title: National Institute for Clinical Excellence guidelines on the surgical management of otitis media with effusion: are they being followed and have they changed practice?
abstract: OBJECTIVE
  UK National Institute of Clinical Excellence (NICE) guidelines on surgical management of otitis media with effusion (OME) in children call for an initial 3 month period of observation, with ventilation tube (VT) insertion considered for children with persistent bilateral OME with a hearing level in better ear of 25-30 dB HL or worse ("core criteria"), or for children not meeting those audiologic criteria but when OME has significant impact on developmental, social or educational status (exceptional circumstances). We aimed to establish whether guidelines are followed and whether they have changed clinical practice.
  
  
  METHODS
  Retrospective case-notes review in five different centres, analysing practice in accordance with guidelines in all children having first VT insertion before (July-December 06) and after (July-December 08) guidelines introduction.
  
  
  RESULTS
  Records of 319 children were studied, 173 before and 146 after guidelines introduction. There were no significant differences in practice according to guidelines before and after their introduction with respect to having 2 audiograms 3 months apart (57.8 vs. 54.8%), OME persisting at least 3 months (94.8 vs. 92.5%), or fulfilment of the 25 dB audiometric criteria (68.2 vs. 61.0%). Practice in accordance with the core criteria fell significantly from 43.9 to 32.2% (Chi squared p=0.032). However, if the exceptional cases were included there was no significant difference (85.5 vs. 87.0%), as the proportion of exceptional cases rose from 48.3 to 62.2% (Chi squared p=0.021).
  
  
  CONCLUSIONS
  This study shows that 87.0% of children have VTs inserted in accordance with NICE guidelines providing exceptional cases are included, but only 32.2% comply with the core criteria. A significant number have surgery due to the invoking of exceptional criteria, suggesting that clinicians are personalising the treatment to each individual child.
authors.affiliation: Division of Otorhinolaryngology Head & Neck Surgery, The University of Nottingham, United Kingdom. matija.daniel@nottingham.ac.uk
authors.forename: Matija
authors.initials: M
authors.lastname: Daniel
authors.forename: Tawakir
authors.initials: T
authors.lastname: Kamani
authors.forename: Suliman
authors.initials: S
authors.lastname: El-Shunnar
authors.forename: Marie-Claire
authors.initials: MC
authors.lastname: Jaberoo
authors.forename: Anna
authors.initials: A
authors.lastname: Harrison
authors.forename: Seema
authors.initials: S
authors.lastname: Yalamanchili
authors.forename: Laura
authors.initials: L
authors.lastname: Harrison
authors.forename: Wai-Sum
authors.initials: WS
authors.lastname: Cho
authors.forename: Neil
authors.initials: N
authors.lastname: Fergie
authors.forename: Roger
authors.initials: R
authors.lastname: Bayston
authors.forename: John P
authors.initials: JP
authors.lastname: Birchall
mesh_terms: D000047:Academies and Institutes / Q000592:standards; D000158:Acoustic Impedance Tests / Q000379:methods; D000233:Adenoidectomy / Q000379:methods / Q000592:standards; D001299:Audiometry / Q000379:methods; D002648:Child; D002675:Child, Preschool; D015331:Cohort Studies; D005260:Female; D005500:Follow-Up Studies; D019983:Guideline Adherence; D006801:Humans; D008297:Male; D008876:Middle Ear Ventilation / Q000379:methods / Q000592:standards*; D010034:Otitis Media with Effusion / Q000175:diagnosis / Q000601:surgery*; D011183:Postoperative Complications / Q000503:physiopathology; D017410:Practice Guidelines as Topic; D010818:Practice Patterns, Physicians' / Q000592:standards; D011787:Quality of Health Care; D012189:Retrospective Studies; D018570:Risk Assessment; D012720:Severity of Illness Index; D016896:Treatment Outcome; D006113:United Kingdom