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CMAJ • May 2, 2000; 162 (9)
© 2000 Canadian Medical Association or its licensors

Research
Recherche

Otolaryngologists' perceptions of the indications for tympanostomy tube insertion in children

Warren J. McIsaac, Peter C. Coyte, Ruth Croxford, Carl V. Asche, Jacob Friedberg and William Feldman

Dr. McIsaac is with the Department of Family and Community Medicine, University of Toronto, and the Department of Family Medicine, Mount Sinai Hospital, Toronto, Ont.; Dr. Coyte is with the Department of Health Administration and the Institute for Policy Analysis, University of Toronto, the Institute for Clinical Evaluative Sciences, the Arthritis Community Research and Evaluation Unit, Wellesley Hospital Research Institute, and the Department of Otolaryngology, Mount Sinai Hospital, Toronto, Ont.; Ms. Croxford is with the Clinical Epidemiology Unit, Sunnybrook & Women's College Health Sciences Centre, Toronto, Ont.; Mr. Asche is with Bristol-Myers Squibb, Montreal, Que., the Department of Economics, University of Surrey, Guildford, UK, and the Gerontology Research Centre, Simon Fraser University, Burnaby, BC; Dr. Friedberg is with the Departments of Otolaryngology, Hospital for Sick Children and Mount Sinai Hospital, Toronto, Ont.; and Dr. Feldman is with the Department of Paediatrics, University of Toronto, Toronto, Ont.

Background: Bilateral myringotomy with insertion of tympanostomy tubes is the most common operation that children in Canada undergo. Area variations in surgical rates for this procedure have raised questions about indications used to decide about surgery. The objective of this study was to describe the factors that influence otolaryngologists to recommend tympanostomy tube insertion in children with otitis media and their level of agreement about indications for surgery.

Methods: A survey was sent to all 227 otolaryngologists in Ontario in the fall of 1996. The influence of 17 clinical and social factors on recommendations to insert tympanostomy tubes were assessed. Case vignettes were used to determine the effect of multiple factors in decisions about the need for surgical management.

Results: Surveys were returned by 138 (68.3%) of the 202 eligible otolaryngologists. There was agreement (more than 90% of respondents) about 6 indications for surgery: persistent effusion, a lack of improvement after 3 months of antibiotic therapy, a history of persistent effusion for 3 or more months per episode of otitis media, more than 7 episodes of otitis media in 6 months, a bilateral conductive hearing loss of 20 dB or more and a persistently abnormal tympanic membrane. Some respondents were more likely to recommend tube insertion if there were parental concerns about hearing problems or the frequency or severity of episodes of otitis media. Otolaryngologists agreed about the role of tympanostomy tubes in 1 of 4 case vignettes but disagreed about whether adenoidectomy should also be performed in that instance. Most viewed tympanostomy tube insertion as beneficial, with few adverse effects.

Interpretation: There is a lack of consensus among practising otolaryngologists in Ontario as to which children with recurrent otitis media or persistent effusion should undergo bilateral myringotomy with tympanostomy tube insertion. These findings suggest the need to revisit clinical guidelines for this procedure.




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J. Schmelzle, R. V. Birtwhistle, and A. K.W. Tan
Acute otitis media in children with tympanostomy tubes
Can Fam Physician, August 1, 2008; 54(8): 1123 - 1127.
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P. C. Coyte, R. Croxford, C. V. Asche, T. To, W. Feldman, and J. Friedberg
Physician and Population Determinants of Rates of Middle-Ear Surgery in Ontario
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