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Choose Wisely in Treating the Ear

McCormick, Michael E. MD; Shah, Rahul K. MD; Roberson, David W. MD AAO-HNSF Patient Safety and Quality Improvement Committee

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doi: 10.1097/01.HJ.0000430864.86245.e8
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As part of the American Board of Internal Medicine Foundation's Choosing Wisely campaign, the American Academy of Otolaryngology–Head and Neck Surgery Foundation (AAO-HNSF) recently published its list of “Five Things Physicians and Patients Should Question.” The goals of the campaign were to promote awareness of the overuse of tests and treatments and to improve the overall quality of American healthcare.

The AAO-HNSF Patient Safety and Quality Improvement Committee was charged with leading an unbiased and equitable process to arrive at five conditions. The committee reviewed 20 initial items for consideration and then refined the list based on the amount of supporting clinical evidence and the frequency of use of the test, procedure, or treatment. Three of the final five items address diseases of the ear.

1. Don't order a computed tomography (CT) scan of the head/brain for sudden hearing loss. The support for this item comes from a recent AAO-HNSF Clinical Practice Guideline (Otolaryngol Head Neck Surg 2012;146[suppl 3]:S1-35).

Michael E. McCormick, MD

The role of imaging in a patient with sudden sensorineural hearing loss (SSNHL) is to identify pathology that may be causing acute symptoms. SSNHL typically results from an abnormality of the cochlea, cochleovestibular nerve (CN VIII), or brainstem. While we are unable to accurately image the inside of the cochlea with current modalities, more central etiologies, such as the CN VIII and brainstem, are best evaluated by magnetic resonance imaging.

Rahul K. Shah, MD

Therefore, a routine CT scan of the head/brain adds no diagnostic yield to the workup of these patients in most clinical situations. Furthermore, CT scans expose the patient to potentially harmful radiation and intravenous contrast (Expert Opin Drug Metab Toxicol 2009;5[4]:403-416; Arch Intern Med 2009;169[22]:2078-2086).

2. Don't prescribe oral antibiotics for uncomplicated acute tympanostomy tube otorrhea. Ototopical antibiotic drops are typically 100 to 1,000 times more concentrated than oral preparations and do not need to undergo systemic metabolism and biodistribution (Drugs 1999;58[3]:509-531). As a consequence, topical preparations often can treat bacteria that oral antibiotics cannot. Using antibiotic eardrops instead of oral agents can also help prevent the development and spread of resistant bacteria (Pediatr Infect Dis J 2001;20[1]:102-103) and avoids the systemic side effects associated with oral therapy, such as vomiting, diarrhea, and rash.

Figure. David:
W. Roberson, MD

3. Don't prescribe oral antibiotics for uncomplicated acute external otitis. Similar to the first recommendation, this item is supported by evidence from an AAO-HNSF Clinical Practice Guideline (Otolaryngol Head Neck Surg 2006;134[suppl 4]:S4-S23). The item applies primarily to healthy patients without complications or extension beyond the ear canal. In addition to the benefits of curbing overuse of oral antibiotics, there are multiple nonantibiotic preparations that are efficacious.

Awareness of and general adherence to these simple recommendations by our health professional colleagues could potentially save an immeasurable amount of resources while improving the quality and perhaps outcomes of care in the United States.

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