Guidelines in otorhinolaryngology: a critical view.

Over the last two decades, evidence and systematic review have been the keystones of guideline development. 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 evidencebased medicine means integrating individual clinical expertise with the best available external clinical evidence from systematic research. The GRADE approach (http://www.gradeworkinggroup.org) points to the importance of an estimate of the intervention effect and the confidence that the estimate is correct, and was the first to stress the balance of desirable and undesirable effects. Over 20 organizations, including the World Health Organization (WHO), the BMJ, and the Cochrane Collaboration have adopted the GRADE system. In the last decade, the Appraisal of Guidelines for Research & Evaluation (AGREE) Instrument (http://www.agreetrust.org) was developed to address the quality of practice guidelines in a systematic way. Several evidence-based guidelines have been developed 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 improves the quality of life of our patients, there has also been ample proof that adherence to guidelines is often insufficient.7 This editorial attempts to evaluate potential reasons why we do not use guidelines as much as we should. One of the major issues is that we are still not able to develop worldwide guidelines; there can be significant difference in the guidelines on the same topics produced by different countries. Aarts et al. demonstrated that the guidelines on a similar topic may show dissimilarities regarding conclusions, levels of evidence, and citations used.8 This