McIsaac W J, Coyte P C, Croxford R, Asche C V, Friedberg J, Feldman W
Department of Family and Community Medicine, University of Toronto, Ont.
CMAJ. 2000 May 2;162(9):1285-8.
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.
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.
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.
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.
双侧鼓膜切开置管术是加拿大儿童最常接受的手术。该手术的手术率存在地区差异，这引发了关于决定手术的指征的问题。本研究的目的是描述影响耳鼻喉科医生推荐为患有中耳炎的儿童进行鼓膜切开置管术的因素，以及他们对手术指征的一致程度。
1996年秋季，向安大略省的所有227名耳鼻喉科医生发送了一份调查问卷。评估了17种临床和社会因素对推荐插入鼓膜置管的影响。使用病例 vignettes 来确定多种因素在决定手术治疗必要性方面的作用。
202名符合条件的耳鼻喉科医生中有138名（68.3%）回复了调查问卷。对于6种手术指征存在共识（超过90%的受访者）：持续性积液、抗生素治疗3个月后无改善、每例中耳炎发作持续积液3个月或更长时间、6个月内中耳炎发作超过7次、双侧传导性听力损失20dB或更多以及鼓膜持续异常。如果家长担心听力问题或中耳炎发作的频率或严重程度，一些受访者更有可能推荐置管。耳鼻喉科医生在4个病例 vignettes 中的1个中对鼓膜置管的作用达成了一致，但在该情况下是否也应进行腺样体切除术存在分歧。大多数人认为鼓膜切开置管术是有益的，不良影响很少。
安大略省的执业耳鼻喉科医生对于哪些复发性中耳炎或持续性积液的儿童应接受双侧鼓膜切开置管术缺乏共识。这些发现表明需要重新审视该手术 的临床指南。
