Introduction.

The ENT Extension of Excellence (EEE) meeting has evolved over the years and is now considered by many to represent the world's foremost invitational think-tank conference on ototopical therapy as it applies to the discharging ear. Again this year, much time and effort were expended by the participants in an effort to provide you with information, via this supplement, that covers the diagnosis, pathophysiology, and treatment of the discharging ear and the controversies that are inherent in its management.

As chairman of the 2006 EEE meeting (and hence the supplement editor), I started out with a rather ambitious program, which consisted of:

* evidence-based medicine (EBM) lectures

* debates highlighting controversies in ototopical therapies

* state-of-the-art "How I do it" lectures

* panel discussions that addressed our role as physicians, educators, and protectors of the public

I envisaged that with our collective experience, we could produce a supplement that would settle, once and for all, every controversy in ototopical therapy by using an EBM approach.

Such was not the case.

I was reminded by more than one member of our August group that nothing is immutable, that treatments continually change, and that any attempt to apply strict EBM criteria to every article we reviewed for the purpose of compiling this supplement would be nearly impossible and certainly impractical. In fact, in many instances, evidence is entirely lacking. So rather than witness some of my colleagues threaten to commit seppuku (ritual disembowelment in Japanese), I took their advice and toned down the rhetoric. In the end, I think we have created a wonderful supplement that provides the practitioner with a well-balanced and carefully thought-out approach to the discharging ear.

Does this supplement represent "best practice" and is it contemporary? The answer is probably yes. Is it timeless? Probably not, as medicine does mirror life, and things constantly change.

At any rate, I wish to leave the reader with a few reflections on EBM and how it will likely impact us in the future. If I may paraphrase the great Irish playwright George Bernard Shaw (with many apologies), it has been disparagingly said of EBM that "Those who can, do; those who can't, teach; and those who can do neither quote evidence-based medicine." This is somewhat facile and ill-thought, I believe. Undoubtedly, at a certain level it is easy to become cynical of what appears to be the tyranny of EBM (i.e., you should obey the literature rather than rely on your clinical acumen) and the nihilism of EBM (i.e., if there is no published evidence that something works, why are you still doing it?). Of course, reliance on EBM does not, and should never, mean that one's own clinical experience is disregarded; clinical experience should certainly be incorporated into the decision-making process at some level. But we should recognize that the goal of EBM is, and has always been, to improve patient care.

What EBM attempts is to de-emphasize intuition, unsystematic clinical experience, and pathophysiologic rationale as sufficient grounds for all clinical decision making. It stresses the importance of objective data obtained by clinical research in solving problems and providing care. EBM requires that one be able to critically appraise the literature--in other words, to determine if a study is really good and if it accurately represents the problem that it is trying to solve.

It is regrettable that this supplement cannot cover all the issues that were raised or fully convey the high drama and energies that were in play during the 2006 EEE meeting. I suspect that next year's meeting will be no different in many ways. But rest assured that we will continue to build upon the knowledge we gain in the interim, so that we may further define the role of ototopical therapy in the management of the discharging ear.

John Rutka, MD, FRCSC 

Supplement Editor