Guidelines
AAO-HNSF Guidelines on Tympanostomy Tubes in Children
In February 2022, the American Academy of Otolaryngology–Head and Neck Surgery Foundation (AAO-HNSF) issued updated recommendations regarding tympanostomy tubes (TTs) in children. [31]
The following were listed as strong recommendations:
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Topical antibiotic ear drops alone, without oral antibiotics, should be prescribed for children with uncomplicated acute TT otorrhea.
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The child's ears should be examined within 3 months of TT insertion, AND families should be educated regarding the need for routine periodic follow-up until the tubes extrude.
The following were listed as recommendations:
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TT insertion should not be performed in children with a single episode of otitis media (OM) with effusion (OME) of < 3 months' duration from the date of either onset (if known) or diagnosis (if onset is unknown).
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A hearing evaluation is indicated if OME persists for ≥3 months or before surgery when a child becomes a candidate for TT insertion.
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Bilateral TT insertion should be offered to children with bilateral OME for ≥3 months and documented hearing difficulties.
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Children with chronic OME who do not receive TTs should be reevaluated at 3- to 6-month intervals until effusion is no longer present, significant hearing loss is detected, or structural abnormalities of the tympanic membrane or middle ear are suspected.
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TT insertion should not be performed in children with recurrent acute OM (AOM) who do not have middle-ear effusion (MEE) in either ear at assessment for TT candidacy.
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Bilateral TT insertion should be offered to children with recurrent AOM who have unilateral or bilateral MEE at assessment for TT candidacy.
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Efforts should be made to determine whether a child with recurrent AOM or with OME of any duration is at increased risk for speech, language, or learning problems from OM because of baseline factors.
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In children who meet criteria for TT insertion, long-term tubes should not be placed initially unless specifically warranted by anticipated need for prolonged middle-ear ventilation beyond what a short-term tube supplies.
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In the perioperative period, caregivers of children with TTs should be educated regarding expected duration of tube function, recommended follow-up schedule, and detection of complications.
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Antibiotic ear drops should not be routinely prescribed after TT placement.
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Routine prophylactic water precautions should not be encouraged for children with TTs.
The following were listed as options:
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TT insertion may be performed in children with unilateral or bilateral OME for ≥3 months (chronic OME) and symptoms likely to be attributable to OME, including (but not limited to) balance (vestibular) problems, poor school performance, behavioral problems, ear discomfort, or reduced quality of life.
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TT insertion may be performed in at-risk children with unilateral or bilateral OME that is likely to persist as reflected by a type B (flat) tympanogram or a documented effusion for ≥3 months.
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Adenoidectomy may be performed as an adjunct to TT insertion in children with symptoms directly related to the adenoids or in children aged ≥4 years as a potential means of reducing future recurrence of OM or need for repeat TT insertion.
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AAO-HNSF/AAP/AAFP Guidelines for Otitis Media With Effusion
In February 2016, the AAO-HNSF, the American Academy of Pediatrics (AAP), and the American Academy of Family Practice (AAFP) issued the following updated guidelines for OME [29] :
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The clinician should perform pneumatic otoscopy to assess for OME in a child with otalgia, hearing loss, or both
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Clinicians should obtain tympanometry in children with suspected OME for whom the diagnosis is uncertain after performing (or attempting) pneumatic otoscopy
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Clinicians should evaluate at-risk children for OME at the time of diagnosis of an at-risk condition and at 12-18 months of age (if diagnosed as being at risk prior to this time)
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Clinicians should not routinely screen children for OME who are not at risk and do not have symptoms that may be attributable to OME, such as hearing difficulties, balance (vestibular) problems, poor school performance, behavioral problems, or ear discomfort
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Clinicians should manage the child with OME who is not at risk with watchful waiting for 3 months from the date of effusion onset (if known) or 3 months from the date of diagnosis (if onset is unknown)
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Clinicians should recommend against using intranasal steroids or systemic steroids for treating OME
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Clinicians should recommend against using systemic antibiotics for treating OME
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Clinicians should recommend against using antihistamines, decongestants, or both for treating OME
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Clinicians should obtain an age-appropriate hearing test if OME persists for ≥3 months or for OME of any duration in an at-risk child
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Clinicians should reevaluate, at 3- to 6-month intervals, children with chronic OME until effusion is no longer present, significant hearing loss is identified, or structural abnormalities of the eardrum or middle ear are suspected
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Clinicians should recommend TTs when surgery is performed for OME in a child aged < 4 years; adenoidectomy should not be performed unless a distinct indication (eg, nasal obstruction, chronic adenoiditis) exists other than OME
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Clinicians should recommend TTs, adenoidectomy, or both when surgery is performed for OME in a child aged ≥4 years
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AAP/AAFP Guidelines for Acute Otitis Media
In February 2013, the AAP and the AAFP published updated guidelines for the medical management of AOM. [24] Their recommendations are summarized as follows:
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AOM management should include pain evaluation and treatment
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Antibiotics should be prescribed for bilateral or unilateral AOM in children aged at least 6 months with severe signs or symptoms (moderate or severe otalgia or otalgia for 48 hours or longer or temperature 39°C or higher) and for nonsevere, bilateral AOM in children aged 6-23 months
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On the basis of joint decision-making with the parents, unilateral, nonsevere AOM in children aged 6-23 months or nonsevere AOM in older children may be managed either with antibiotics or with close follow-up and withholding antibiotics unless the child worsens or does not improve within 48-72 hours of symptom onset
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Amoxicillin is the antibiotic of choice unless the child received it within 30 days, has concurrent purulent conjunctivitis, or is allergic to penicillin; in these cases, clinicians should prescribe an antibiotic with additional beta-lactamase coverage
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Clinicians should reevaluate a child whose symptoms have worsened or not responded to the initial antibiotic treatment within 48-72 hours and change treatment if indicated
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In children with recurrent AOM, TTs—but not prophylactic antibiotics—may be indicated to reduce the frequency of AOM episodes
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Clinicians should recommend pneumococcal conjugate vaccine and annual influenza vaccine to all children according to updated schedules
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Clinicians should encourage exclusive breastfeeding for 6 months or longer
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Media Gallery
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Diagram of the normal tympanic membrane anatomy.
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Healthy tympanic membrane.
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Acute otitis media with purulent effusion behind a bulging tympanic membrane.
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Chronic otitis media with a retraction pocket of the pars flaccida.
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Cholesteatoma of the pars flaccida.
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Central/pars tensa tympanic membrane perforation with a healthy middle ear membrane.
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Central/pars tensa tympanic membrane perforation with a tympanostomy tube in place.
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Various tympanostomy tube styles and sizes.
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Initial presentation of a young girl with chronic right ear pain and multiple untreated middle ear infections.
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Acute coalescent mastoiditis with a Bezold abscess in a young girl who presented with chronic right ear pain and multiple untreated middle ear infections.
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A young girl who presented with chronic right ear pain and multiple untreated middle ear infections on the operating table for mastoidectomy and drainage of Bezold abscess.
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Aspirating pus from the Bezold abscess for Gram staining, culturing, and sensitivity testing in a young girl who presented with chronic right ear pain and multiple untreated middle ear infections.
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Surgical incision to aspirate pus in a young girl who presented with chronic right ear pain and multiple untreated middle ear infections.
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Freer elevator demonstrating extension of an abscess cavity from the mastoid into the neck in a young girl who presented with chronic right ear pain and multiple untreated middle ear infections.
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Incision is closed and a drain is placed in the abscess cavity in a young girl who presented with chronic right ear pain and multiple untreated middle ear infections.
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Postoperative bandage in a young girl who presented with chronic right ear pain and multiple untreated middle ear infections.
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The wound now appears clean and dry on postoperative day 4. This young girl initially presented with chronic right ear pain and multiple untreated middle ear infections.
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Postoperative day 4: Mom is smiling. This young girl initially presented with chronic right ear pain and multiple untreated middle ear infections.
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