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December 2001 It is my opinion that routine follow-up examination visits for acute otitis media (AOM) are unnecessary and usually unrewarding or confusing. This includes children older than 2 months. Before you take to the streets in protest, hear me out, please. Almost 15 years ago, my study published in the family medicine literature clearly showed that such follow-up visits were unrewarding for older children with AOM. At that time I believed, without proof, that such routine follow-up visits were still necessary for children younger than 3 years because of concern that I would fail to detect persistent otitis media with effusion (OME). In doing so I worried that I might overlook a conductive hearing loss in my patient with its sequelae of delay in acquisition of language milestones. Little by little I tested the veracity of that worry. During the past 5 years, I have instructed parents of children of all ages that the scheduled return visit was not required in absence of persisting symptoms of ear pain, general fussiness, imbalance, sleep disturbance or fever. This policy taught me 2 things: None of the children who were diagnosed with AOM using precise criteria suffered serious harm or recognized language delay from this policy; the anticipated reduction in office income from loss of revenue for those follow-up visits was counterbalanced by freeing up of those slots for other patients. Consider the expenditure for parents to bring their child to the office, wait for the child to be examined, and be told to reschedule another visit because the child had a middle ear effusion. Consider the injudicious use of antibiotics by some pediatricians or physician extenders, because the tympanic membrane appeared dull, red or even immobile to positive pressure with the pneumatic otoscope. Most visits for AOM occur in the late fall, winter and spring when the office schedule fills up quickly. What are we gaining by such routine reevaluation examinations? At the scheduled reevaluation visit, do we really expect to diagnose an occult suppurative complication of AOM such as acute mastoiditis, without antecedent pain, high fever, and an ill-appearing child? Should those symptoms occur, they are by themselves reason for prompt evaluation of that child. Although OME can be diagnosed in most children immediately following completion of a 7- to 10-day course of antibiotics for AOM, 90% of such effusions resolve spontaneously within 3 months. Of those effusions that do not resolve in a child younger than 2 years, almost all such children will return to the medical office for scheduled health assessment (check-up) within 90 days. During that time, parents should observe their child for impaired hearing, indistinct speech, language acquisition, imbalance, new onset sleep problems, and new onset irritability or fretfulness. Reevaluation visits for assessment of such problems can be selectively scheduled rather than routine reevaluation for all children with AOM.
I wonder how many of my colleagues in pediatric primary care disagree with my proposal. Goals I have achieved by testing my suggestions over the past 5 years include reduction of unnecessary visits; reduction of parental concern because the physician detected an asymptomatic OME on the reevaluation visit; and reduction of prescriptions for antibiotics because the tympanic membrane still did not appear normal. Perhaps, we can also reduce referrals to our otolaryngologist colleagues because our patient was seen in follow-up 3 or 4 times because of minimally symptomatic but seemingly recalcitrant AOM and the mother insists on seeing a specialist. Let me know what you think. Am I missing something? For more information: |
Might I suggest that those of you who
presently recommend routine reevaluation visits for AOM to children younger
than 5 years lower the criteria to 2- or 3-year-olds. Those who still recommend
routine reevaluation visits only to infants and toddlers should consider
further restricting the follow-up visits to high-risk individuals. Selectively
reschedule those children with bilateral AOM who have been otitis-prone in the
past, those who have a history of persistent bilateral OME, those with some
language delay and those who fail to respond clinically to one course of
antibiotics for AOM.