I was rounding the bases on another month of servitude in the pediatric emergency department in 2015, an occasionally frustrating experience as I struggled to reconcile lessons from the adult ED that seemingly weren't applicable to our smaller patients.
I hated and continue to despise the mantra that “kids aren't little adults,” and I developed an aversion to resistance to the evidence-informed mania in emergency medicine. FOAM had begun to dominate medical education and bedside learning, and the myth-busting of long-held truths by literary luminaries drove a fervor to incorporate broad and data-driven lessons into every clinical encounter.
The uptake was not as brisk or welcomed on the pediatric side of the curtain, however. This was understandable because research often excludes children, and evidence about patients under 18 was sparse. Though I would strive to extrapolate via face validity and biologic plausibility, adopting new practices or reconsidered models was difficult.
Imagine my excitement when Williamson, et al., published a pediatric trial that has informed my practice ever since and provided insight into the ways we can combine the anatomic and physiologic principles we learned in medical school with the evolving clinical literature. (CMAJ. 2015;1813]7[:961; http://bit.ly/2NJfmZh.)
No Side Effects
Otitis media with effusion is everywhere. More than 80 percent of children will experience the condition before hitting age 4. (Clin Otolaryngol Allied Sci. 1990;15:147.) And, anecdotally at least, it's not uncommon for adults to complain of similar symptoms for weeks to months after an upper respiratory infection or episode of acute otitis media. Glue ear, as we've descriptively come to call it, is not completely understood, but basically is a result of inflammatory fluid buildup—dead neutrophils resigned to an early grave—and Eustachian tube dysfunction or obstruction. It's literally water in the ear that patients just can't get rid of and a condition we routinely encounter.
These patients, young and old alike, often have rounds of antibiotics or antihistamines thrown at them to no avail (or even to harm). (Cochrane Database Syst Rev. 2011 Sep 7;:CD003423.) Or they are advised to wait patiently for spontaneous resolution (about 20% do in a month) or undergo ENT intervention with tympanostomy or grommet placement. Glue ear in the meantime can cause significant hearing loss, which can lead to social dysfunction in older patients and even speech difficulty and developmental delays in children. (Ann Otol Rhinol Laryngol. 1983;92[2 Pt 1]:172.)
Glue ear can also lead to balance disruption and falls in the very young or very old. Steroids seem to help, oral more so than nasal, with heterogeneity among several meta-analyses but general agreement that a short course of prednisone or pack of methylprednisolone might hasten resolution. (Cochrane Database Syst Rev. 2011 May 11;(5):CD001935.)
A Simple Intervention
The small open-label trial by Williamson, et al., investigated the role of nasal balloon autoinflation to treat glue ear. Patients were directed to insufflate three times a day using an Otovent nasal balloon (no conflicts of interest among the authors or me). (Watch a video demonstrating the technique at http://bit.ly/38szEOG.) The results were tremendous. Those receiving autoinflation were about 30 percent more likely than controls to have normal tympanograms at one month, leading to a number needed to treat of just nine for what amounts to a fairly low-cost intervention with essentially no risk of side effects.
I loved this study. I was a resident at the time, but I excitedly brought the paper into the pediatric ED, thrilled to have a safe and studied “new” technique to bring to my younger patients. Yet I hit resistance. “Not applicable.” “Not enough evidence.” “Not our population.” “Patients will hate it.” I was crestfallen.
The evidence-based medicine dismissal long-ascribed to the delicate and particular nature of the pediatric population seemed, in fact, to be an entrenchment not against change in haste but against change at all. Undeterred, I brought the practice to the adult side and to the urgent care clinic where I secretly moonlighted on my days off. The technique worked, and has continued to work for the years I've been recommending it to patients. Combining autoinflation with oral steroids seems to provide the best balance between expectations and efficacy, and I've heard more positive feedback about this simple intervention than nearly any other because patients and their parents are relieved to be free of the chronic annoyance of a refractory serous otitis media.
I've discovered more than a dozen small investigations of identical or similar techniques since reading that 2015 study and embraced the Cochrane review that was completed two years earlier, concluding that the evidence for autoinflation in the short term appeared favorable, though the authors lamented the heterogeneity and weak nature of the studies available. (Cochrane Database Syst Rev. 2013 May 31;:CD006285.)
Nonetheless, patients seem to be two to four times more likely to have tympanographic improvement, particularly with a different autoinflation method called politzerization, available commercially as the EarPopper (quite a bit more expensive than the Otovent balloons). What's more, a qualitative interview study exploring patient, parent, and caregiver attitudes about nasal autoinflation was extremely positive. Parents described the nasal balloon as acceptable and appealing to children, and health care providers perceived the method to be a low-cost, low-risk strategy. (Br J Gen Pract. 2019;69:e24; http://bit.ly/2Gbq32O.)
Evidence-based medicine is not the blind application of the latest study, nor is it an excuse for timid refusal to adapt without gigantic and repetitive randomized data. Evidence-based medicine demands a synthesis of the literature with the degrees we fought so hard to achieve and the anatomic, physiologic, and pathologic principles we pored over for hours as students and trainees. What's more, modern evidence-based practice requires that we incorporate patients' and families' values and avidity to provide safe, effective, and desirable solutions. We must have the knowledge and tenacity to welcome change, while retaining the skepticism and protectiveness our patients deserve. Glue ear can be safely and effectively treated with the addition and incorporation of nasal autoinflation, and it is a low-cost and well-received intervention that can be applied to all ages, even little adults.
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Dr. Pescatoreis an emergency physician in New Jersey and the host with Ali Raja, MD, of the podcast EMN Live, which focuses on hot topics in emergency medicine:http://bit.ly/EMNLive. Follow him on Twitter@Rick_Pescatore, and read his past columns athttp://bit.ly/EMN-Pescatore.