Otolaryngologists' perceptions of the indications for tympanostomy tube insertion in children

Background: Bilateral myringotomy with insertion of tympanostomy tubes is t he most common operation that children in Canada undergo. Area variations i n 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. Methods: A survey was sent to all 227 otolaryngologists in Ontario in the f all of 1996. The influence of 17 clinical and social factors on recommendat ions to insert tympanostomy tubes were assessed. Case vignettes were used t o determine the effect of multiple factors in decisions about the need for surgical management. Results: Surveys were returned by 138 (68.3%) of the 202 eligible otolaryng ologists. There was agreement (more than 90% of respondents) about 6 indica tions for surgery: persistent effusion, a lack of improvement after 3 month s of antibiotic therapy, a history of persistent effusion for 3 or more mon ths per episode of otitis media, more than 7 episodes of otitis media in 6 months, a bilateral conductive hearing loss of 29 dB or more and a persiste ntly abnormal tympanic membrane. Some respondents were more likely to recom mend 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 d isagreed about whether adenoidectomy should also be performed in that insta nce. Most viewed tympanostomy tube insertion as beneficial, with few advers e effects. Interpretation: There is a lack of consensus among practising otolaryngolog ists in Ontario as to which children with recurrent otitis media or persist ent effusion should undergo bilateral myringotomy with tympanostomy tube in sertion. These findings suggest the need to revisit clinical guidelines for this procedure.