A Consensus-based Practical Guide on the Management of retraction pockets of pars tensa and pars flaccida

Matthew Yung, Codruta Neumann, Matthew Yung
2013 Int. Adv. Otol   unpublished
Introduction The European Academy of Otology and Neurotology (EAONO) wishes to produce guidelines on a number of otological conditions and their management. Guideline documents are supposed to be based on the highest level of evidence available. Unfortunately, this is not often possible, especially for surgical conditions or procedures. There are very few high quality randomised control studies or even comparative studies on surgical procedures. The problems include controlling the surgical
more » ... ng the surgical skill of surgeons, recruiting sufficient numbers, observer bias, adequate follow up periods, and getting internal and external validity for the studied populations. In the absence of high quality evidence, guidelines should be based on consensus[Brouwers et al., 2010]. This paper describes the effort by the authors to formulate consensus statements on the 'Management of retraction pockets of pars tensa and pars flaccida'. A previous systematic review by authors has shown that there is no high level of evidence to support any surgical intervention over watchful waiting in the management of mild to moderate degrees of retraction pockets and there is also no good evidence to favour one particular treatment over the others [Neumann C and Yung MW, 2012]. Similar conclusions have been made by a Cochrane review [Nankivell and Pothier, 2010]. Retraction pocket is one of the topics in the proposed EAONO (European Academy of Otology and Neuro-Otology) guidelines on 'The Management of Chronic Otitis Media'. The present paper describes the consensus 12 This is a consensus-based practical guide produced by the European Academy of Otology and Neurotology (EAONO) on the 'Management of retraction pockets of pars tensa and pars flaccida'. A previous systematic review did not show any evidence to support one particular treatment over the others, or even over watchful waiting. In the absence of evidence, the present practical guide is based on consensus using the Delphi Technique. It is a cyclical process that gathers information, summarises it and re-submits the summaries to participating EAONO members until a consensus is reached. A set of statements were prepared by the authors and sent to all EAONO members. After 2 rounds of consensus cycle, all but one of the statements reached the target 80% consensus. The key statements on the 'Management of retraction pockets of the pars tensa and pars flaccida' cover the difference between retraction pockets and Cholesteatoma, the importance of describing a retraction pocket accurately, the indications for surgery, the types of surgical treatment in the paediatric and adult populations, the minimal follow-up periods and the value of pre-operative Eustachian function test. Out of a total of 364 EAONO, only 46 responded to the first consensus cycle and 26 responded to the second cycle. The problem of low response rate needs to be addressed for future EAONO consensus documents to increase their credibility. Because of the low response rate, a high bar of 80% agreement is used for every single statement in the practical guide.