no studies showing improved outcomes from better documentation of OME histories, there is a clear need for better mechanisms to convey information and expectations from primary care clinicians to consultants and subspecialists.

When referring a child for evaluation to an otolaryngologist, the primary care physician should explain the following to the parent or caregiver of the patient:

- Reason for referral: Explain that the child is seeing an otolaryngologist for evaluation, which is likely to include ear examination and audiologic testing, and not necessarily simply to be scheduled for surgery.

- What to expect: Explain that surgery may be recommended, and let the parent know that the otolaryngologist will explain the options, benefits, and risks further.

- Decision-making process: Explain that there are many alternatives for management and that surgical decisions are elective; the parent or caregiver should be encouraged to express to the surgeonany concerns he or she may have about the recommendations made.

When referring a child to an otolaryngologist, audiologist, or speech-language pathologist, the minimum information that should be conveyed in writing includes:

- Duration of OME: State how long fluid has been present.

- Laterality of OME: State whether one or both ears have been affected.

- Results of prior hearing testing or tympanometry.

- Suspected speech or language problems: State whether there had been a delay in speech and language development or whether the parent or a caregiver has expressed concerns about the child's communication abilities, school achievement, or attentiveness.

- Conditions that might exacerbate the deleterious effects of OME: State whether the child has conditions such as permanent hearing loss, impaired cognition, developmental delays, cleft lip or palate, or an unstable or nonsupportive family or home environment.

- AOM history: State whether the child has a history of recurrent AOM.

Additional medical information that should be provided to the otolaryngologist by the primary care clinician includes:

- Parental attitude toward surgery: State whether the parents have expressed a strong preference for or against surgery as a management option.

- Related conditions that might require concomitant surgery: State whether there have been other conditions that might warrant surgery if the child is going to have general anesthesia (eg, nasal obstruction and snoring that might be an indication for adenoidectomy or obstructive breathing during sleep that might mean tonsillectomy is indicated).

- General health status: State whether there are any conditions that might present problems for surgery or administering general anesthesia, such as congenital heart abnormality, bleeding disorder, asthma or reactive airway disease, or family history of malignant hyperthermia.

After evaluating the child, the otolaryngologist, audiologist, or speech-language pathologist should inform the referring physician regarding his or her diagnostic impression, plans for additional assessment, and recommendations for ongoing monitoring and management.