This paper presents an approach to evaluating the quality of evidence from a network meta-analysis, inspired by the GRADE methodology for pairwise meta-analyses. The authors propose a framework that considers the key role of indirect comparisons, the contributions of direct evidence to network estimates, the importance of the transitivity assumption, and the possibility of disagreement between direct and indirect evidence. The framework is applied to a systematic review comparing topical antibiotics without steroids for chronically discharging ears with underlying eardrum perforations. The proposed approach allows for the assessment of confidence in the results of a network meta-analysis, distinguishing between confidence in effect sizes and confidence in treatment rankings. The framework considers the quality of evidence for each pairwise comparison and the overall ranking of treatments, taking into account study limitations, inconsistency, indirectness, imprecision, and publication bias. The authors emphasize the importance of considering the contributions of direct evidence to the network meta-analysis estimates and the network structure when assessing the quality of evidence. They also highlight the importance of evaluating the transitivity assumption and the potential for inconsistency between direct and indirect evidence. The framework is applied to the example of topical antibiotics for discharging ears, where the authors assess the quality of evidence for each pairwise comparison and the overall treatment ranking. The results show that the quality of evidence for some comparisons is lower due to study limitations, inconsistency, or imprecision, while others are considered to have higher quality evidence. The authors conclude that the proposed framework provides a useful tool for evaluating the quality of evidence from a network meta-analysis and for making informed decisions based on the results.This paper presents an approach to evaluating the quality of evidence from a network meta-analysis, inspired by the GRADE methodology for pairwise meta-analyses. The authors propose a framework that considers the key role of indirect comparisons, the contributions of direct evidence to network estimates, the importance of the transitivity assumption, and the possibility of disagreement between direct and indirect evidence. The framework is applied to a systematic review comparing topical antibiotics without steroids for chronically discharging ears with underlying eardrum perforations. The proposed approach allows for the assessment of confidence in the results of a network meta-analysis, distinguishing between confidence in effect sizes and confidence in treatment rankings. The framework considers the quality of evidence for each pairwise comparison and the overall ranking of treatments, taking into account study limitations, inconsistency, indirectness, imprecision, and publication bias. The authors emphasize the importance of considering the contributions of direct evidence to the network meta-analysis estimates and the network structure when assessing the quality of evidence. They also highlight the importance of evaluating the transitivity assumption and the potential for inconsistency between direct and indirect evidence. The framework is applied to the example of topical antibiotics for discharging ears, where the authors assess the quality of evidence for each pairwise comparison and the overall treatment ranking. The results show that the quality of evidence for some comparisons is lower due to study limitations, inconsistency, or imprecision, while others are considered to have higher quality evidence. The authors conclude that the proposed framework provides a useful tool for evaluating the quality of evidence from a network meta-analysis and for making informed decisions based on the results.