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New AOM scale may provide better measure for clinical diagnosis
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A scale that uses images to grade acute otitis media severity may provide another avenue for clinical research and aid in telemedicine applications, according to findings in a paper published online.
Thorbjörn Lundberg, MD, of the department of public health and clinical medicine at Umeå University in Sweden, and colleagues developed a scale using images from 32 patients that were taken over three different periods. It is currently being tested in South Africa.
The researchers said “interrater agreement was moderate, and intra-rater agreement was good” using the final scale.
Further, they said tympanic membrane redness was of less importance, as was vascularization compared with other AOM measuring tools.
“We believe that our new scale could contribute to an important move toward improved grading of AOM,” the researchers said. “Together with tympanometry and a grading system of symptoms, it could be a reliable instrument in telemedical applications, as well as in clinical research on AOM.”
They said their study had a low number of reviewers, which highlighted the difficulty of arriving at an accurate AOM diagnosis, even among clinicians who are well-practiced in the diagnosis.
“A thorough training period preceding the use of our scale is important and would most likely enhance the level of agreement,” Lundberg and colleagues said.
Disclosure: Lundberg reports no relevant financial disclosures.
Perspective
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Stan L. Block, MD
AOM is the most common bacterial infection in childhood, and the most common (real) reason for antibiotic prescribing. Improvements in diagnostic accuracy of AOM are always welcomed. This paper analyzing a new AOM grading scale by Lundberg and colleagues from Sweden presents most of the salient controversies regarding the diagnosis of AOM. The authors used a video endoscope to record the tympanic membrane (TM) appearance in 32 patients, and they then refined and developed a diagnostic scale based on two reviews from four otolaryngologic experts.
The authors were able to discern that erythema was not only uncommon, but also an unimportant aspect in the diagnosis of AOM. This distinctly contrasts with previous recommendations and guidelines, such as the 2004 Diagnosis and Management of Acute Otitis Media Practice Guidelines endorsed by the AAP/AAFP (AAP. Pediatrics. 2004;113:1451-1465).
Interestingly, TM mobility was not even considered in their diagnostic criteria for AOM. The photos in the paper must also be seen in color.
The following were not considered AOM: retracted TM, retracted TM with fluid, and an amber (orange) fluid-filled TM.
The following were considered diagnostic of AOM:
- - Purulent opaque air fluid level;
- - Purulent opaque TM in neutral position;
- - Bulging or bullous opaque TM; and
- - "Chagrinated" (cobblestoned or wet-perforated) TM.
They did not address the ear with profuse purulent otorrhea (because no TM finding is discernible), which I consider definitive for AOM as well.
Previous authors (Shaikh N. Pediatr Infect Dis J. 2011;30:822-826) have likewise demonstrated that distinct erythema is an uncommon isolated finding (2%) in AOM, and that knowledge of TM mobility changed the diagnosis of AOM in only three of 945 cases.
The Swedish study had the following limitations: the study population was aged 2 to 16 years – definitely not representative of the age group with the most episodes of AOM. Furthermore, the biggest challenge for the clinician is the TM examination of the infant or toddler, who is typically uncooperative, has waxy and smaller ear canals, and often requires a taxing level of physical restraint from both the parent and the examiner. Use of the universally available, short "disposable" specula notably hinders visualization and accuracy in children aged younger than 36 months. The diagnosis of AOM or not in the child younger than 5 months of age is entirely dependent upon the use of the 2.5 mm "original" speculum.
If one thinks that the video endoscope is the panacea to your diagnostic conundrums – unlikely.
We are currently using a high-grade video endoscope in a clinical trial for AOM in children aged 6 to 24 months. The wonderful instrument is very expensive and requires much practice. The video procedure itself demands frequent cleaning of the camera lens and speculum aperture, a nearly perfectly clean ear canal, absolute restraint of the child, and probably a separate synchronized computer to record and transmit the data. This will likely not be done in "real time" as well. And if you are not very careful, gentle, and quick with the instrument, the exam becomes quite uncomfortable for the young child, which will make future TM exams even more challenging.
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