In this third blog in the series about glue ear (OME) in children I will consider shared decision making, and management strategies in children with, and without, additional needs. Making the right decision for individual children with glue ear can be challenging, but is crucial if the potential negative impact upon childhood development is to be avoided.

Despite Otitis Media with Effusion (OME) being the commonest cause of childhood hearing loss, an evidenced based management strategy has remained elusive, reflecting the variety of causal factors, the influence of co-morbidity, the influence of age and the differing nature of the available interventions. Therefore, variation exists in management strategies (surgical & non-surgical) and the information provided to parents and patients. There remains a need to agree a ‘best practice’ strategy for childhood OME. This strategy must benefit from best available evidence and shared decision making (SDM) between clinician, parents (and patient for older children). In addition, the current clinical pathway in the UK (NICE CG60) lacks emphasis on early identification of, and early intervention in, children at greatest risk of adverse consequences from OME.

The opinion of parents is crucial to selecting the most appropriate intervention for each child, with the likelihood being that ‘no treatment’, ‘environmental interventions’ (preferential classroom seating etc.), ‘hearing devices’ and ‘ventilation tubes’ will all represent the optimal management for individuals across a population.

Neither hearing aids (HAs) or ventilation tubes (VTs/grommets) are a cure for the underlying tendency to develop OME. The decrease in prevalence of OME with increasing age is likely to reflect a variety of factors, including change in anatomy and function of the Eustachian tube, maturation of the immune system, and possibly reduction in reflux events. The VT strategy is based upon an expectation that the underlying tendency towards OME will have decreased by the time that the VT is no longer functioning (extrudes from the eardrum/TM). Whilst the VT is working (in situ and patent) there is no effusion in the middle ear (ME). The HA strategy is based on an expectation that the OME will resolve spontaneously at some point in the future, and HAs will be an acceptable intervention until such time.

Therefore, the age of the child and co-morbidities associated with the tendency towards OME lasting longer, are crucial to selecting the best intervention for a child with OME and hearing loss impacting on development. Here are 2 illustrative examples of children who may not have ‘out-grown’ the tendency towards OME by the time a ventilation tube extrudes, and may be better served by HAs: 1. A 2-year-old child with no other health needs and no ear infections, may avoid repeated VT insertions under general anaesthesia, 2. A 6-year-old child with a repaired cleft palate may be better served by HAs, as Eustachian tube dysfunction (ETD) often persists into adolescence (you could make a similar case for a child with Down syndrome). I’m not suggesting VTs are obsolete, as they remain an entirely reasonable management options, example: 1. There is a reasonable chance that a 4 or 5-year-old will have out-grown the tendency towards OME when the VT extrudes, and 2. If the parents feel the child will use the HA as a projectile then there is limited benefit in selecting HAs!

So, as is often the case in medicine, we need to choose the right intervention for the right child. We need the right information to guide the decision-making process and the opinion of parents is crucial!