Open-ended tympanometric screening: A new concept

Clinical value of the Eustachian Tube Function Scoring System T-ETDQ: a prospective diagnostic study

PURPOSE

Tubomanometry (TMM) and the seven-item Eustachian Tube Dysfunction Questionnaire (ETDQ-7) was integrated to establish the Tubomanometry Eustachian Tube Dysfunction Questionnaire (T-ETDQ), and its reliability, potential clinical application, and diagnostic value for Eustachian tube function were investigated.

METHODS

This prospective diagnostic study included patients visiting the ENT Department of our Hospital, between April and June 2021. Patients were grouped into Eustachian tube dysfunction (ETD) and control groups according to tympanometry diagnosis results. The diagnostic value of the T-ETDQ was evaluated using receiver-operating characteristic (ROC) curve analysis.

RESULTS

There were 48 patients with Obstructive ETD and 24 patients without. The area under the ROC curve (AUC) of T-ETDQ was 0.898 (95% confidence interval [CI] 0.826-0.969), and the highest sensitivity and specificity were 76.7% and 86.7% respectively when the positive cutoff value was 4.72. The AUC of Eustachian tube score (ETS) was 0.731 (95% CI 0.625-0.837) and the highest sensitivity and specificity were 48.3% and 90.0% respectively when the positive cut-off value was 4.5. The ETS and T-ETDQ had kappa values of 0.311 and 0.585, respectively (P < 0.001 for both), showing both methods were comparable to tympanometry; however, T-ETDQ had more consistent results than ETS.

CONCLUSION

T-ETDQ can effectively quantify and evaluate ETD severity in adults, has a higher diagnostic value than ETS, making it a suitable diagnostic tool.

Otitis Media and Child Development

Otitis media with effusion (OME) is the major cause of auditory dysfunction in preschool and early-grade schoolchildren. At especially high risk are children with cleft palate/lip; some groups of mentally retarded children; children from underprivileged communities and children with severe or profound sensorineural hearing loss. In neonates the major concern is to identify those with severe sensorineural hearing loss but awareness of the likelihood of OME is also vital. The hearing loss associated with OME in its early stages may be as small as 10–15 dB and in consequence conventional hearing tests employing pure tones are inadequate as screening procedures. Acoustic impedance testing has proved to be a practicable, acceptable, sensitive and efficient method of identification of OME in infants and children. Impedance measurement cannot, as yet, provide accurate assessment of hearing loss, but this is probably not a serious drawback. The primary requirement is to detect OME in order that swift and effective treatment can be instituted.

A systematic review of clinical research addressing the prevalence, aetiology, diagnosis, prognosis and therapy of otitis media in Australian Aboriginal children

The objective of this review was to systemically identify and summarize all the clinically relevant evidence available from studies addressing the prevalence, aetiology, diagnosis, prognosis and therapy of otitis media in Australian Aboriginal children. Electronic searching of Medline, the Australian Medical Index and the Aboriginal and Torres Strait Islander Health Bibliographic Index was performed. This was supplemented by hand searching the Menzies School of Health Research otitis media collection, the Aboriginal and Torres Strait Islander Health Information Bulletin and Aboriginal Health: an annotated bibliography. Data were extracted and placed in a series of evidence tables relevant to clinical practice. There were 59 studies that met the inclusion criteria. The majority were surveys, and only 19 addressed diagnosis, prognosis or therapy. Severe otitis media in rural Aboriginal children does not occur in isolation but as part of a spectrum of chronic bacterial infections of the respiratory tract. Although the aspects of poverty that result in this condition remain to be clarified, exposure to other young children with chronic nasal discharge is likely to be important. Whilst there is a considerable amount of literature on otitis media in Australian Aboriginal children, the number of studies most relevant to improving health outcomes is small. A systematic approach to disease surveillance, diagnosis, and application of medical interventions is required urgently. Future medical research should be concerned with the evaluation of interventions and the generalisabilty of studies from different populations.

Tympanometry as a screening test for treatable hearing loss in the elderly

One hundred and fourteen adults with hearing loss, but without otorrhoea, were studied with the aim of establishing whether tympanometry could be used as a screening test to identify potentially treatable aural pathology. Tympanometry was compared with independent otoscopy. No middle ear pathology likely to be of significance in an elderly person was found in ears with a normal tympanogram. All ears with significant pathology gave an abnormal tympanogram, and in addition there was a false positive rate of 6.8%. We suggest that elderly patients with dry ears and a normal tympanogram could be fitted with a hearing aid without specialist otological examination.

Daily impedance audiometric screening of children in a day-care institution. Changes through one month

Fifty-seven children in a fairly new day-care institution were examined daily by impedance audiometry through 4 weeks. A Madsen Electronics ZS 330 tympanoscope was used. The tympanometric curves were divided into types A, C1, C2, and B, indicating pressures over -99 mmH2O, from -100 to -199 mmH2O, below -199 mmH2O and completely flat curves, but in cases in which the compliance was less than 0.25 ml, combined with an absent ipsilateral stapedial reflex, were also interpreted as type B. The object was to ascertain how quickly the types changed and how stable the B curves were. Types A + C1, C2, and B changed daily into other types in 4.3%, 32.8%, and 9.5% respectively. A total of 43 episodes of B curves occurred. Of them 16 lasted for only one day and thereamongst 9 became quite flat. Only a few lasted for 8-23 days and 8 for 26 days or over.

Pass/fail criteria in screening for otitis media in children with learning disorders

A group of 75 children with language/learning disorders were screened for middle ear problems using serial tympanometry and otoscopy. Using a fail criterion of -200 mm H2O for tympanometry, 68% of the ears identified as pathological by otoscopy were identified by two serial tympanometry screens. The concurrence of otoscopy and serial tympanometry indicated a failure rate of 18% of the ears tested. It is concluded that for children in special populations, such as those with language/learning disorders, who may need careful monitoring for identification of middle ear problems, a combination of otoscopy and a single test of tympanometry may improve the reliability of screening programs.

Epidemiology of secretory otitis media. A descriptive cohort study

To determine the prevalence, incidence, and course of secretory otitis media in an age-group population, 404 3-year-old children in a town in Denmark were examined at 6-, 8-, and 12-week intervals over a 6-month period. At each of the four examinations approximately 20% of the children had middle ear effusion (MEE); it was found at least once in 42% of the children, and 6% had persistent effusion at all four examinations. Average duration of MEE was 3 months. Since spontaneous recovery rarely occurred when MEE had been present for more than 3 months, active intervention is recommended after the condition has been followed for this length of time. The highly fluctuating course of MEE demonstrated in early childhood has important implications for concepts in pediatric middle ear disease and treatment.

Epidemiology and middle ear effusion and tubal dysfunction. A one-year prospective study comprising monthly tympanometry in 387 non-selected 7-year-old children

In a Danish school district comprising 387 7-year-old pupils 10 electroacoustic otoadmittance tests showed in the course of one year a 31% total morbidity of middle ear effusion (MEE), while 30% constantly had normal tympanograms on both sides. The point prevalence of MEE ranged from 9 to 3%, highest during the winter and spring months. In most cases MEE was present only at one examination, but in one-quarter of the cases it persisted for 3 months or longer. Spontaneous recovery occurred in a mean of about 2 months. MEE setting in during the period september to February lasted longer than cases setting in at other times of the year. The middle ear status was extremely dynamic, about one-quarter of the children changing status (type of tympanogram) between consecutive tests and 17% 5 or more times. Spontaneous improvement was frequent (90%) and so was complete recovery (76%), but in about one-third of the cases there was recurrences. It is emphasized that an indication for treatment cannot as a rule be based on one test and should await observation for about 3 or 4 months.

Eustachian tube function in normal children and adults

Eustachian tubal function was studied in 85 otologically healthy children, 3-12 years of age. Middle ear pressure and muscular opening function was measured by tympanometry performed in a pressure chamber, and the results were compared with those obtained from 92 normal adults. Children were found to have a less good muscular opening function and more negative middle ear pressures within wider ranges, compared with adults. Improvement was also seen in children with increasing age. The results seemed to indicate a relation between muscular opening function and middle ear pressure. Even if it were possible to grade the muscular opening function by means of the test procedure, it would still not be possible to define what should be regarded as normal or abnormal tubal function. This report is the first in a series of tubal function studies in normal children.

Use of tympanostomy tubes in otitis media

Tympanostomy tubes (TT) are frequently employed as treatment for otitis media (OM) although there is little-clinical or experimental evidence of their efficacy. Potential detriments of TT include cost, risk of inhalation anesthesia, intraoperative complications, and tympanic membrane (TM) damage. Potential benefits include elimination of the conductive hearing loss (CHL), reduction in the occurrence of acute purulent OM, and avoidance of sequelae. The cost/benefit ratio of TT has never been accurately determined and morbid complications of inhalation anesthesia and the surgical procedure appear to be rate. There is evidence that TT significantly reduce the CHL of OM as well as reduce the incidence of recurrent acute purulent OM and help avoid sequelae. It is therefore determined that the risk of TT insertion for middle ear effusion (occasional TM changes) can be justified, in properly selected patients, by the benefits (immediate improvement in hearing and reduction in the incidence of recurrent acute purulent OM).

Screening for middle ear disease in a school for the deaf

During the 1977-78 academic year, a study was conducted at the Western Pennsylvania School for the Deaf (WPSD) to evaluate, in a population of profoundly deaf students: 1) the incidence of middle ear (ME) effusion; 2) the correlation between high negative ME pressure (HNP) and ME effusion; and 3) the effect of HNP (> -100 mm H2L) on auditory acuity. All 446 students at WPSD were screened three times (fall, winter, and spring) by both otoscopy and tympanometry and were then classified as belonging to one of five categories according to the status of their ME. Otoscopic, tympanometric, and audiometric evaluations were conducted monthly for 41 study-group students with HNP and 41 controls with normal ears. Tabulations of the incidence of ME conditions over the year-long period showed that 8% of the students had effusion, 21% HNP, 1% inactive disease, 26% residual disease, and 44% normal ME. The majority of severe ME problems occurred in children between the ages of two and eight years. HNP proved insufficient to predict the occurrence of an effusion in children aged 6 to 21 years. However, only 21% of the ears in which HNP was identified returned to and remained normal for the entire year, as contrasted with the initially normal or "controls," of which 77% remained normal. In this profoundly deaf population, the correlation between HNP and threshold shifts proved difficult to document. A small but significantly greater fluctuation in threshold during the period of a year was noted, however, when the students with HMP were compared with the controls.

Impedance screening for children. A need for more research

Two sets of recommendations for impedance screening have been generated recently for use with preschool and school age children. One set of these recommendations, developed in Nashville, purports that it is premature to mass-screen on a routine basis for the detection of middle ear disease. These recommendations do encourage, however, the screening of special populations of children considered at risk for otitis media. This paper offers support for Nashville recommendations and suggests that there is a critical need for additional research before we begin to screen in mass. Areas in need of further research and clarification included the use of impedance as a screening tool, natural history and medical management of middle ear disease, and the educational and linguistic complications of middle ear disease. Hence, while the potential value for screening is recognized by the Nashville recommendations, they also recognize the need for more study of the procedure and the disease.

Tympanometry in three-year-old children. III. Correlation between tympanometry and findings at paracentesis in a prospectively followed population of otherwise healthy children aged 3--4 years

Paracentesis was performed on 46 three- to four-year-old children out of all 523 three-year-olds in a geographically defined area, because these 46 children had persistently showed abnormal tympanograms over a 6-month period. The findings were correlated to the parameters middle ear pressure, absolute compliance, absolute gradient, and relative gradient. As regards the state of effusion in the middle ear, all these parameters--except for the middle ear pressure--showed a high predictive value. The significance of the findings in the tympanometric diagnosis of middle ear disease in the younger age groups is outlined.

Long-term observation of ears with reduced middle ear pressure

335 ears from 210 childred in which tympanometry initially indicated middle ear pressure less than or equal to -100 mm H2O or a flat tympanogram have been reinvestigated 3 years later. When the inital investigation was performed all children were 7 years old. The present study reveals that 25% of these ears still have middle ear pressure less than or equal to -100 mm H2O and 16% middle ear pressure less than or equal to -150 mm H2O. In normal material of the same age group 9% have middle ear pressure less than or equal to -100 mm H2O and 4% middle ear pressure less than or equal to -150 mm H2O. The study also reveals effusion in 10% of ears with normal screening audiograms. In ears with normal screening audiograms and middle ear pressure greater than or equal to -145 mm H2O effusion was found in 5% and in ears with abnormal screening audiograms and middle ear pressure less than or equal to -150 mm H2O effusion was found in 81%. As tympanometric criterion for otologist referral, middle ear pressure less than or equal to -150 mm H2O or a flat tympanogram is suggested. The inclusion of tympanometry in routine screening for middle ear pathology in children is recommended.

Deafness after bacterial meningitis

Seventeen children with previous bacterial meningitis and 17 sib controls were examined clinically and otoscopically. They were also tested with air-conduction and bone-conduction audiometry and evaluated by tympanometry. There were no major neurological abnormalities and few otoscopical signs of ear disease. 21% of the ears showed abnormalities on air-conduction audiometry but all were normal on bone-conduction audiometry. 30% had abnormal middle-ear pressures (more negative than 100 mm water) on tympanometry and 7% had abnormal compliance of the drum. There were no significant differences on any test between the postmeningitis children and the sib controls. Population studies have confirmed that minor hearing loss due to middle-ear dysfunction is common in children, but is probably temporary in most of them. We have found no excess of middle-ear dysfunction and no sensorineural deafness in these postmeningitis children, but other workers have shown that nerve deafness may occur in association with clinical neurological damage. However, much of the deafness attributed to bacterial meningitis in other studies may well reflect population variability.

Ossicular discontinuity

Because of the numerous and varied surgical approaches to ear pathology devised and expanded in the past two decades, we are destined to be confronted with increasingly frequent cases of ossicular defects behind an intact eardrum. Using a technique which is the converse of the established "patch" test a simple office procedure is described which may help establish the diagnosis of ossicular discontinuity in the adult with an intact eardrum. An audiogram is obtained and then a myringotomy performed with insertion of a large ventilation tube. A second audiogram is then done. A rise in the air conduction level, in the absence of fluid, is suggestive of ossicular discontinuity.