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      Clinical Practice Guideline : Tympanostomy Tubes in Children

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          Abstract

          Insertion of tympanostomy tubes is the most common ambulatory surgery performed on children in the United States. Tympanostomy tubes are most often inserted because of persistent middle ear fluid, frequent ear infections, or ear infections that persist after antibiotic therapy. Despite the frequency of tympanostomy tube insertion, there are currently no clinical practice guidelines in the United States that address specific indications for surgery. This guideline is intended for any clinician involved in managing children, aged 6 months to 12 years, with tympanostomy tubes or being considered for tympanostomy tubes in any care setting, as an intervention for otitis media of any type. The primary purpose of this clinical practice guideline is to provide clinicians with evidence-based recommendations on patient selection and surgical indications for and management of tympanostomy tubes in children. The development group broadly discussed indications for tube placement, perioperative management, care of children with indwelling tubes, and outcomes of tympanostomy tube surgery. Given the lack of current published guidance on surgical indications, the group focused on situations in which tube insertion would be optional, recommended, or not recommended. Additional emphasis was placed on opportunities for quality improvement, particularly regarding shared decision making and care of children with existing tubes. ACTION STATEMENTS: The development group made a strong recommendation that clinicians should prescribe topical antibiotic eardrops only, without oral antibiotics, for children with uncomplicated acute tympanostomy tube otorrhea. The panel made recommendations that (1) clinicians should not perform tympanostomy tube insertion in children with a single episode of otitis media with effusion (OME) of less than 3 months' duration; (2) clinicians should obtain an age-appropriate hearing test if OME persists for 3 months or longer (chronic OME) or prior to surgery when a child becomes a candidate for tympanostomy tube insertion; (3) clinicians should offer bilateral tympanostomy tube insertion to children with bilateral OME for 3 months or longer (chronic OME) and documented hearing difficulties; (4) clinicians should reevaluate, at 3- to 6-month intervals, children with chronic OME who did not receive tympanostomy tubes until the effusion is no longer present, significant hearing loss is detected, or structural abnormalities of the tympanic membrane or middle ear are suspected; (5) clinicians should not perform tympanostomy tube insertion in children with recurrent acute otitis media (AOM) who do not have middle ear effusion in either ear at the time of assessment for tube candidacy; (6) clinicians should offer bilateral tympanostomy tube insertion to children with recurrent AOM who have unilateral or bilateral middle ear effusion at the time of assessment for tube candidacy; (7) clinicians should determine if a child with recurrent AOM or with OME of any duration is at increased risk for speech, language, or learning problems from otitis media because of baseline sensory, physical, cognitive, or behavioral factors; (8) in the perioperative period, clinicians should educate caregivers of children with tympanostomy tubes regarding the expected duration of tube function, recommended follow-up schedule, and detection of complications; (9) clinicians should not encourage routine, prophylactic water precautions (use of earplugs, headbands; avoidance of swimming or water sports) for children with tympanostomy tubes. The development group provided the following options: (1) clinicians may perform tympanostomy tube insertion in children with unilateral or bilateral OME for 3 months or longer (chronic OME) and symptoms that are likely attributable to OME including, but not limited to, vestibular problems, poor school performance, behavioral problems, ear discomfort, or reduced quality of life and (2) clinicians may perform tympanostomy tube insertion in at-risk children with unilateral or bilateral OME that is unlikely to resolve quickly as reflected by a type B (flat) tympanogram or persistence of effusion for 3 months or longer (chronic OME).

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          Health supervision for children with Down syndrome.

          These guidelines are designed to assist the pediatrician in caring for the child in whom a diagnosis of Down syndrome has been confirmed by chromosome analysis. Although a pediatrician's initial contact with the child is usually during infancy, occasionally the pregnant woman who has been given a prenatal diagnosis of Down syndrome will be referred for review of the condition and the genetic counseling provided. Therefore, this report offers guidance for this situation as well.
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            Is Open Access

            The GuideLine Implementability Appraisal (GLIA): development of an instrument to identify obstacles to guideline implementation

            Background Clinical practice guidelines are not uniformly successful in influencing clinicians' behaviour toward best practices. Implementability refers to a set of characteristics that predict ease of (and obstacles to) guideline implementation. Our objective is to develop and validate a tool for appraisal of implementability of clinical guidelines. Methods Indicators of implementability were identified from the literature and used to create items and dimensions of the GuideLine Implementability Appraisal (GLIA). GLIA consists of 31 items, arranged into 10 dimensions. Questions from 9 of the 10 dimensions are applied individually to each recommendation of the guideline. Decidability and Executability are critical dimensions. Other dimensions are Global, Presentation and Formatting, Measurable Outcomes, Apparent Validity, Flexibility, Effect on Process of Care, Novelty/Innovation, and Computability. We conducted a series of validation activities, including validation of the construct of implementability, expert review of content for clarity, relevance, and comprehensiveness, and assessment of construct validity of the instrument. Finally, GLIA was applied to a draft guideline under development by national professional societies. Results Evidence of content validity and preliminary support for construct validity were obtained. The GLIA proved to be useful in identifying barriers to implementation in the draft guideline and the guideline was revised accordingly. Conclusion GLIA may be useful to guideline developers who can apply the results to remedy defects in their guidelines. Likewise, guideline implementers may use GLIA to select implementable recommendations and to devise implementation strategies that address identified barriers. By aiding the design and operationalization of highly implementable guidelines, our goal is that application of GLIA may help to improve health outcomes, but further evaluation will be required to support this potential benefit.
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              Standardized reporting of clinical practice guidelines: a proposal from the Conference on Guideline Standardization.

              Despite enormous energies invested in authoring clinical practice guidelines, the quality of individual guidelines varies considerably. The Conference on Guideline Standardization (COGS) was convened in April 2002 to define a standard for guideline reporting that would promote guideline quality and facilitate implementation. Twenty-three people with expertise and experience in guideline development, dissemination, and implementation participated. A list of candidate guideline components was assembled from the Institute of Medicine Provisional Instrument for Assessing Clinical Guidelines, the National Guideline Clearinghouse, the Guideline Elements Model, and other published guideline models. In a 2-stage modified Delphi process, panelists first rated their agreement with the statement that "[Item name] is a necessary component of practice guidelines" on a 9-point scale. An individualized report was prepared for each panelist; the report summarized the panelist's rating for each item and the median and dispersion of rankings of all the panelists. In a second round, panelists separately rated necessity for validity and necessity for practical application. Items achieving a median rank of 7 or higher on either scale, with low disagreement index, were retained as necessary guideline components. Representatives of 22 organizations active in guideline development reviewed the proposed items and commented favorably. Closely related items were consolidated into 18 topics to create the COGS checklist. This checklist provides a framework to support more comprehensive documentation of practice guidelines. Most organizations that are active in guideline development found the component items to be comprehensive and to fit within their existing development methods.
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                Author and article information

                Journal
                Otolaryngology–Head and Neck Surgery
                Otolaryngol Head Neck Surg
                SAGE Publications
                0194-5998
                1097-6817
                July 2013
                July 2013
                July 2013
                July 2013
                : 149
                : 1_suppl
                : S1-S35
                Affiliations
                [1 ]Department of Otolaryngology, State University of New York Downstate Medical Center, Brooklyn, New York, USA
                [2 ]Department of Otolaryngology, Virginia Mason Medical Center, Seattle, Washington, USA
                [3 ]Department of Otolaryngology, University of Michigan, Ann Arbor, Michigan, USA
                [4 ]Department of Otolaryngology—Head and Neck Surgery, Johns Hopkins University, Baltimore, Maryland, USA
                [5 ]Department of Research and Quality Improvement, American Academy of Otolaryngology—Head and Neck Surgery Foundation, Alexandria, Virginia, USA
                [6 ]The Ear, Nose, Throat & Plastic Surgery Associates, Winter Park, Florida, USA
                [7 ]Department of Otology, Head and Neck Surgery, UCLA Medical Center, Los Angeles, California, USA
                [8 ]Pomona Pediatrics, Pomona, New York, USA
                [9 ]Department of Speech and Hearing Sciences, UNC School of Medicine, Chapel Hill, North Carolina, USA
                [10 ]Mothers Against Medical Error, Columbia, South Carolina, USA
                [11 ]Neurotology Division, Otolaryngology and Hearing and Speech Sciences, Vanderbilt University Medical Center, Nashville, Tennessee, USA
                [12 ]Department of Anesthesiology, Johns Hopkins University, Baltimore, Maryland, USA
                [13 ]Division of Otolaryngology, UCONN Health Center, Farmington, Connecticut, USA
                [14 ]Cochrane IBD Review Group, London, Ontario, Canada
                [15 ]Connecticut Pediatric Otolaryngology, Yale University School of Medicine, New Haven, Connecticut, USA
                [16 ]Department of Otolaryngology—Head and Neck Surgery, Vanderbilt University Medical Center, Nashville, Tennessee, USA
                [17 ]Trisomy 21 Program, Developmental Behavioral Pediatrics, Children’s Hospital of Philadelphia, Philadelphia, Pennsylvania, USA
                [18 ]Department of Otolaryngology, Baylor College of Medicine, Houston, Texas, USA
                [19 ]Department of Family and Community Medicine, Medical College of Wisconsin, Milwaukee, Wisconsin, USA
                Article
                10.1177/0194599813487302
                23818543
                f586c2c6-2db4-4b74-88eb-0ed239817be1
                © 2013

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