General Commissioning Policy

Treatment / Adenoidectomy
For the treatment of / Otitis Media with Effusion and Sleep Apnoea
Background / NHS Scarborough and Ryedale CCGcommissions’ healthcare on behalf of its local population across primary, secondary and tertiary care sectors. Commissioning policy including clinical referral pathways and thresholds have been developed and defined using appropriate NICE guidance and other peer reviewed evidence and are summarised here in order to guide and inform referrers.
This policy defines the SCRCCG commissioning position for adenoidectomy for the management of otitis media with effusion (OME) and/or sleep apnoea
Commissioning position / Adenoidectomy combined with grommets may be considered in children who fulfil the criteria for grommets as follows:
The CCG will only agree to fund treatment with grommets for children under 12 years old with bilateral otitis media with effusion (OME) under the following circumstances:
There has been a period of 3 months watchful waiting from the date of the first appointment with an audiologist AND
OME persists after 3 months and the child suffers from at least one of the following:

At least 5 recurrences of acute otitis media in a year
Evidenced delay in speech development
Hearing level in the better ear of 25-30 dBHL or worse averaged at 0.5, 1, 2, & 4 KHZ (or equivalent dBH where dBHL not available)
Hearing loss of less than 25-30 dBHL where the impact on a child’s development, social or educational status is judged to be significant*
A second disability such as Down’s syndrome or cleft palate (cleft palate is a contraindication to adenoidectomy)

OR
OME is overlaying sensorineural deafness or is delaying diagnosis or treatment with aids or cochlear implants (this would be an indication for immediate grommets).
*Evidence from GP or Community Healthcare professional that symptoms prevent the child from carrying out vital educational activities or symptoms prevent the child from carrying out other vital activities.
Requirements for approval
Two sets of hearing results through audiologist assessment three months apart. Documented evidence of the impact of hearing loss on the child’s development as defined above.
All other reasons for grommets in children are not funded.
Other indications for adenoidectomy in conjunction with tonsillectomy that can be considered include:
Sleep apnoea
All referrals for Sleep Apnoea must comply with NICE TAG 139 and have completed an Epworth Sleep Score (see separate threshold)
A literature review by Ryan6 in 2005 was published in Thorax. This found that, in children, including those that are obese, “adenotonsillectomy was curative for 75-100%”. However, a Cochrane review7 (2006) noted that there is no randomised trial data relating to adenotonsillectomy for obstructive sleep apnoea in children and more research is needed.
Patients who are not eligible for treatment under this policy may be considered on an individual basis where their GP or consultant believes exceptional circumstances exist that warrant deviation from the rule of this policy. Individual cases will be reviewed as per the CCG policy.
Effective from / October 2015
Summary of evidence / rationale / Clinical Evidence, last updated in November 20058, states that:
ventilation tubes (grommets) and adenoidectomy represents a trade-off between benefits and harms:

Adenoidectomy on its own is of unknown effectiveness.
In a Cochrane review of grommets9, the reviewers note some improvement in outcomes that look at adenoidectomy and grommet insertion compared to grommet insertion alone.
In 2005, in a randomised control trial (n=193) comparing watchful waiting with adenotonsillectomy for otitis media, Oomen et al10 found no significant difference in the occurrence of otitis media between the Adenotonsillectomy group and the watchful waiting group.

Information to include in the Referral letter / The GP referral letter should contain:

Details of how the patient meets the above criteria OR demonstrates clinical exceptionality
Impact on activities of daily living
Treatments and interventions tried including the results
Drug history (prescribed and non-prescribed)
Relevant past medical/surgical history
Current regular medication
BMI

Date / October 2015, reviewed December 2017
Review Date / December 2019
Contact for this policy / SRCCG Service Improvement Team

References:

1 MRC Multicentre Otitis Media Study Group (2001). Surgery for persistent otitis media with effusion: generalisability of results from the UK trial (TARGET). Clin.Otolaryngol (26); 417-424.

2. Rosenfeld et al (2004). Clinical practice guideline: Otitis media with effusion.

Otolaryngology- Head and Neck Surgery (130);5;s95-s118.

3. Rovers, M et al (2000). The Effect of Ventilation Tubes on Language Development in Infants with Otitis Media with Effusion: A Randomised Trial. Paediatrics (106);3.

4. Paradise, J.L (2001). Effect of early or delayed insertion of tympanostomy tubes for persistent otitis media on developmental outcomes at the age of three years. NEJM (344);16;1179-1187.

5. Paradise, J.L (2005). Developmental Outcomes after Early or Delayed Insertion of Tympanostomy Tubes. NEJM (353);6;576-587.

6. Ryan, C.F (2005). Sleep 9: An approach to treatment of obstructive sleep apnoea/hypopnoea syndrome including upper airway surgery. Thorax (60);595- 604.

7. Lim, J and McKean, M (2001). Adenotonsillectomy for obstructive sleep apnoea in children. Cochrane Database of Systematic Reviews Issue 3.

8. BMJ Clinical Evidence: Otitis media with effusion (available online at free registration required.

9. Cochrane Database of Systematic Reviews. Grommets (ventilation tubes) for hearing loss associated with OME in children.

10. Oomen. K et al (2005). Effect of adenotonsillectomy on middle ear status in children. Laryngoscope Apr;115(4):731-4.Black's Medical Dictionary. 40th Edition. A&C Black. London 2002.

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