Choosing Wisely - pediatric otolaryngology recommendations

The recommendations, published in the Journal of Otolaryngology-Head & Neck Surgery, are meant to help physicians and patients make treatment decisions regarding common pediatric otolaryngology presentations. The recommendations are described below:

X-rays do not add value to the diagnosis or treatment plan for children with nasal fractures and should not be ordered to avoid their associated costs and radiation exposure.

Uncomplicated acute bacterial sinusitis (ABS) is a diagnosis that is made based on clinical criteria and has a low prevalence amongst children presenting with respiratory symptoms. Although a normal x-ray, CT, or MRI can help to rule out ABS, an abnormal result does not confirm the diagnosis. Given that many children will have abnormal findings on imaging due to viral upper respiratory infections and/or other inflammatory diseases during certain times of the year, combined with the potential for radiation exposure, imaging is not routinely recommended.

Although tympanostomy tube insertion can be associated with short-term quality of life improvements, the natural history of otitis media with effusion (OME) is sufficiently favorable and the majority of uncomplicated OME cases in children will spontaneously resolve within 3 months.

In most cases, medical treatment using antihistamines, decongestants, systemic antibiotics, and steroids has shown little to no effect on the long-term outcomes of uncomplicated OME in children. In addition, there are associated costs and potential side effects of these medications. Therefore, the recommendation is not to routinely prescribe these medical treatments for children with uncomplicated OME.

The use of unnecessary oral antibiotics can promote antibiotic resistance and increase the risk of opportunistic infections. Topical antibiotics achieve higher concentrations in the ear canal and middle ear, demonstrate improved patient satisfaction, are associated with fewer adverse events, and are shown to have equal efficacy for treatment of acute tympanostomy tube otorrhea (TTO) and acute otitis externa (AOE) when compared to oral antibiotics. For these reasons, topical antibiotics rather than oral antibiotics should be prescribed as first-line treatment for acute uncomplicated TTO and uncomplicated AOE.

Codeine has been associated with a high rate of adverse drug reactions in children. This includes life-threatening respiratory depression. Appropriate dosing of codeine is challenging due to the genetic heterogeneity amongst patients for the CYP2D6 enzyme, which is responsible for codeine metabolism.

Administration of perioperative antibiotics for children undergoing elective uncomplicated tonsillectomy shows no significant benefits in regard to common post-tonsillectomy morbidities. Overuse of systemic antibiotics increases bacterial resistance and the risk of adverse drug events unnecessarily. These concerns outweigh the reduction in postoperative fever which is the only potential benefit of perioperative antibiotic administration for elective tonsillectomy. Therefore, perioperative antibiotics are not recommended for children undergoing elective tonsillectomy, unless specific indications are present (e.g., cardiac conditions or those with a peritonsillar abscess or active infection).

8. Don't perform tonsillectomy for children with uncomplicated recurrent throat infections if there have been fewer than 7 episodes in the past year, 5 episodes in each of the past 2 years, or 3 episodes in each of the last 3 years

For children who have a lower number of recurrent throat infections, tonsillectomy has significantly less benefit when compared to those with more frequent infections, and many children with recurrent throat infections naturally improve without intervention. Therefore, where safely possible, avoidance of tonsillectomy for children with a lower number of acute infections is recommended. This avoids unnecessary tonsillectomy and the costs and complications associated with the procedure (e.g., bleeding, pain, infection).

9. Don't perform endoscopic sinus surgery for uncomplicated pediatric chronic rhinosinusitis prior to failure of maximal medical therapy and adenoidectomy

While endoscopic sinus surgery (ESS) has been found to be an effective therapy in children with uncomplicated chronic rhinosinusitis, comparable outcomes can be achieved with medical therapy and adenoidectomy. A stepwise approach of medical therapy, progressing to adenoidectomy, then to ESS allows children to be treated with less invasive and more cost-effective interventions as initial therapy while saving ESS for those who are refractory to primary interventions. Maximal medical therapy should be exhausted prior to surgical intervention for uncomplicated patients. In cases with complications such as orbital or skull base involvement, ESS can be employed more readily.

"These recommendations are not hard "rules" but are rather intended to promote discussion amongst physicians and patients regarding evidence-based approaches to reduce inappropriate or unnecessary treatment for pediatric otolaryngology patients," wrote the authors. "Relevance for patients revolves primarily around providing a concise description as to why practitioners may opt for or against certain treatments."

Reference:

McDonough, M., Hathi, K., Corsten, G. et al. Choosing Wisely Canada – pediatric otolaryngology recommendations. J of Otolaryngol - Head & Neck Surg 50, 61 (2021). https://doi.org/10.1186/s40463-021-00533-x