BrazJOtorhinolaryngol.2015;81(4):345---346
www.bjorl.org
Brazilian
Journal
of
OTORHINOLARYNGOLOGY
EDITORIAL
Guidelines
in
otorhinolaryngology:
a
critical
view
夽
Guidelines
em
otorrinolaringologia:
uma
visão
crítica
Over the last two decades, evidence and systematic review have been the keystones of guideline develop-ment. Evidence-based medicine was defined by Sacket et al. as ‘‘the conscientious, explicit, and judicious use of current best evidence in making decisions about the care of individual patients’’.1 This practice of
evidence-based medicine means integrating individual clinical
expertise with the best available external clinical
evi-dence from systematic research. The GRADE approach
(http://www.gradeworkinggroup.org) pointstothe
impor-tance of an estimate of the intervention effect and the
confidence thatthe estimateis correct,andwasthe first
tostressthebalanceofdesirableandundesirableeffects.
Over20organizations,includingtheWorldHealth
Organiza-tion(WHO),theBMJ,andtheCochraneCollaborationhave
adoptedtheGRADEsystem.Inthelastdecade,theAppraisal
ofGuidelinesforResearch&Evaluation(AGREE)Instrument (http://www.agreetrust.org)wasdevelopedtoaddressthe qualityofpracticeguidelinesinasystematicway.
Several evidence-based guidelines have been
devel-oped within otorhinolaryngology, both at national and
international levels.2---4 However, we are still far from
evidence-based practice in our daily work.5,6 Although it
has been shown that adhering to guidelines significantly
improvesthequalityoflifeofourpatients,therehasalso
been ample proof that adherence to guidelines is often
insufficient.7 This editorial attempts to evaluate
poten-tial reasonswhy we donot use guidelinesasmuchaswe
should.
One of the major issues is that we are still not able
todevelop worldwideguidelines;there can besignificant
differencein the guidelines onthe same topicsproduced
bydifferentcountries.Aartsetal.demonstratedthat the
guidelinesonasimilartopicmayshowdissimilarities regard-ingconclusions,levelsofevidence,andcitationsused.8This
夽
Please cite this article as: Fokkens W, Pundir V. Guidelines
in otorhinolaryngology: a critical view. Braz J Otorhinolaryngol.
2015;81:345---6.
reducesthecredibilityofsuchguidelines.Althoughweare
awareofdifferencesinhealthcaresystems,itisimperative
tohave guidelines that aremethodologically impeccable,
areacknowledgedworldwide,andthataccountforpotential
regionaldifferences.Thus,currentlywhenusingguidelines, theclinicianhastopersonallyascertaintheirquality. The AGREEinstrumentisausefulaidinthisaspect.
Moreover,theclinicianhastorealizethatoftenthe
evi-denceonwhichtheguidelinesarebasedisnotoverwhelming
andinsomesituationsahighlevelofevidenceisvery
dif-ficult or impossible to achieve. Forinstance, the number
of randomized surgical trials is expected to remain very
limited.When evidence is scarce and/or of limited
qual-ity,theauthorsof guidelinesoftentry toadvise basedon
thelimitedevidenceavailable,butthelimitationsoftheir
foundationsareoftennotappreciatedwhenelaborate
diag-nosticortreatmentschemesarepresented.Theoppositeis
alsooftentrue: guidelinesmaygivetheanswerstoalong
listofquestionswithoutprovidingguidanceandorientation,
makingthem very difficult to read anddigest, thus
ham-peringtheiruseindailypractice.Finally,whentreatingour patientsitisimportanttorealizethattheavailableevidence
maybeaccumulated in adifferent population groupthan
thatofthepatient:trialsoftenexcludepatientswith cer-taincharacteristics,suchassmokers,childrenandpatients
over65,orpregnantwoman.
Lastly,weshouldkeepinmindthatmedicineisan ever-evolvingfield.Guidelinesareupdatedregularlyin lightof
newevidenceandwe must ensurethat we usethe latest
guidelinesinourdailypractice.
If the reader interprets this editorial as an argument
againstusingguidelines,he/sheismistaken.Guidelinesare
agreathelp inourdaily practiceandprovide supportfor
those who are not willing or able to study all available
literature. In most countries,deliberately deviating from
guidelines has to be acknowledged in the patient notes
andjustifiedfor good reason.However,we have toavoid
to using a guideline as a cookbook for our patients and
always remember the wise words of Sacket:
‘‘Evidence-basedmedicineistheconscientious,explicit,andjudicious
http://dx.doi.org/10.1016/j.bjorl.2015.05.002
1808-8694/©2015Associac¸ãoBrasileirade OtorrinolaringologiaeCirurgiaCérvico-Facial.Published byElsevierEditoraLtda.Allrights
346 EDITORIAL
useofcurrentbestevidenceinmakingdecisionsaboutthe
careofindividualpatients.’’
Conflicts
of
interest
Theauthorsdeclarenoconflictsofinterest.
References
1.SackettDL,RosenbergWM,GrayJA,HaynesRB,RichardsonWS. Evidence-basedmedicine:whatitisandwhatitisn’t.BMJ(Clin ResEd).1996;312:71---2.
2.MelloJFJr,MionOdeG,AndradeNA,Anselmo-LimaWT,Stamm AE, Almeida WL, et al. Brazilian Academy of Rhinology posi-tionpaperontopicalintranasaltherapy.BrazJOtorhinolaryngol. 2013;79:391---400.
3.BousquetJ,AddisA,AdcockI,AgacheI,AgustiA,AlonsoA,etal. Integratedcarepathwaysforairwaydiseases(AIRWAYS-ICPs).Eur RespirJ.2014;44:304---23.
4.FokkensWJ,LundVJ,MullolJ,BachertC,AlobidI,BaroodyF, etal.EPOS2012Europeanpositionpaperonrhinosinusitisand nasalpolyps2012.Asummaryforotorhinolaryngologists. Rhinol-ogy.2012;50:1---12.
5.Al-HussainiA, Owens D, Tomkinson A. Have two UK national guidelines had any effect on grommets day-case utilisation and rate over the last 10 years? European archives of oto-rhino-laryngology: official journal ofthe European Federation of Oto-Rhino-Laryngological Societies (EUFOS): affiliated with theGermanSocietyforOto-Rhino-Laryngology.HeadNeckSurg. 2012;269:2053---6.
6.DarratI,YaremchukK,PayneS,NelsonM.Astudyofadherence totheAAO-HNS‘‘ClinicalPracticeGuideline:AdultSinusitis’’. EarNoseThroatJ.2014;93:338---52.
7.Bousquet J, Lund VJ, van Cauwenberge P, Bremard-Oury C, MounedjiN,StevensMT,etal.Implementationofguidelinesfor seasonalallergicrhinitis:arandomizedcontrolledtrial.Allergy. 2003;58:733---41.
8.AartsMC,vanderHeijdenGJ,RoversMM,GrolmanW. Remark-able differences between three evidence-based guidelines on management of obstructive sleep apnea-hypopnea syndrome. Laryngoscope.2013;123:283---91.
WytskeFokkens∗, VishalPundir
DepartmentofOtorhinolaryngology,AcademicMedical Centre,Amsterdam,TheNetherlands
∗Correspondingauthor.
