Williamson, I. (Ian), Dr., Benge, Sarah, Barton, S., Petrou, Stavros, Letley, L., Fasey, N., Abangm, G., Dakin, H. and Little, P. (2009) A double-blind randomised placebo-controlled trial of topical intranasal corticosteroids in 4- to 11-year-old children with persistent bilateral otitis media with effusion in primary care. Health Technology Assessment, Vol.13 (No.37). pp. 1-274. doi:10.3310/hta13370

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Abstract

Objectives:
To determine the clinical effectiveness and cost-effectiveness of topical mometasone in children with bilateral otitis media with effusion (OME).

Design:
A double-blind randomised placebo-controlled trial with an intention to treat analysis; the 10.6% of patients lost to follow-up at 1 month were censored in the analysis.

Setting:
76 Medical Research Council General Practice Research Framework practices throughout the UK between 2004 and 2007.

Participants:
A sample of 217 children aged 4–11 years was selected from those presenting to their GP with one or more episodes of otitis media or ear-related problems in the previous 12 months whom the research nurse confirmed had bilateral glue ear using microtympanometry (B B or B C2 types using a modified Jerger classification) at randomisation.

Interventions:
Mometasone 50 µg in each nostril or placebo spray once daily for 3 months.

Main outcome measures:
The primary outcome was the proportions of children cleared of OME assessed by tympanometry at 1 month. Secondary outcomes included clearance at 3 months and 9 months; adverse events; OM8-30 scores (a functional health status responsive disease-specific measure); hearing loss; days with otalgia; cost-effectiveness; and health utilities.

Results:
Of the topical steroid group, 40.6% (39/96) demonstrated tympanometric clearance (C1 or A type) in one or both ears at 1 month, compared with 44.9% (44/98) of the placebo group. The absolute risk reduction at 1 month was –4.3% (95% CI –18.05% to 9.26%); the odds ratio (OR) was 0.84 (95% CI 0.48 to 1.48). Four covariates were pre-specified for inclusion in logistic regression analysis: age as a continuous variable (p = 0.94), season (p = 0.70), atopy (p = 0.61) and clinical severity (p = 0.006). The adjusted OR (AOR) at 1 month for the main outcome was 0.93 (95% CI 0.50 to 1.75). Secondary analysis at 3 months showed 58.1% of the steroid group had resolved and 52.3% of the placebo group, AOR 1.45 (95% CI 0.74 to 2.84). At 9 months 55.6% of the treated group remained clear in at least one ear and 65.3% of the placebo group, AOR 0.82 (95% CI 0.39 to 1.75). Adverse events (although relatively minor) occurred in 7–22% of children and included nasal stinging, epistaxis, dry throat and cough. The OM8-30 scores (p = 0.55) reported hearing difficulty (p = 0.08), and days with otalgia (p = 0.46) were not significantly different between groups at 3 months. The economic evaluation found the active treatment arm to be dominated by placebo, accruing slightly (but not significantly) higher costs and fewer quality-adjusted life-years (QALYs), with a 24.2% probability that topical steroids are a cost-effective use of NHS resources at a ceiling ratio of £20,000 per QALY gained.

Conclusions:
Use of topical intranasal corticosteroids is very unlikely to be a clinically effective treatment for OME (glue ear) in the primary care setting.

Item Type:	Journal Article
Subjects:	R Medicine > RF Otorhinolaryngology R Medicine > RM Therapeutics. Pharmacology
Divisions:	Faculty of Science, Engineering and Medicine > Medicine > Warwick Medical School > Health Sciences Faculty of Science, Engineering and Medicine > Medicine > Warwick Medical School
Library of Congress Subject Headings (LCSH):	Otitis media with effusion in children -- Treatment, Adrenocortical hormones, Intranasal medication, Placebos (Medicine), Clinical trials
Journal or Publication Title:	Health Technology Assessment
Publisher:	National Coordinating Centre for Health Technology Assessment
ISSN:	1366-5278
Official Date:	August 2009
Dates:	Date Event August 2009 Published
Volume:	Vol.13
Number:	No.37
Page Range:	pp. 1-274
DOI:	10.3310/hta13370
Status:	Peer Reviewed
Publication Status:	Published
Access rights to Published version:	Open Access
Funder:	NIHR Health Technology Assessment Programme (Great Britain) (NIHR HTA)

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