Otitis Media Guidelines for Australian Aboriginal and Torres Strait Islander Children

Menzies School of Health Research. (2020).

(Version 1.1), Available from: https://otitismediaguidelines.com/.

This clinical practice guideline provides recommendations regarding the prevention and management of otitis media (OM) in children of Australian Aboriginal and Torres Strait Islander descent. Only recommendations within audiology scope of practice are included within this article summary.

National Health and Medical Research Council Centre of Research Excellence in Ear and Hearing Health of Aboriginal and Torres Strait Children (Australia); GlaxoSmithKline

A digital summary of this guideline is available via the Otitis Media Guidelines app.

Expectant mothers should receive information about:<br /> <ul> <li>The importance of the prevention, early detection, and treatment of OM in order to prevent associated hearing loss and associated impacts on language, social skills, and education.</li> <li>The importance of neonatal screening.</li> <li>The impact of crowding and increased interactions with young children on germ spreading and OM risk&nbsp;(<strong>Consensus Recommendation</strong>).</li> </ul>

Information about OM and effective communication strategies for people with hearing loss should be provided throughout the community. Families and care partners should be told:<br /> <ul> <li>The onset of OM in infants of Aboriginal descent may occur within the first weeks or months of life.</li> <li>The early onset of OM is associated with high risk of persistent OM with effusion (OME) throughout early childhood, recurrent acute OM with or without perforation (AOMwiP and AOMwoP), chronic suppurative OM (CSOM), hearing loss, language delay, learning disability, and behavior problems.&nbsp;</li> <li>Other upper respiratory infections increase risk of acute OM.&nbsp;</li> <li>Some features of OM (e.g., ear pain) may not be present during active infection.</li> <li>Regular health clinic check-ups and ear examinations are recommended. Ear examinations should be requested at every visit for both ears.</li> <li>All forms of OM are associated with hearing loss of varying degrees.</li> <li>Language input and stimulation is important for language development.</li> <li>To seek medical assistance as soon as possible whenever their child develops ear pain or discharge, especially in young children&nbsp;(<strong>Consensus Recommendation</strong>).</li> </ul>

Mothers should be encouraged, when possible, to continue to breast feed for at least 6 months in order to reduce the risk of OM during the first 2 years of life&nbsp;(<strong>Strong Recommendation; Very Low Quality of Evidence</strong>). Pacifier use after 6 months of age should be restricted due to OM risk&nbsp;(<strong>Weak Recommendation; Very Low Quality of Evidence</strong>).<strong>&nbsp;</strong>

If the child is bottle-fed, mothers should be advised that an upright position is recommended, if possible, in order to reduce risk of OM (<strong>Consensus Recommendation</strong>).

Frequent hand washing and drying should be encourages for children in order to prevent the risk of OM, especially in crowded settings (e.g., day care)<br /> <ul> <li>Children should perform hand hygiene after blowing their noses or coughing.</li> <li>Their faces and hands should be kept clean of nasal discharge (<strong>Strong Recommendation; Low Quality Evidence</strong>).</li> </ul>

Children should not be exposed for people who are smoking, as it is a risk factor for OM (<strong>Strong Recommendation; Very Low Quality Evidence</strong>).

OME should be diagnosed in children with evidence of middle ear effusion with intact tympanic membranes in the absence of signs and symptoms of acute inflammation. Care partners should be educated that antibiotics, hearing assessment, speech and language treatment, and possibly surgery may be considered if OME has persisted for &gt;3 months<strong>. </strong>Appropriate referrals should be made for otolaryngology (ENT) services, pediatrician services, audiological evaluation, or speech therapy for children with persistent OME (<strong>Consensus Recommendation</strong>).<strong>&nbsp;</strong>

The following recommendations were made regarding AOMwoP:<br /> <ul> <li><span style="color: #333333;">Accurate diagnosis of AOMwoP requires otoscopic assessment of tympanic membrane (TM) appearance alongside evaluation of the compliance or mobility of the TM via pneumatic otoscopy or tympanometry. A bulging, cloudy, or red TM are most consistent with a diagnosis of AOMwoP.</span></li> <li><span style="color: #333333;">When appropriate, educate care partners that: </span><span style="color: #333333;">AOMwoP often resolves spontaneously in populations with low risk of CSOM, that antibiotic adherence is especially important for children with increased risk of CSOM, that temporary hearing loss is likely, that they should seek medical assistance in the child develops ear discharge or pain or if their is concerns about language development, and that children, especially those in high-risk populations, may be asymptomatic.</span></li> <li><span style="color: #333333;">The child should be reviewed after 4-7 days and at 3 months following treatment, or earlier if there is any sign of deterioration.'</span></li> <li><span style="color: #333333;">Audiometric testing is not recommended for a singular episode of AOMwoP, however children at high risk of more than one episode should be referred to audiology</span><strong style="color: #333333;"> </strong><span style="color: #333333;">(</span><strong style="color: #333333;">Consensus Recommendation</strong><span style="color: #333333;">).</span><strong style="color: #333333;">&nbsp;</strong></li> </ul>

Watchful waiting for signs of infection should be applied if the child is &gt;2 years old, is not part of a high-risk population for CSOM, does not have a perforation, adequate follow-up in 48 hours can be assured, and the child does not meet any criteria for immediate treatment&nbsp;(<strong>Weak Recommendation; Moderate Quality of Evidence</strong>).

The following recommendations were made regarding AOMwiP:<br /> <ul> <li><span style="color: #333333;">During evaluation of children with AOMwiP, the duration of ear discharge and size/position of TM perforation should be documented. </span></li> <li><span style="color: #333333;">When appropriate, educate care partners about: how to clean/dry mop the ears with tissue spears, the importance of medication adherence, the likelihood of temporary hearing loss, and the importance of seeking medical assistance if there are any concerns of delayed speech and language development.</span></li> <li><span style="color: #333333;">The child should be reviewed weekly until the signs of AOMwiP have resolved and with 4 weeks of treatment cessation for children at high risk of CSOM.</span></li> <li><span style="color: #333333;">Treatment and management of CSOM should be commenced if there is persistent discharge through an easily visible perforation despite treatment.&nbsp;</span></li> <li><span style="color: #333333;">Audiometric testing is not recommended for a singular episode of AOMwiP</span><strong style="color: #333333;">&nbsp;</strong><span style="color: #333333;">(</span><strong style="color: #333333;">Consensus Recommendation</strong><span style="color: #333333;">).</span><strong style="color: #333333;">&nbsp;</strong></li> </ul>

The following recommendations were made regarding recurrent acute otitis media (i.e., 3 or more episodes of acute OM within a 6 month period or 4 or more episodes with 1 year):<br /> <ul> <li>Care partners should be educated that children who have had acute OM are at risk for further episodes, the importance of medication adherence, the risk of hearing loss, and the importance of seeking medical assistance in the instances of ear pain, ear discharge, or concerns regarding delayed speech and language.</li> <li>Refer to ENT for consideration of tympanostomy tubes with or without adenoidectomy if recurrent acute OM fails to improve following treatment.&nbsp;</li> <li>For children with persistent OME between acute OM episodes, monitor for hearing impairment or speech and language delays. If hearing loss is &gt;30dB refer for hearing aids.</li> <li>Audiometric evaluation is recommended for recurrent acute OM (<strong>Consensus Recommendation</strong>).&nbsp;</li> </ul>

The following recommendations were made regarding CSOM:<br /> <ul> <ul> <li><span style="color: #333333;">During evaluation, only diagnosis CSOM in children who have persistent ear discharge over 2-6 weeks and/or if a perforation is easily visualized and is either &gt;2% or determined to be adequate allow for passage of topical treatments.</span></li> <li><span style="color: #333333;">The duration of discharge and the size and position of perforations should be documented.&nbsp;<br /></span></li> <li><span style="color: #333333;">In order to rule out cholesteatoma, patients with attic perforation or persistent crusting /granulation should be referred to an ENT immediately.</span></li> <li><span style="color: #333333;">When appropriate, educate care partners about: the importance of medication adherence, the discharge visibly outside of the ear canal indicating profuse discharge, likely hearing loss and the important of hearing evaluation, and the importance of seeking medical assistance if there are any concerns of delayed speech and language development.</span></li> <li><span style="color: #333333;">The child should be reviewed weekly until the signs of CSOM have resolved and additionally at 4 weeks after the resolution of symptoms.</span></li> <li><span style="color: #333333;">Audiology, ENT, and speech therapy referral should be performed for all children with CSOM at the time of diagnosis&nbsp;(<strong>Consensus Recommendation</strong>).</span></li> </ul> </ul>

The following recommendations were made regarding dry perforation:<br /> <ul> <li><span style="color: #333333;">When appropriate, educate care partners about: increased risk of developing CSOM, the importance of seeking medical assistance as soon as any ear discharge is present, the importance of hearing assessment, and the need to support speech and language development in children with CSOM. </span></li> <li><span style="color: #333333;">A referral to audiology should be conducted to monitor the effects of any post-surgical interventions and for any dry perforation persists for 3 months or more.</span></li> <li><span style="color: #333333;">A referral to speech therapy services should be made for all children with language, learning, or behavioral problems.</span></li> <li><span style="color: #333333;">A referral to an ENT specialist should be performed for children &gt;6 years of age with a dry perforation lasting for more than 6-12 months and for children with recurrent infections or conductive hearing loss of 20 or more dB (<strong>Consensus Recommendation</strong>).</span></li> </ul>

The following recommendations were made regarding tympanostomy tube otorrhoea (TTO): <br /> <ul> <li><span style="color: #333333;">When appropriate, educate care partners about: the frequency of TTO in children with tympanostomy tubes (approximately 50%), the importance of follow-up with the child's ENT and primary care provider, and the importance of seeking medical assistance following ear discharge.</span></li> <li><span style="color: #333333;">Continuous TTO for 4 weeks that has not responded to treatment and intermittent or recurrent TTO for 3 months should be discussed with the treating ENT specialist urgently&nbsp;(<strong>Consensus Recommendation</strong>).</span></li> </ul>

Families and care partners should be educated that:<br /> <ul> <li>Hearing loss occurs in all children with OM.</li> <li>It is important to identify and treat hearing loss and a hearing evaluation should occur if ear trouble persists for 3 months or more.&nbsp;</li> <li>The first 4 years of life are the most important for learning language and communication skills. Learning, language, and communication skills may be reduced if these children are not promptly helped to hear well. These skills are important for social relationships, school learning, and job prospects as well as learning language, culture and traditions, and participation in family and community life.&nbsp;</li> <li>Family and care partners can assist in developing these skills by talking with babies and children daily and as much as possible (e.g. stories, singing, reading), by playing listening games, by reducing background noise and ensuring that the child can see the face of anyone talking to them, conversing and ensuring both the child and the communication partner are fully paying attention, following the child's interest, by ensuring the daily use of any prescribed hearing aids, and by taking part in their children's early learning at home, in child care centers, and in preschool (<strong>Consensus Recommendation</strong>).&nbsp;</li> </ul>

The following recommendations were made regarding screening and surveillance for children with or at risk of developing OM:<br /> <ul> <li>Universal hearing screenings is recommended to provide early detection of significant, permanent hearing loss. Family and staff should be educated that a pass on this screening does not guarantee that the child's hearing will remain normal. Follow-up should occur with any referrals generated from neonatal screenings.</li> <li>Regular OM surveillance from birth upwards is preferred to pre-school and school entry screenings. Children with recurrent, persistent, and chronic OM should be placed on a review register and managed according to their diagnosis as outlined in these guidelines.</li> <li>Routine and opportunistic ear and hearing checks should include otoscopy, tympanometry using 1000Hz probe tone for children whose corrected age is &lt;6 months and using a 226Hz tone for children aged 6 months or older, and audiometric testing for children over the age of 3.5 years. Otoacoustic emissions testing may also be included.</li> <li>For populations with known high prevalence of early onset, chronic middle ear disease, such as individuals of Australian Aboriginal and Torres Strait Islander descent, resources should be first directed to strengthen primary healthcare surveillance for youngest children.</li> <li>Direct linkage of school-age screening and primary health case should occur, and screening programs should not be the sole or primary strategy for OM diagnosis and treatment&nbsp;(<strong>Consensus Recomemndation</strong>).</li> </ul>

Audiologist referral should occur for babies and children for which:<br /> <ul> <li>there is suspected hearing loss;</li> <li>CSOM is diagnosed;</li> <li>any other form of OM has persisted for 3 or more months; or</li> <li>there are speech, language, or developmental delays.&nbsp;</li> </ul> Appropriate hearing assessment should occur to diagnose the degree and type of hearing loss, confirm middle ear condition, inform clinical decision making, monitor intervention outcomes, and plan hearing and communication (re)habilitation. In the event of delayed access to services family and care partners should be encourages to provide interventions to reduce the impact of hearing loss, with referral to SLP services as needed&nbsp;(<strong>Consensus Recommendation</strong>).<strong>&nbsp;</strong>

Prompt referral for hearing aid consultation should occur:<br /> <ul> <li>upon diagnosis of bilateral CSOM in children aged 3 or younger;</li> <li>other forms of OM persist for 3 or more months with associated hearing los of &gt;30 dB;</li> <li>when family or care partners feel that their child may require hearing aids; or</li> <li>hearing could be expected by ENT specialty management, however, the expected wait for these services is greater than 6 months.</li> </ul> Healthcare providers can support the family by providing emotional support and by providing helpful strategies&nbsp; for toddlers and young children resisting hearing aid use (<strong>Consensus Recommendation</strong>).

Children with OM should be referred to speech language pathologist (SLP) immediately if:<br /> <ul> <li>by 3-6 months of age they are not communicating by vocalizing or eye gaze;</li> <li>by 9 months they have poor feeding or oral coordination;</li> <li>by 12 months they are not babbling;</li> <li>by 20 months they are not speaking and are communicating only by pointing or using gestures;</li> <li>by 24 months they are using &lt;20 words and are not following simple requests; or</li> <li>by 30 months they do not produce 2 work combinations.&nbsp;</li> </ul> Children with hearing aids aged 0-5 should be supported to receive SLP intervention services (<strong>Consensus Recommendation</strong>).

Schools may consult audiologists and hearing advisory teachers for strategies to assist children with OM and hearing loss. These may include:<br /> <ul> <li>education regarding hygiene practices to reduce OM risk;</li> <li>creating a positive school culture in which all students are educated to understand, support, and include their peers with hearing loss and any associated devices;&nbsp;</li> <li>creating hearing support plans documenting accommodations for children with hearing loss and personal hearing devices;</li> <li>utilizing technology to improve the auditory signal for all students;&nbsp;</li> <li>utilizing classroom modifications to improve the auditory signal (e.g., preferential seating, reducing background noise, improving the acoustic design of the classroom);</li> <li>encouraging the use of communication strategies;</li> <li>utilizing supportive teaching techniques (e.g., pairing verbal and visual information); and</li> <li>cultivating strong relationships with healthcare providers&nbsp;(<strong>Consensus Recommendations</strong>).<strong>&nbsp;</strong></li> </ul>