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    UNIVERSITY OF THE PHILIPPINES PHILIPPINE GENERAL HOSPITAL

    DEPARTMENT OF OTORHINOLARYNGOLOGY

    with the continuing medical education support of

    GLAXO SMITHKLINE PHILIPPINES

    CLINICAL PRACTICE GUIDELINES

    RUZANNE MAGIBA-CARO MD EDILBERTO M. JOSE MD Co-chairs

    ERASMO GONZALO D.V. LLANES MD JASON S. GUEVARA MD CHRISTINE JOY S. ARQUIZA MD VINCENT MARK M. JARDIN MD CHRISTOPHER MALORRE E. CALAQUIAN MD JERIEL JOHN C. MAJAM MD JOSE ROBERTO V. CLARIDAD MD DANILO R. LEGITA MD ERICK G. DUCUT MD

    CONSENSUS PANEL

    GENEROSO T. ABES MD MPH Department Chair

    MARIANO B. CAPARAS MD ROMEO L. VILLARTA, JR. MD MPH JOSELITO C. JAMIR MD JOSE FLORENCIO F. LAPEA, JR. MA MD EUTRAPIO S. GUEVARA JR MD TERESA LUISA I. GLORIA-CRUZ MD MHPEd ALFREDO Q.Y. PONTEJOS JR MD RAMON ANTONIO B. LOPA MD JAIME F. FLOR MD ROBERTO M. PANGAN DMD MD PhD JOSEFINO G. HERNANDEZ MD MARIA RINA T. REYES-QUINTOS MD MCAud RENE S. TUAZON MD MELFRED L. HERNANDEZ MD MHA JACOB S. MATUBIS MD NATHANIEL W. YANG MD CESAR V. VILLAFUERTE JR MD MHA ARMANDO M. CHIONG, JR. MD CHARLOTTE M. CHIONG MD AGNES N. TIRONA-REMULLA MD ABNER L. CHAN MD JEANNETTE MARIE S. MATSUO MD FELIX P. NOLASCO MD

    RESIDENTS

    LINA ROSE A. ALCANCES MD MOH MICHAEL F. GALICIA MD ERWIN M. ESLAVA MD DESIREE B. VANGUARDIA MD HERBERT Q. GUTIERREZ MD CAMILLE SIDONIE A. ESPINA MD ERIC T. VINCULADO MD MARY APPLE PIE M. GARCIA MD MARIO ADRIAN M. ZAFRA MD FELICIDAD B. MENDOZA MD FORTUNA CORAZON A. ABERIN MD LEI-JOAN V. MOLO MD ARSENIO CLARO A. CABUNGCAL MD IVY D. PATDU MD RYNER JOSE C. CARRILLO MD FLORENCE YUL N. SAQUIAN MD PHILIP B. FULLANTE MD JOSEPH ROY VINCENT B. UMALI MD

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    UP-PGH DEPARTMENT OF OTORHINOLARYNGOLOGY CLINICAL PRACTICE GUIDELINES

    PURPOSE OF THE CLINICAL PRACTICE GUIDELINES The UP-PGH Department of Otorhinolaryngology handles about 45,000 patients a year. It must ermbrace the influx of new concepts, current techniques, diagnostic and therapeutic options. At the same time, it has to struggle to keep a balance between this and the availability of its limited resources. The development of clinical practice guidelines in selected areas is designed to help fill in the gap to maximize patient care in the department. TARGET POPULATION, SETTING AND PROVIDERS OF CARE Charity patients seen by the consultant and resident staff of the UP-PGH Department of Otorhinolaryngology are the target population. The conditions include: (1) chronic suppurative otitis media in adults; (2) nasal polyps in adults; (3) acute and chronic tonsillitis in children and adults; (4) obstructive sleep apnea in children; (5) thyroid masses in adults; (6) cleft lip and palate in children and adolescents; and (7) tracheostomy and decannulation in children and adults. METHODS OF GUIDELINE DEVELOPMENT The UP-PGH Department of Otorhinolaryngology has six subspecialty study groups to which consultants and residents are assigned. Each of the study groups chose one common clinical condition, which they felt needed a protocol for effective and efficient management. They conducted the literature search and developed evidence-based recommendations (EBR). In the case of the Cranio-Maxillofacial, Plastic and Reconstructive Surgery study group, they met with the rest of the CLAP team in the development of the EBR. The consultant and resident staff convened in Caliraya, Laguna on September 2-3, 2003, to deliberate on the EBRs, modify, arrive at a consensus and ratify the CPG. PANEL RECOMMENDATIONS AND LEVELS OF EVIDENCE All literature were classified according to levels of evidence and grades of recommendations based on guidelines from the US Agency for Health Care Policy and Research and are set out as follows:

    STATEMENTS OF EVIDENCE GRADES OF RECOMMENDATION

    Ia Obtained from meta-analysis of randomized controlled trials

    A

    Requires at least one randomized controlled trial as part of a body of literature of overall good quality and consistency addressing the specific recommendation

    Ib Obtained from at least one randomized controlled trial

    IIa Obtained from at least one well-designed controlled study without randomization

    B

    Requires the availability of well conducted clinical trials but no randomized clinical trials on the topic of recommendation IIb Obtained from at least one other type

    of well-designed quasi-experimental study

    III Obtained from well-designed non-experimental descriptive studies, such as comparative studies, correlation studies and case studies

    IV Obtained from expert committee reports or opinions and/or clinical experience of respected authorities

    C

    Requires evidence obtained from expert committee reports or opinions and/or clinical experiences of respected authorities. Indicates an absence of directly applicable clinical studies of good quality

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    UP-PGH DEPARTMENT OF OTORHINOLARYNGOLOGY CLINICAL PRACTICE GUIDELINES CHRONIC SUPPURATIVE OTITIS MEDIA IN ADULTS SCOPE OF THE PRACTICE GUIDELINE This clinical practice guideline is for use by the Department of Otorhinolaryngology of the College of Medicine - Philippine General Hospital, University of the Philippines Manila. It covers the diagnosis and management of chronic suppurative otitis media in adults (19 years old and above). OBJECTIVES The objectives of the guideline are (1) to emphasize the requisites of diagnosis of chronic suppurative otitis media in adults; (2) to evaluate current diagnostic techniques; and (3) to describe treatment options. LITERATURE SEARCH This guideline is based on the 1997 Clinical Practice Guidelines of the Philippine Society of Otolaryngology Head and Neck Surgery and revised according to new evidence. The National Library of Medicines PubMed database and Cochrane Reviews database were searched for literature using the keyword otitis media, suppurative. The search was limited to articles involving humans and those published in English in the last fifteen years, WHO reports, and the PGH Annual Report. It yielded 549 articles. Thirty-eight (38) abstracts were chosen and results were further assessed for relevance. Full text articles were obtained when possible. The chosen articles were divided as follows:

    Meta-analysis 2 Randomized controlled trial 2 Non-randomized controlled study 3 Descriptive study 1 Committee report 1

    DEFINITION Chronic suppurative otitis media (CSOM) is a persistent inflammation of the middle ear or mastoid cavity. Synonyms include chronic otitis media (without effusion), chronic mastoiditis and chronic tympanomastoiditis. Chronic suppurative otitis media is characterized by persistent or recurrent ear discharge (otorrhea) over 3 months through a perforation of the tympanic membrane.

    9 Typical findings may include thickened granular middle ear mucosa, mucosal polyps

    and cholesteatoma within the middle ear. Chronic suppurative otitis media does not include chronic perforations of the eardrum that are dry, discharge only occasionally, and have no signs of active infection.

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    PREVALENCE Worldwide prevalence of chronic suppurative otitis media is 65-330 million people. Between 39 to 200 million (60%) suffer from significant hearing impairment. Otitis media has been estimated to cost 28,000 deaths and a loss of over 2 million in Disability Adjusted Life Years (DALY) in 2000, 94% of which are in developing countries. Most of these deaths are presumably due to chronic suppurative otitis media, because acute otitis media is a self-limiting infection

    2.

    In the Philippines, the prevalence of CSOM is estimated at 2.5% to 29.5% based on several surveys among children in Metro Manila and Mindanao.

    9 It has been reported that CSOM

    patients constitute 14% of outpatient consults at the University of Santo Tomas Hospital 4, and

    30% of emergency cases and 60% of operated ears at the PGH 9. The number of referrals

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    (pediatric and adult patients) with diagnosis of CSOM in the ORL-Outpatient Ear Specialty Clinic of the Philippine General Hospital numbers to 325 in 2002. RECOMMENDATIONS ON THE DIAGNOSIS OF CHRONIC SUPPURATIVE OTITIS MEDIA The assessment begins with a thorough history of the frequency, duration, and characteristics of the discharge. Physical examination of the affected ear requires cleansing of the external auditory canal before the tympanic membrane can be accurately assessed. The eardrum must be adequately visualized for accurate diagnosis and treatment.

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    1. CSOM is diagnosed by the presence of a tympanic membrane perforation and a history

    of persistent or recurrent ear discharge for more than 3 months. Grade C Recommendation

    The presence of tympanic membrane perforation and persistent or recurrent otorrhea for more than 3 months is still considered by the panel to be diagnostic of CSOM. (Task Force of the Fourth International Symposium of Otitis Media Florida, June 1987).

    4 Critical to this

    definition is the history of chronic active otorrhea for more than 3 months. The histopathologic definition of CSOM was not used.

    2. Pure tone audiometry and speech testing (PTA-ST) must be performed as part of the

    total diagnostic assessment. Grade C Recommendation

    The panel recognized the value of the PTA-ST in the initial evaluation of patients with CSOM because it provides information on the etiology of hearing loss (conductive, mixed and sensorineural) in the ipsilateral and contralateral ear. Moreover, it gives baseline data on the pre-operative hearing s

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