Otitis Media: Diagnosis [Clinical Review Discussion]

Otitis media presents in two primary forms, acute otitis media (AOM) and otitis media with effusion (OME). With the heightened concerns relating to the increasing number of antibiotic resistant microbes and inappropriate use of antibiotics, the first diagnostic concern is to distinguish between the two variants. AOM is characterized by the signs of infection (fever, otalgia, irritability, headache, rhinitis, pulling at ears) combined with a bulging, sometimes red tympanic membrane and often treated with antibiotics (1). OME does not have the signs of infection and is characterized by a neutral or retracted tympanic membrane. Recommended treatment is “watchful waiting” for 3 months (2).

Combining symptomology with examination of the tympanic membrane with an otoscope has been considered a standard diagnostic procedure by many physicians. Study after study shows this protocol is lacking in diagnostic accuracy. In a study of 383 pediatric residents only 41% gave an accurate diagnosis when examining AOM, OME and normal ears (3). A second study of 50 children compared general practitioners (GP) and otorhinolaryngology residents (OR). GP’s gave a diagnosis of OM in 64% of patients while the OR’s gave a diagnosis of OM in 44%. Further investigation found GP’s based their diagnosis on symptoms and color of the tympanic membrane while OR’s used mobility and position of the tympanic membrane as clinical evidence of OM (4). Lack of diagnostic acumen may be the result of lack of formal training. A 2001 survey found only 59% of U.S. medical schools had formalized training for the diagnosis of OM (5). Finally a study of 309 children revealed a 56% decrease in diagnosis of AOM with 80% fewer episodes when proper diagnostic criteria was used (6).