Comparison and analysis of otitis media with effusion in children with guidelines of several countries
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Abstract: Otitis media with effusion (OME) is defined as a collection of fluid in the middle ear without signs or symptoms of ear infection. If it sustains for more than 3 months, it is called chronic OME. It is difficult for parents to be aware of the disease because of the limited age of the patients and the incubation period of the disease. With the standardization of the treatments of the disease, several countries have issued OME guideline for children. The earliest guideline in our country was issued in 2008 and has not been updated yet. Afterwards, the following are guidelines issued by the United Kingdom, Germany, Korea, Sweden, America, France and Japan. Guidelines issued after 2013 are based on the quality of evidence to evaluate references. Therefore, this review divides the issued guidelines from 2013 and aims to introduce the development and content of the OME guidelines in children.
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Key words:
- otitis media with effusion /
- child /
- tympanostomy tube placement /
- hearing /
- adenoidectomy
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表 1 国内外儿童OME诊疗指南/共识一览表
国家/学会 内容 发表时间/年 适用年龄 中国 OME 2008 儿童 瑞典 鼓膜置管 2008 儿童 英国 OME手术治疗 2008 < 12岁 德国 OME 2012 儿童 韩国 OME 2012 < 15岁 美国 鼓膜置管 2013 6个月~12岁 丹麦 OME 2016 0~5岁 美国 OME (1994,2004)2016a) 2个月~12岁 日本 OME 2017 < 12岁 IFOS OME 2017 儿童 法国 OME 2018 < 12岁 注:a)1994年发表OME诊疗指南第1版,2004年发表第2版,2016年发表第3版。 表 2 国内外儿童OME诊疗指南/共识在鼓膜置管、腺样体切除方面的建议
国家/学会(发表时间) 鼓膜置管标准 置管后处理 腺样体切除 GERD 中国(2008) OME病程>3个月;高危或较好耳的听阈≥40 dB HL;再次鼓膜置管的指征为鼓膜置管脱出或取管后复发 未提及 再次置管时,可同时行腺样体切除术 未提及 瑞典(2008) 结合听力和社会交往能力来评估;双耳OME病程≥3个月、听阈≥25 dB HL;双耳OME病程≥6个月、听阈≥25 dB HL;任何显著功能障碍影响社交;双耳脱管后出现早期复发 有脓性分泌物时可局部滴含有激素的抗生素;不伴全身症状的耳漏不建议口服抗生素;建议置管后立即检查听力,首次复查为置管后3个月,此后每年复查1次直至脱管且中耳恢复正常 3岁以上的儿童第2次鼓膜置管时,无论腺样体大小都建议切除腺样体。学龄前儿童反复发作AOM不是腺样体切除术的适应证 未提及 英国(2008) 双耳OME病程≥3个月;较好耳的听阈>25~30 dB HL 没有建议通气管保留时间 没有持续或经常上呼吸道症状不建议联合行腺样体切除 未提及 美国(2013/2016)a) 建议置管:双侧慢性OME病程≥3个月并伴有听力障碍;伴有中耳积液的复发性AOM。考虑置管:≥3个月有临床症状的单侧OME;高危儿童持续B型鼓室图≥3个月 建议对通气管耳漏局部使用抗生素滴剂,但强烈不推荐口服抗生素。建议脱管后观察6~12个月明确无再发中耳积液 < 4岁者不建议手术 未提及 丹麦(2016) rAOM;双耳慢性OME伴听力下降;听力正常的慢性OME患儿,只有当其出现行为、前庭问题或生活质量下降时才考虑置管 未提及 rAOM首次置管或经过慎重考虑的慢性OME置管 未提及 日本(2017) 必须置管:双耳OME病程≥3个月,并且双耳中度以上听力下降;单耳或双耳OME病程≥3个月,并且发现鼓膜病变。推荐置管:单耳或双耳OME病程≥3个月,并且听力轻度下降。考虑置管:单耳或双耳OME病程≥3个月,并伴有OME相关的临床症状 置管后建议保留2~3年。置管后耳漏经保守治疗无效或严重感染(肉芽形成)也可考虑取管。留管时间越长OME恢复越好,但也要考虑通气管的并发症。3岁以内AOM患儿听力检测较困难,故鼓膜置管需要慎重考虑 对于没有上气道疾病的OME患儿,不推荐将腺样体切除术作为首选治疗。但对于首次置管后复发、明确没有腭裂的OME患儿可于再次置管手术中切除腺样体 未提及 IFOS(2017) 建议个体化治疗,重点放在儿童的听力以及交流困难方面 通气管保留时间:短期为6~12个月,长期为12~24个月 伴有鼻塞的OME患儿且年龄≥4岁,可在鼓膜置管同时行腺样体切除术 提出GERD和过敏是影响诊疗的高危因素 法国(2018) 正确的鼓膜置管手术可以使OME患儿恢复听力。对于3岁以下的幼儿鼓膜置管可减少OME的复发率 未提及 对于同时伴有夜间打鼾、鼻咽部感染的OME患儿,4岁以后可以在鼓膜置管的同时联合腺样体切除术治疗 OME有消化道症状或7岁以上的严重OME建议排查GERD 注:a)美国2013年的鼓膜置管指南与2016年的OME诊疗指南合并表示。德国及韩国2012年OME诊疗指南在鼓膜置管、腺样体切除方面没有给出具体建议,故未纳入此表格。 -
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