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Bulging tympanic membrane more common in bilateral AOM
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Clinicians should consider the symptoms of a child with acute otitis media combined with otoscopic findings as an indication of severity and focus less on bilateral infection when determining treatment, according to study data published online.
Aino Ruohola, MD, PhD, of the department of pediatrics at Turku University Hospital in Finland, and colleagues reported questionnaire data on 232 children aged younger than 3 years but older than 6 months.
Aino Ruohola
The researchers noted some common traits among the 98 children with bilateral AOM; specifically, that they tended to be younger and more commonly had a fever. Bulging of the tympanic membrane and purulent effusion were also more commonly noted in the bilateral group.
Ruohola and colleagues studied 17 symptoms and only fever was a differing symptom between the groups, occurring in 54% and 36% in bilateral and unilateral AOM groups, respectively. Of the otoscopic signs, two out of four severe signs were equal between bilateral and unilateral AOM.
However, despite these common traits, Ruohola and colleagues concluded that bilateral AOM seems to be a clinically only slightly more severe illness than unilateral AOM. Moreover, they noted that it is important to consider the individual patient.
The researchers concluded that all clinicians know that the symptoms not only vary between individuals, but also within individuals. Furthermore, the otoscopic signs change on a daily basis, and children with unilateral AOM may develop bilateral AOM.
“When assessing AOM severity, bilaterality should not be used alone as a determining factor to assess the severity of AOM,” Ruohola told Infectious Diseases in Children. “We think our results are important because some guidelines recommend more active treatment in the case of bilateral AOM. Our current and previous results do not support such recommendations.”
Disclosure: Ruohola reports no relevant financial disclosures.
Perspective
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Jerome O. Klein, MD
The crackerjack otitis media team from Turku Finland have provided another interesting set of observations from their project to evaluate diagnostics and treatment of acute otitis media in the primary care setting. They sought to determine whether or not parent history of signs and results of otoscopic examinations were different in bilateral vs. unilateral AOM. Guidelines for management of AOM from the Netherlands, Sweden, Italy and England had included more aggressive use of antimicrobial agents for children with bilateral AOM contrasted with unilateral AOM. To determine the validity of these guidelines, Uitti and colleagues enrolled children 6 to 35 months of age with signs of AOM: 98 with bilateral and 134 with unilateral disease. The physicians obtained a history from parents at the initial visit using a standardized questionnaire of 17 signs associated with ear infections. The physicians were all trained otoscopists, and each child was evaluated using pneumatic otoscopy, tympanometry and video otoscopy.
The results indicated that severity of signs as provided by parent history did not differ between children with bilateral or unilateral AOM but for temperature elevation (>38°C). Temperature elevation was more frequent and slightly higher in children with bilateral disease. Otoscopic signs did differ in bilateral vs. unilateral disease: Moderate/marked bulging of the tympanic membrane (TM) and purulent fluid were significantly more common in children with bilateral disease.
AOM is a dynamic disease. One observation at onset may not tell the whole story: signs may become more severe or disappear; unilateral disease may progress to bilateral disease. My observations of a compliant patient with AOM (my then 3-year-old daughter) included the following observations: Saturday morning — awoke febrile with severe otalgia and bulging TM and purulent middle ear fluid; Saturday evening — rupture of the TM, with pus draining in the canal and defervescence and relief of ear ache; Sunday morning — afebrile and normal mobility of the intact TM; Sunday evening — re-accumulation of pus in the middle ear, bulging of the TM and fever and ear ache; Monday morning — the TM had ruptured during the evening with defervescence and a quiet sleep; and subsequent continued resolution of the diseased ears.
The primary care physician has to judge the severity of AOM at only one point in time in the continuum of the dynamic of AOM. The results of the Turku study indicate that otoscopic signs are a better indicator of severe disease (other than fever) and that history of signs of disease and presence of bilateral vs. unilateral AOM should not be used as a determining criterion for management.
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