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Date: December 9th, 2015

Guest Skeptics: Dr. Fareen Zaver is a Chief Resident in Emergency Medicine at the George Washington University, specifically in charge of the medical education resident curriculum and Grand Rounds schedule. She is the co-founder and lead editor of the ALiEM AIR-Pro series and is pursuing an academic career in Medical Education. She was born and raised in Calgary, Alberta and has constantly stood out with her Canadian accent and roots. She will always be a diehard Calgary Flames fan and is joining the University of Calgary Emergency Medicine department in August when she completes her residency.

Dr. Stefanie Gilbert is a Chief Resident in Emergency Medicine at The George Washington University in the heart of the nation’s capital. Her career interests include ED administration with a focus on operations and quality improvement. Prior to residency, she completed a Bachelor of Science degree in Kinesiology at The University of Michigan in Ann Arbor, MI followed by medical school at Wayne State University in downtown Detroit. She is proud of her Michigan roots and is a true wolverine at heart.

SGEM Journal Club Rules:

* You must talk/tweet about SGEM-JC

* The answer to any SGEM-JC question can be –“it all depends”

* Don’t Panic – even your faculty is not sure of some of the answers

* It’s all about the methods!

* Be skeptical of anything you learn, even if you heard it on SGEM-JC

Case: Ms. Jones is a 45-year-old woman who presents to her local community hospital with the “worst headache” of her life that started suddenly four hours ago. She has a normal neurologic exam. She gets a non-contrast head CT that is read as normal by your local radiologist.

Background: We have talked about SAH a couple of times on the SGEM with the most recent time being the Hot Off the Press paper by Sayer et al in AEM. That retrospective UK study reported a NNTap (Number Needed to Tap) to diagnose one aneurysm not picked up on CT scan was 250.

There are a couple of other studies suggesting that a LP was not automatically needed to exclude the diagnosis of a SAH in patients presenting with an acute headache as the negative predictive value of a normal head CT performed at an academic, tertiary care hospital within 6 hours of headache onset is 100% (Perry et al BMJ 2011 and Backes et al Stroke 2012).

Dr. Jeff Perry’s group came up with the Ottawa SAH Rule that we covered on SGEM#48. The bottom line from that review was the “tool” was not ready for prime time because of the need for validation studies.

There has been at least one validation study done by Bellolio et al of the Ottawa SAH Tool showing 100% sensitivity and 7.6% specificity. They concluded the low specificity and its applicability to only a minority of emergency department patients limited the potential usefulness of the Ottawa SAH Rule. This study was done at an academic center. There have apparently been no studies done at non-academic sites until now.

Clinical Question: Can a SAH be ruled out in a patient presenting to a non-academic ED within 6hrs of headache onset by a head CT read by a community staff radiologist?

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Date: December 3rd, 2015

Guest Skeptic: Dr. Ryan Radecki is Clinical Practice Lead at Kaiser Permanente North West and Clinical Assistant Professor of Emergency Medicine – The University of Texas Medical School at Houston. He has a blog called Emergency Medicine Literature of Note.  

Case: A 67-year-old man presents with a history of atrial fibrillation and hypertension. He takes metoprolol 50mg twice daily and dabigatran 150mg twice daily. He had been having mild epigastric pain for about one week and had one episode of coffee ground emesis that night. He arrives via ambulance with a blood pressure of 120/70, heart rate of 74 beats per minute and O2 saturation of 98% on room air.

Background: Dabigatran is a non-vitamin K antagonist anticoagulant that works by inhibiting thrombin. It is approved for the prevention and treatment of venous thromboembolism. It is also approved treatment of non-valvular atrial fibrillation to prevent stroke.

Life threatening bleeding can occur while taking dabigatran. Unlike warfarin that can be reversed in a variety of ways, there has been no feasible or effective method for the adjunctive treatment of these life-threatening bleeds in patients using dabigatran. The only current method of removal, hemodialysis, is impractical in the vast majority of clinical situations.

There has been no feasible reversal agent until now. Boehringer Ingleheim the maker of dabigatran has developed a monoclonal antibody fragmin called idarucizumab.

The FDA approved idarucizumab in October as the first reversal agent for dabigatran. As far as we know it has not yet been approved for use in Canada

Clinical Question: Is idarucizumab safe and effective treatment adjunct for patients taking dabigatran with serious bleeding or who require an urgent procedure?

Reference: Pollack CV et al. Idarucizumab for Dabigatran Reversal. NEJM 2015

* Population: Patients 18 years of age or older, reported to have been taking dabigatran

* Group A: Patients with overt, uncontrollable, or life-threatening bleeding

* Group B: Patients who required surgery or other invasive procedure that could not be delayed for at least 8 hours.

* Intervention: All patients received 5g of intravenous idarucizumab in the form of two 2.5g boluses 15 minutes apart.

* Comparison: None, this was a prospective observational trial.

* Outcome:

* Primary Outcome: Maximum percentage reversal of the anticoagulant effect of dabigatran within four hours assessed by measurement of dilute thrombin time or ecarin clotting time.

* Secondary Outcomes: Reduction in the concentration of unbound dabigatran, restoration of hemostasis and suspected thrombotic events or deaths by 90 days.

Authors’ Conclusions: “Idarucizumab completely reversed the anticoagulant effect of dabigatran within minutes.”

Quality Checklist for Observational Trials:

* Did the study address a clearly focused issue? Yes and No. To measure the percentage of dabigatran reversal, a study needs no more than healthy volunteers in a controlled environment. These patients were recruited in a clinical setting more suited to providing patient-oriented outcomes, rather than pharmacokinetic data.

* Did the authors use an appropriate method to answer their question? Yes. In answering their primary outcome, percentage of dabigatran reversal, they use surrogate measures of thrombin time and ecarin clotting time. These surrogates do seem to be correlated to unbound dabigatran, however.

* Was the cohort recruited in an acceptable way...

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Date: November 29th, 2015

Guest Skeptics: Dr. Brandon Ritcey is an Emergency Medicine Resident from the University of Ottawa. Dr. Chris Bond is an Emergency Medicine physician and clinical lecturer at the University of Calgary. His interests include knowledge translation, FOAMed, and all things food and wine related. Chris has a blog called SOCMOB and is the new host of CAEP Cast.

This is another SGEM Hot Off the Press (#SGEMHOP). The goal of the #SGEMHOP is to cut the knowledge translation window down from over ten years to less than one month. This time the paper is from the Canadian Journal of Emergency Medicine (CJEM). We look forward to hearing your feedback via Twitter, Facebook and on the SGEM blog.

Case: A 75-year-old woman has a ground level fall in her apartment. She is brought to the emergency department with an isolated hip injury. She has a past medical history of high blood pressure and gastroesophageal reflex disease. Her only complaint is hip pain. On exam her vital signs are normal. The only abnormality found is a shortened and externally rotated left leg. An x-ray demonstrates a femoral neck fracture. The nurse wants to know what you want to give her for pain.

Background: Oligoanalgesia is a well-recognized problem in the emergency department (Wilson JE and Pendleton JM). It can be defined as inadequate pain control (Motov SM and Khan A). There are various groups at risk for oligoanalgesia and the elderly is one of those groups (Cavalieri TA).

Hip fractures are common in the elderly population. They are often very painful and are a significant cause of morbidity and mortality. Pain management can be challenging in these cases, particularly because of increased complications of opiate medications in this population.

Different types of regional nerve blocks have been tried to address the pain of these fractures.

* Traditional Femoral Nerve Block (FNB) – This involves injecting local anaesthetic directly around the femoral nerve and neurovascular bundle in the groin

* 3-in-1 Femoral Nerve Block – In this technique, you just put pressure distal to the needle while doing a traditional FNB. This allows the anaesthetic to track superiorly and also anaesthetize the obturator and lateral femoral cutaneous nerves.

* Fascia Iliaca Compartment Block (FICB) – The fascia iliaca block indirectly anaesthetizes the same three nerves as the 3 in 1 block by injecting a large volume of dilute anaesthetic lateral to the nerve in the fascia iliaca compartment.

Clinical Question: Do regional nerve blocks effectively reduce pain, decrease opiate use and are they safe compared to standard pain management in patients with hip or femoral neck fractures?

Reference: Ritcey et al. Regional Nerve Blocks for Hip and Femoral Neck Fractures in the Emergency Department: A Systematic Review. CJEM Nov 2015

* Population: Adults over 16 years old with femoral neck or hip fracture

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Date: November 21st, 2015

Guest Skeptic: Dr. Rory Spiegel is an Emergency Medicine resident in New York City. Rory is doing a resuscitation fellowship at Stony Brook University School of Medicine. He also writes a blog called EM Nerd about nihilism, medicine and the art of doing nothing.

Case: An 78-year-old woman presents to your emergency department with right arm weakness and slurred speech for the last two hours.  She has a history of hypertension and diabetes. A CTA is performed that shows an Intracranial arterial occlusion of the right M1 middle cerebral artery segment.

Background: Prior to the publication of MR CLEAN and the four trials published in its wake, the data regarding endovascular therapy has been consistently negative. Over the past year five RCTs examining endovascular therapy for acute ischemic stroke have been published. In direct contrast to the three trials published in 2013, all of the recent trials were impressively positive.

Because of methodological flaws, the true size of benefit these interventions provide is still unclear. Without an understanding of this effect size, it is difficult to assess whether this benefit justifies the resources required to support its implementation on a national level.

Clinical Question: Do endovascular therapies for acute ischemic stroke lead to improved neurological outcomes when compared to medical therapies alone and what is the effect size? 

Reference: Badhiwala, JH et al. Endovascular Thrombectomy for Acute Ischemic Stroke A Meta-analysis. JAMA 2015

* Population: Varied depending on primary trial’s inclusion and exclusion criteria. Essentially, patients presenting with signs and symptoms of acute ischemic stroke with either clinical or radiographic evidence of large vessel occlusion conducive to endovascular intervention.

* Intervention: Various endovascular therapies including intra-arterial tPA and clot retrieval devices.

* Comparison: Optimal medical therapy which included the use of IV tPA in the majority of the patients.

* Outcome: The authors chose to examine functional neurological status at 3-months, as assessed by an ordinal analysis of the modified Rankin Scale (mRS).

Author’s Conclusions: “Among patients with acute ischemic stroke, endovascular therapy with mechanical thrombectomy vs. standard medical care with tPA was associated with improved functional outcomes and higher rates of angiographic revascularization, but no significant difference in symptomatic intracranial hemorrhage or all-cause mortality at 90 days.”

Quality Checks for Therapeutic Systematic Reviews:

* The clinical question is sensible and answerable. Sensible yes, Answerable, with the current data, No.

* The search for studies was detailed and exhaustive. Yes but study selection was questionable.

* The primary studies were of high methodological quality. Variable

* The assessment of studies were reproducible. Yes

* The outcomes were clinically relevant. Questionable

* There was low statistical heterogeneity for the primary outcomes. No

* The treatment effect was large enough and precise enough to be clinically significant. Large enough, yes. Precise enough, No.

Key Results: In their pooled analysis, the authors found a shift towards improved functional outcomes at 90-days in the patients randomized to receive endovascular therapy when compared to standard care.

Odds Ratio 1.56 (95% CI, 1.

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Date: November 13th, 2015

Guest Skeptic: Dr. Salim Rezaie. Salim is an associate clinical professor of Emergency Medicine/Internal Medicine at the University of Texas Health Science Center at San Antonio, Texas. He is the creator/founder of the REBEL EM Blog and REBEL Cast.

Case: A 65-year old male has a witnessed cardiac arrest. He receives immediate CPR, early defibrillation, as well as one round of ACLS medications. He arrives via EMS to your emergency department, where they tell you that he has had a total of 10 – 15 minutes of CPR with no return of spontaneous circulation. You are working in a small community ER with limited staffing.

The patient was already intubated by EMS, but the patient is still requiring CPR. There is a mechanical CPR device in your department and you are considering using it. You cannot recall any trials that have ever shown benefit in clinically important outcomes for adult patients with out-of-hospital cardiac arrest (OHCA), but you also don’t have the staffing to continue prolonged CPR.

Background: In cardiac arrest, high quality, uninterrupted CPR has been promoted as being essential to help improve survival rates. This was emphasized again in the American Heart Association (AHA) 2015 guidelines. Besides encouraging providers to have adequate compression rate and depth, they also want providers to minimizing interruptions in compressions. Great summaries of these new AHA guidelines can be found at BoringEM.

In theory, mechanical CPR should provide CPR at a standard depth and rate for prolonged periods without a decline in quality and without interruptions, which should help improve survival and survival with good neurologic outcomes.

There are many types of mechanical chest compression devices but the two main technologies can be generalized as piston devices and load-distributing bands. The piston driven devices work by compressing on the chest in an up and down type of motion, similar to how we do manual CPR. The load distributing bands wrap all the way around the chest and shorten and lengthen which provides more of a rhythmic type of chest compression.

To date, we are not aware of any individual trials have ever shown superiority on clinically important outcomes for adult patients with OHCA, regardless of device.

A new study was published in NEJM last week that questioned the importance of  continuous chest compressions. Their results showed no superiority to continuous chest compressions by EMS. If you want the SGEM to put our skeptical eye upon this study and do a structured critical review, then vote for this paper using Hot or Not function on the SGEM. 

Clinical Question: Are mechanical chest compression devices superior to manual chest compression when used during resuscitation from OHCA?

Reference: Gates S et al. Mechanical Chest Compression for Out of Hospital Cardiac Arrest: Systematic Review and Meta-Analysis. Resuscitation 2015

* Population: Adult patients following out of hospital cardiac arrest

* Intervention: Mechanical compression devices

* Comparison: Manual compression

* Outcome: Return of spontaneous circulation (ROSC), survival of event, overall survival and survival with good neurologic outcome.

Authors’ Conclusions: “Existing studies do not suggest that mechanical chest compression devices are superior to manual chest compression, when used during resuscitation after out of hospital cardiac arrest.”

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Date: October 28th, 2015

Guest Skeptic: Dr. Justin Morgenstern. Justin is an emergency physician and the director of simulation education at Markham Stouffville Hospital in Ontario. He loves skepticism and medical education, especially when it is free and open access. He is the author of the #FOAMed blog First10EM.com and is an associate editor of Emergency Medicine Cases.

Case: A 60-year-old male with no major past medical history presents to your community emergency department with a three-day history of cough, fever and increasing shortness of breath. He is tachypneic with a respiratory rate of 28 and an oxygen saturation of 89% despite facemask oxygen, but he is mentating normally. Your Respiratory Therapist asks you whether you want her to try the new high flow nasal oxygen machine we have?

Background: High flow nasal oxygen is a novel device that actively humidifies and heats air to make flows of up to 60 liters a minutes tolerable. These incredibly high flows are important, because in order to provide 100% fiO2 to patients in respiratory distress, we must be able to match their minute ventilation.

High flow nasal oxygen also offers the theoretical benefits of low levels of PEEP and allows for much easier communication with our patients.

It has gained popularity in pediatrics for the treatment of severe bronchiolitis and it is seeing wider adoption among adult patients.

Clinical Question: In adult ICU patients with hypoxic respiratory distress not due to chronic obstructive pulmonary disease, asthma, or congestive heart failure, who do not require immediate intubation, does high-flow oxygen therapy or noninvasive ventilation therapy compared to standard therapy alone, reduce the rate of endotracheal intubation and improve outcomes?

Reference: Frat JP et al. High-Flow Oxygen through Nasal Cannula in Acute Hypoxemic Respiratory Failure. NEJM 2015.

* Population: Adult ICU patients with acute hypoxic respiratory failure.

* Inclusion criteria: Must have all four: Respiratory rate > 25/min, PO2/FiO2 ratio ≤ 300, a PCO2 of ≤ 45mmHg and no clinical underlying chronic respiratory failure.

* Exclusion criteria: PaCO2 >45mmHG, exacerbation asthma or COPD, cardiogenic pulmonary edema, hemodynamic instability, use of vasopressors, GCS of 12 or less, contraindications to non-invasive ventilation, urgent need to intubate, DNR order.

* Intervention: 

* High flow nasal oxygen (HFNO),

* Non-invasive positive pressure ventilation (NIV)

* Comparison: Standard face mask oxygen

* Outcome:

* Primary: Rate of intubation at 28 days

* Secondary: Mortality in the ICU, mortality at 90 days, duration of ICU stay and number of ventilator free days. This is different than the two secondary outcomes listed in ClinicalTrails.gov that included ventilator free days at 28 days and ICU morbidity at 28 days.

Authors’ Conclusions: In patients with nonhypercapnic acute hypoxemic respiratory failure, treatment with high-flow oxygen, standard oxygen, or noninvasive ventilation did not result in significantly different intubation rates. There was a significant difference in favor of high-flow oxygen in 90-day mortality.

Quality Checklist for Randomized Clinical Trials:

* The study population included or focused on those in the ED. NO. These were adult patients from 23 ICUs in France and Belgium)

* The patients were adequately randomized. YES.

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Date: October 27th, 2015

Guest Skeptic: Dr. David Sayer is a physician completing his general practice training in the United Kingdom.

Case Scenario: A 34-year-old woman presents with acute onset of headache peaking in 30 minutes with no recent trauma, focal deficits and a normal neurologic examination.

Background: Headaches represent around 2% of all emergency department visits. Of these presentations 1-3% turn out to be a subarachnoid hemorrhage (SAH)  (Edlow, Vermeulen, Perry, Morgenstern).

About 5% of SAH are misdiagnosed on the first emergency department assessment (Vermeulen). This is partly because 50% of SAH present with no neurologic deficit (Weir).

Dr. Jeff Perry and his team have tried to create a clinical decision tool to rule out SAH for acute headaches (SGEM#48). The Ottawa SAH Tool contains six variables to decide if a CT scan is necessary.

Applying the tool could decrease the miss rate of SAH from about five percent down to almost zero with a slight increase in utilization. However, the tool needs further evaluation in implementation studies before it is ready for “prime time”.

Traditional methods of working up a SAH has been non-contrast CT followed by a lumbar puncture (LP). Dr. David Newman has questioned this dogma on his SMART-EM podcast. He suggested LPs are not always needed after a negative CT scan.

Dr. Newman calculated the number needed to LP to identify one SAH for which an intervention was indicated to be 700, prompting the question “are you part of the ‘700 Club’?” Should any of us be part of the 700 Club?

Clinical Question: In emergency department acute headache patients, how frequently does LP diagnose SAH after unremarkable CT scan?

Reference: Sayer et al. An Observational Study of 2248 Patients Presenting with Headache, Suggestive of Subarachnoid Hemorrhage, that Received a Lumbar Puncture Following a Normal CT Head.  Acad Emerg Med Nov 2015

* Population: Adult patients (2248 total, >17 years old) presenting to one of six urban EDs in the United Kingdom with acute headache suspicious for subarachnoid hemorrhage, who had both a negative CT and a lumbar puncture performed.

* Intervention: LP to achieve identification of CT-negative SAH patients

* Comparison: None

* Outcome: Incidence of positive LP (defined only by spectrophometric detection of bilirubin, not by any CSF RBC count) and proportion with cerebral aneurysm identified

Author’s Conclusions: “In patients presenting to the emergency department with acute, non-traumatic severe headache, LP to diagnose or exclude SAH after negative head CT has a very low diagnostic yield, due to low prevalence of the disease and uninterpretable or inconclusive samples. A clinical decision rule may improve diagnostic yield by selecting patients requiring further evaluation with LP following non-diagnostic or normal non-contrast CT brain imaging.”

Quality Checklist for A Diagnostic Study:

* The clinical problem is well defined. YES.

I had the pleasure of being a guest panelist on The Reality Check (TRC) podcast this week. TRC is “Canada’s weekly podcast that explores a wide range of controversies and curiosities using science and critical thinking.”

They invited me on to discuss some of my favourite things like evidence based medicine, knowledge translation and FOAMed. Listen to the show by clicking on this link to the MP3 file or subscribing to TRC on iTunes.

We had lots of fun discussing how social media can cut the knowledge translation window down from over ten years to less than one year. I also got to participate in a “riveting” trivia game called Name That about the Nobel Prizes.

The Reality Check:

* “The Reality Check podcast was created by the Ottawa Skeptics, an organization which aims to promote the use of the scientific method, critical thinking and rational thought in our community. Ottawa Skeptics supports high standards of scientific integrity, academic freedom and the free exchange of ideas. We have one bias: Science is the best method for determining objective truth.”

Check out this science podcast on skeptical and critical thinking. You can follow the TRC on Twitter , subscribe on iTunes and like on Facebook.

Remember to be skeptical of anything you learn, even if you heard it on the Skeptics’ Guide to Emergency Medicine. 

 

 

 

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Date: October 23rd, 2015

Guest Skeptic: Dr. Anand Swaninathan is an assistant program director at NYU/Bellevue Hospital in the Department of Emergency Medicine. He is also part of REBEL EM, The Teaching Course, Emergency Medical Abstracts and a new FOAM site – Core EM.

Case: A 53-year-old woman with no past medical history presents to the emergency department with palpitations for four days. She says she has felt fatigued and a bit short of breath. Vitals reveal a blood pressure of 153/72 and a heart rate of 137 beats per minute. On physical examination, you notice that her heart rate is irregularly irregular and a 12-lead EKG confirms that the patient is in atrial fibrillation with rapid ventricular response.

Background: Atrial fibrillation is a commonly encountered dysrhythmia in the Emergency Department. Atrial flutter is less common but its management is very similar to that of atrial fibrillation.

There is quite a bit of debate on the management of patients with recent onset atrial fibrillation as to whether it is optimal to cardiovert patients or to leave them in atrial fibrillation. 

We did a podcast looking at the Ottawa Aggressive Atrial Fibrillation Protocol on SGEM#88. It is a very effective approach to new onset atrial fibrillation but would not apply to this patient who has had four days of symptoms.

In patients with chronic atrial fibrillation or unknown time of onset and a rapid ventricular response, rate control and consideration and initiation of anticoagulation therapy are the standard emergency department approach.

Both beta-blockers and calcium channel blockers are commonly used for rate control in the emergency department, but it is unclear whether one of these agents is superior to the other as there is scant high-quality data on the topic (Demircan 2005).

Clinical Question: In patients with atrial fibrillation and rapid ventricular response, what agent, beta blocker or calcium channel blocker, will obtain rate control the fastest?

Reference: Fromm C et al. Diltiazem vs. metoprolol in the management of atrial fibrillation or flutter with rapid ventricular rate in the emergency department. J Emerg Med 2015.

This paper was picked via the SGEM Hot or Not function. Each week we post five recent publications and ask SGEMers to rate each paper as Hot or Not. Have your voice heard and pick the articles for us to review.

* Population: Adult patients > 18 years presenting with atrial fibrillation or atrial flutter.

* Exclusion: SBP<90 mmHg, ventricular rate greater than or equal to 220 beats per minute, QRS >0.100 seconds, 2nd or 3rd degree atrioventricular block, temperature >38.0 ˚C, acute ST elevation myocardial infarction, known history of NYHA Class IV heart failure or active wheezing with a history of bronchial asthma or COPD.

* Intervention: Diltiazem 0.25 mg/kg (max dose of 30 mg) or metoprolol 0.15 mg/kg (max dose of 10 mg) IV

* Comparison: As Above

* Outcome:

* Primary: Heart Rate < 100 beats per minute (bpm) within 30 minutes of drug administration

* Safety: HR<60 and SBP<90mmHg

Authors’ Conclusions: “Diltiazem was more effective in achieving rate control in ED patients with AFF and did so with no increased incidence of adverse effects.”

Quality Checklist for Randomized Clinical Trials:

*

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Date: October 15th, 2015

Guest Skeptic: Dr. Richard Lubell is a community pediatrician in London, Ontario with over 30 years of experience. He is an associate professor in the Department of Pediatrics at Western University.

Case: A four-year-old boy presents to the emergency department after being picked up from school. The mother is worried he has another ear infection. This is because the teacher thought he was having trouble hearing in class. The child completed a course of antibiotics two months ago for acute otitis media. On examination the child looks well and has no fever. Otoscopic examination demonstrates some fluid behind the tympanic membrane.

Background: Otitis media with effusion or glue ear can be defined as a condition that that persists for more than six weeks. There were over two million cases diagnosed in the USA in 2004 with a cost of approximately four billion dollars.

Otitis media with effusion has been reported as the most common chronic condition of childhood and the most common reason for surgery in this age group. The reason we are so concerned about these effusion is hearing loss. Fluid in the middle early can cause a conductive hearing loss that if unrecognized and untreated can translate to broader developmental difficulties.

There are a number of ways to check for middle ear effusions all with various strengths and weaknesses:

* Otoscopy: This allows you to look at the tympanic membrane and see if there is fluid but this does not tell you if the ear drum actually moves.

* Pneumatic Otoscopy: This gives you a more dynamic assessment of the tympanic membrane (does it move in response to pressure changes).

* Tympanometry: This give you objective/quantitative measure of the compliance of the tympanic membrane.

* Pure Tone Audiometry: This can determine the degree and type of hearing loss. Depending on the results it can suggest a conductive hearing loss due to fluid in the middle ear.

Tympanometric evaluation to diagnose otitis media with effusion can give three main results:

* Type A normal

* Type B (flat) abnormal

* Type C indicates negative pressure in middle ear and possibly an abnormality

Various treatments have been tried for treating otitis media with effusion:

* Antibiotics – “our review do not support the routine use of antibiotics for children up to 18 years with otitis media with effusion”. Van Zon et al CDSR 2012

* Antihistamines/Decongestants – “No statistical or clinical benefit was found for any of the interventions or outcomes studied. However, treated study subjects experienced 11% more side effects than untreated subjects (number needed to treat to harm = 9). Griffin and Flynn CDSR 2011

* Oral or Topical Nasal Steroids –“there is no evidence of longer-term benefit and no evidence that they relieve symptoms of hearing loss. We found no evidence of benefit from treatment of OME with topical intranasal steroids, alone or in combination with an antibiotic, either at short or longer-term follow up.” Simpson et al CDSR 2011

* Grommets (venting tubes) –“effect of grommets on hearing, as measured by standard tests, appears small and diminishes after six to nine months by which time natural resolution also leads to improved hearing in the non-surgically treated children” Browning et al CDSR 2010

* Nasal Balloon Devices – “All of the studies were small,