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Afify HM, Mohammed KK, Hassanien AE. Insight into Automatic Image Diagnosis of Ear Conditions Based on Optimized Deep Learning Approach. Ann Biomed Eng 2024; 52:865-876. [PMID: 38097895 PMCID: PMC10940396 DOI: 10.1007/s10439-023-03422-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/27/2023] [Accepted: 12/06/2023] [Indexed: 03/16/2024]
Abstract
Examining otoscopic images for ear diseases is necessary when the clinical diagnosis of ear diseases extracted from the knowledge of otolaryngologists is limited. Improved diagnosis approaches based on otoscopic image processing are urgently needed. Recently, convolutional neural networks (CNNs) have been carried out for medical diagnosis to obtain higher accuracy than standard machine learning algorithms and specialists' expertise. Therefore, the proposed approach involves using the Bayesian hyperparameter optimization with the CNN architecture for automatic diagnosis of ear imagery database including four classes: normal, myringosclerosis, earwax plug, and chronic otitis media (COM). The suggested approach was trained using 616 otoscopic images, and the performance of this approach was assessed using 264 testing images. In this paper, the performance of ear disease classification was compared in terms of accuracy, sensitivity, specificity, and positive predictive value (PPV). The results produced a classification accuracy of 98.10%, a sensitivity of 98.11%, a specificity of 99.36%, and a PPV of 98.10%. Finally, the suggested approach demonstrates how to locate optimal CNN hyperparameters for accurate diagnosis of ear diseases while taking time into account. As a result, the usefulness and dependability of the suggested approach will lead to the establishment of an automated tool for better categorization and prediction of different ear diseases.
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Affiliation(s)
- Heba M Afify
- Systems and Biomedical Engineering Department, Higher Institute of Engineering in Shorouk Academy, Al Shorouk City, Cairo, Egypt.
- Scientific Research Group in Egypt (SRGE), Cairo, Egypt.
| | - Kamel K Mohammed
- Center for Virus Research and Studies, Al Azhar University, Cairo, Egypt
- Scientific Research Group in Egypt (SRGE), Cairo, Egypt
| | - Aboul Ella Hassanien
- College of Business Administration, Kuwait University, Kuwait, Kuwait
- Scientific Research Group in Egypt (SRGE), Cairo, Egypt
- Faculty of Computers and Information, Cairo University, Giza, Egypt
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2
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Mohammed KK, Hassanien AE, Afify HM. Classification of Ear Imagery Database using Bayesian Optimization based on CNN-LSTM Architecture. J Digit Imaging 2022; 35:947-961. [PMID: 35296939 PMCID: PMC9485378 DOI: 10.1007/s10278-022-00617-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/15/2021] [Revised: 02/25/2022] [Accepted: 02/27/2022] [Indexed: 11/28/2022] Open
Abstract
The external and middle ear conditions are diagnosed using a digital otoscope. The clinical diagnosis of ear conditions is suffered from restricted accuracy due to the increased dependency on otolaryngologist expertise, patient complaint, blurring of the otoscopic images, and complexity of lesions definition. There is a high requirement for improved diagnosis algorithms based on otoscopic image processing. This paper presented an ear diagnosis approach based on a convolutional neural network (CNN) as feature extraction and long short-term memory (LSTM) as a classifier algorithm. However, the suggested LSTM model accuracy may be decreased by the omission of a hyperparameter tuning process. Therefore, Bayesian optimization is used for selecting the hyperparameters to improve the results of the LSTM network to obtain a good classification. This study is based on an ear imagery database that consists of four categories: normal, myringosclerosis, earwax plug, and chronic otitis media (COM). This study used 880 otoscopic images divided into 792 training images and 88 testing images to evaluate the approach performance. In this paper, the evaluation metrics of ear condition classification are based on a percentage of accuracy, sensitivity, specificity, and positive predictive value (PPV). The findings yielded a classification accuracy of 100%, a sensitivity of 100%, a specificity of 100%, and a PPV of 100% for the testing database. Finally, the proposed approach shows how to find the best hyperparameters concerning the Bayesian optimization for reliable diagnosis of ear conditions under the consideration of LSTM architecture. This approach demonstrates that CNN-LSTM has higher performance and lower training time than CNN, which has not been used in previous studies for classifying ear diseases. Consequently, the usefulness and reliability of the proposed approach will create an automatic tool for improving the classification and prediction of various ear pathologies.
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Affiliation(s)
- Kamel K Mohammed
- Center for Virus Research and Studies, Al Azhar University, Cairo, Egypt.,Scientific Research Group in Egypt (SRGE), Cairo, Egypt
| | - Aboul Ella Hassanien
- Faculty of Computers and Information, Cairo University, Giza, Egypt.,Scientific Research Group in Egypt (SRGE), Cairo, Egypt
| | - Heba M Afify
- Systems and Biomedical Engineering Department, Higher Institute of Engineering in Shorouk Academy, Al Shorouk City, Cairo, Egypt. .,Scientific Research Group in Egypt (SRGE), Cairo, Egypt.
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Esposito S, Bianchini S, Argentiero A, Gobbi R, Vicini C, Principi N. New Approaches and Technologies to Improve Accuracy of Acute Otitis Media Diagnosis. Diagnostics (Basel) 2021; 11:2392. [PMID: 34943628 PMCID: PMC8700495 DOI: 10.3390/diagnostics11122392] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/20/2021] [Revised: 12/10/2021] [Accepted: 12/17/2021] [Indexed: 12/18/2022] Open
Abstract
Several studies have shown that in recent years incidence of acute otitis media (AOM) has declined worldwide. However, related medical, social, and economic problems for patients, their families, and society remain very high. Better knowledge of potential risk factors for AOM development and more effective preventive interventions, particularly in AOM-prone children, can further reduce disease incidence. However, a more accurate AOM diagnosis seems essential to achieve this goal. Diagnostic uncertainty is common, and to avoid risks related to a disease caused mainly by bacteria, several children without AOM are treated with antibiotics and followed as true AOM cases. The main objective of this manuscript is to discuss the most common difficulties that presently limit accurate AOM diagnosis and the new approaches and technologies that have been proposed to improve disease detection. We showed that misdiagnosis can be dangerous or lead to relevant therapeutic mistakes. The need to improve AOM diagnosis has allowed the identification of a long list of technologies to visualize and evaluate the tympanic membrane and to assess middle-ear effusion. Most of the new instruments, including light field otoscopy, optical coherence tomography, low-coherence interferometry, and Raman spectroscopy, are far from being introduced in clinical practice. Video-otoscopy can be effective, especially when it is used in association with telemedicine, parents' cooperation, and artificial intelligence. Introduction of otologic telemedicine and use of artificial intelligence among pediatricians and ENT specialists must be strongly promoted in order to reduce mistakes in AOM diagnosis.
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Affiliation(s)
- Susanna Esposito
- Pediatric Clinic, Pietro Barilla Children’s Hospital, Department of Medicine and Surgery, University of Parma, Via Gramsci 14, 43126 Parma, Italy; (S.B.); (A.A.)
| | - Sonia Bianchini
- Pediatric Clinic, Pietro Barilla Children’s Hospital, Department of Medicine and Surgery, University of Parma, Via Gramsci 14, 43126 Parma, Italy; (S.B.); (A.A.)
| | - Alberto Argentiero
- Pediatric Clinic, Pietro Barilla Children’s Hospital, Department of Medicine and Surgery, University of Parma, Via Gramsci 14, 43126 Parma, Italy; (S.B.); (A.A.)
| | - Riccardo Gobbi
- Head-Neck and Oral Surgery Unit, Department of Head-Neck Surgery, Otolaryngology, Morgagni Piertoni Hospital, 47121 Forlì, Italy; (R.G.); (C.V.)
| | - Claudio Vicini
- Head-Neck and Oral Surgery Unit, Department of Head-Neck Surgery, Otolaryngology, Morgagni Piertoni Hospital, 47121 Forlì, Italy; (R.G.); (C.V.)
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Chan J, Raju S, Nandakumar R, Bly R, Gollakota S. Detecting middle ear fluid using smartphones. Sci Transl Med 2020; 11:11/492/eaav1102. [PMID: 31092691 DOI: 10.1126/scitranslmed.aav1102] [Citation(s) in RCA: 29] [Impact Index Per Article: 7.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/23/2018] [Revised: 02/15/2019] [Accepted: 04/12/2019] [Indexed: 12/15/2022]
Abstract
The presence of middle ear fluid is a key diagnostic marker for two of the most common pediatric ear diseases: acute otitis media and otitis media with effusion. We present an accessible solution that uses speakers and microphones within existing smartphones to detect middle ear fluid by assessing eardrum mobility. We conducted a clinical study on 98 patient ears at a pediatric surgical center. Using leave-one-out cross-validation to estimate performance on unseen data, we obtained an area under the curve (AUC) of 0.898 for the smartphone-based machine learning algorithm. In comparison, commercial acoustic reflectometry, which requires custom hardware, achieved an AUC of 0.776. Furthermore, we achieved 85% sensitivity and 82% specificity, comparable to published performance measures for tympanometry and pneumatic otoscopy. Similar results were obtained when testing across multiple smartphone platforms. Parents of pediatric patients (n = 25 ears) demonstrated similar performance to trained clinicians when using the smartphone-based system. These results demonstrate the potential for a smartphone to be a low-barrier and effective screening tool for detecting the presence of middle ear fluid.
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Affiliation(s)
- Justin Chan
- Paul G. Allen School of Computer Science & Engineering, University of Washington, Seattle, WA 98195, USA.
| | - Sharat Raju
- Department of Otolaryngology-Head and Neck Surgery, University of Washington, Seattle, WA 98195, USA. .,Seattle Children's Hospital and Research Institute, Seattle, WA 98105, USA
| | - Rajalakshmi Nandakumar
- Paul G. Allen School of Computer Science & Engineering, University of Washington, Seattle, WA 98195, USA
| | - Randall Bly
- Department of Otolaryngology-Head and Neck Surgery, University of Washington, Seattle, WA 98195, USA.,Seattle Children's Hospital and Research Institute, Seattle, WA 98105, USA
| | - Shyamnath Gollakota
- Paul G. Allen School of Computer Science & Engineering, University of Washington, Seattle, WA 98195, USA.
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Abstract
HYPOTHESIS The artificial intelligence and image processing technology can develop automatic diagnostic algorithm for pediatric otitis media (OM) with accuracy comparable to that from well-trained otologists. BACKGROUND OM is a public health issue that occurs commonly in pediatric population. Caring for OM may incur significant indirect cost that stems mainly from loss of school or working days seeking for medical consultation. It makes great sense for the homecare of OM. In this study, we aim to develop an automatic diagnostic algorithm for pediatric OM. METHODS A total of 1,230 otoscopic images were collected. Among them, 214 images diagnosed of acute otitis media (AOM) and otitis media with effusion (OME) are used as the database for image classification in this study. For the OM image classification system, the image database is randomly partitioned into the test and train subsets. Of each image in the train and test sets, the desired eardrum image region is first segmented, then multiple image features such as color, and shape are extracted. The multitask joint sparse representation-based classification to combine different features of the OM image is used for classification. RESULTS The multitask joint sparse representation algorithm was applied for the classification of the AOM and OME images. The approach is able to differentiate the OME from AOM images and achieves the classification accuracy as high as 91.41%. CONCLUSION Our results demonstrated that this automatic diagnosis algorithm has acceptable accuracy to diagnose pediatric OM. The cost-effective algorithm can assist parents for early detection and continuous monitoring at home to decrease consequence of the disease.
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Hu L, Li W, Lin H, Li Y, Zhang H, Svanberg K, Svanberg S. Towards an optical diagnostic system for otitis media using a combination of otoscopy and spectroscopy. JOURNAL OF BIOPHOTONICS 2019; 12:e201800305. [PMID: 30719866 DOI: 10.1002/jbio.201800305] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 08/17/2018] [Revised: 01/26/2019] [Accepted: 02/01/2019] [Indexed: 05/16/2023]
Abstract
An improved method, where conventional otoscope investigation of human suspicious otitis media is combined with diffuse reflectance spectroscopy and gas in scattering media absorption spectroscopy (GASMAS) is being developed. Otitis media is one of the most common infectious diseases in children, whose Eustachian tube connecting the middle ear with the nasal cavity is more horizontal than for adults, which leads to impaired fluid drainage. At present, the use of an otoscope to visually observe possible changes in the tympanic membrane appearance is the main diagnostics method for otitis media. Inaccurate diagnosis related to similar symptoms, and the difficulty for small children to describe the condition experienced, frequently leads to over-prescription of antibiotics and alarming increase in bacterial resistance development. More accurate diagnostic methods are highly desirable. Diffuse reflectance spectroscopy is a non-invasive quantitative spectroscopic technique that enables to objectively quantify changes in the hemoglobin content of the tympanic membrane related to inflammation. If an infection is present, the ventilatory function of the Eustachian tube is frequently impaired and the middle-ear cavity will be filled with fluid. GASMAS, a non-invasive detection method, can non-invasively determine if gas is replaced by fluid in the middle-ear cavity.
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Affiliation(s)
- Lingna Hu
- Center of Optical and Electromagnetic Research, South China Academy of Advanced Optoelectronics, South China Normal University, Guangzhou, China
| | - Wansha Li
- Center of Optical and Electromagnetic Research, South China Academy of Advanced Optoelectronics, South China Normal University, Guangzhou, China
| | - Huiying Lin
- Center of Optical and Electromagnetic Research, South China Academy of Advanced Optoelectronics, South China Normal University, Guangzhou, China
| | - Ying Li
- Center of Optical and Electromagnetic Research, South China Academy of Advanced Optoelectronics, South China Normal University, Guangzhou, China
| | - Hao Zhang
- Center of Optical and Electromagnetic Research, South China Academy of Advanced Optoelectronics, South China Normal University, Guangzhou, China
| | - Katarina Svanberg
- Center of Optical and Electromagnetic Research, South China Academy of Advanced Optoelectronics, South China Normal University, Guangzhou, China
- Lund Laser Center, Lund University, Lund, Sweden
| | - Sune Svanberg
- Center of Optical and Electromagnetic Research, South China Academy of Advanced Optoelectronics, South China Normal University, Guangzhou, China
- Lund Laser Center, Lund University, Lund, Sweden
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7
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Automated Classification of the Tympanic Membrane Using a Convolutional Neural Network. APPLIED SCIENCES-BASEL 2019. [DOI: 10.3390/app9091827] [Citation(s) in RCA: 27] [Impact Index Per Article: 5.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Precise evaluation of the tympanic membrane (TM) is required for accurate diagnosis of middle ear diseases. However, making an accurate assessment is sometimes difficult. Artificial intelligence is often employed for image processing, especially for performing high level analysis such as image classification, segmentation and matching. In particular, convolutional neural networks (CNNs) are increasingly used in medical image recognition. This study demonstrates the usefulness and reliability of CNNs in recognizing the side and perforation of TMs in medical images. CNN was constructed with typically six layers. After random assignment of the available images to the training, validation and test sets, training was performed. The accuracy of the CNN model was consequently evaluated using a new dataset. A class activation map (CAM) was used to evaluate feature extraction. The CNN model accuracy of detecting the TM side in the test dataset was 97.9%, whereas that of detecting the presence of perforation was 91.0%. The side of the TM and the presence of a perforation affect the activation sites. The results show that CNNs can be a useful tool for classifying TM lesions and identifying TM sides. Further research is required to consider real-time analysis and to improve classification accuracy.
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Erkkola-Anttinen N, Laine MK, Tähtinen PA, Ruohola A. Can changes in parentally measured acoustic reflectometry levels predict the middle ear status? Int J Pediatr Otorhinolaryngol 2017; 95:72-74. [PMID: 28576537 DOI: 10.1016/j.ijporl.2017.02.002] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/19/2016] [Revised: 02/02/2017] [Accepted: 02/03/2017] [Indexed: 11/16/2022]
Abstract
OBJECTIVE Spectral gradient acoustic reflectometry (SG-AR) may be used to detect middle ear effusion. Our aim was to investigate whether increasing SG-AR levels between two SG-AR examinations indicate deterioration from a healthy middle ear to acute otitis media (AOM). METHODS We enrolled 185 children (age 6-35 months) whose parents were willing to use the SG-AR at home daily. Measurement pairs of parental home SG-AR examination results were generated and analyzed. There was one SG-AR examination result obtained within ±1 day of the reference visit and another result within ±1 day of the subsequent visit. We defined the SG-AR level as increasing when the difference between two measurements was ≥2 levels from a lower to a higher level, suggesting development of AOM. When the SG-AR level difference was ≤1, we defined this no change of the SG-AR level. The middle ear diagnosis was determined by pneumatic otoscopy at the study clinic. RESULTS 361 paired SG-AR home measurements were obtained. The reference measurement was related to a healthy middle ear as determined by pneumatic otoscopy. Increasing SG-AR levels (59/361), were 63% (95% CI 50%-74%) sensitive and 94% (91%-97%) specific for deterioration of a healthy middle ear to AOM. The positive predictive value was 71% (58%-82%) and the negative predictive value was 92% (88%-95%). When there was no SG-AR level difference between the SG-AR examinations, the corresponding figures were 88% (95% CI 84%-92%), 69% (56%-79%), 93% (89%-95%) and 57% (45%-68%), respectively. CONCLUSIONS This study shows that increasing SG-AR levels might not be sufficiently sensitive to detect deterioration of the middle ear status from healthy middle ear to AOM in symptomatic children. Importantly, however, the development of AOM seems to be unlikely in an initially healthy middle ear when there is no difference between the SG-AR levels in two separate measurements.
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Affiliation(s)
- Nora Erkkola-Anttinen
- Department of Paediatrics and Adolescent Medicine, Turku University Hospital, Turku, Finland; Department of Paediatrics and Adolescent Medicine, University of Turku, Turku, Finland; City of Turku Welfare Division, Primary Healthcare Services, Turku, Finland.
| | - Miia K Laine
- Department of Clinical Microbiology, Turku University Hospital, Turku, Finland; Department of Medical Microbiology and Immunology, University of Turku, Turku, Finland
| | - Paula A Tähtinen
- Department of Paediatrics and Adolescent Medicine, Turku University Hospital, Turku, Finland; Department of Paediatrics and Adolescent Medicine, University of Turku, Turku, Finland
| | - Aino Ruohola
- Department of Paediatrics and Adolescent Medicine, Turku University Hospital, Turku, Finland; Department of Paediatrics and Adolescent Medicine, University of Turku, Turku, Finland
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Casselbrant ML, Gravel JS, Margolis RH, Bellussi L, Dhooge I, Downs MP, Karma P, Marchisio P, Ogra PL, Passali D, Stewart IA, van Cauwenberge PB, Vernon-Feagans L. 8. Diagnosis and Screening. Ann Otol Rhinol Laryngol 2016. [DOI: 10.1177/00034894021110s311] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
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10
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Innovative technologies in diagnosing acute otitis media. JAAPA 2015; 29:37-41. [PMID: 26704652 DOI: 10.1097/01.jaa.0000475464.30842.8e] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
New guidelines for managing acute otitis media include stricter criteria for properly diagnosing the condition and ensuring an accurate diagnosis before clinicians make treatment decisions. This is key because of the increase in antibiotic-resistant pathogens. This article focuses on how clinicians can use ancillary techniques and technologies to improve diagnostic accuracy for acute otitis media. Techniques include proper cerumen removal, visualizing the tympanic membrane with the correct otoscope, pneumatic otoscopy, using a spectral gradient acoustic reflectometer, and tympanometry.
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11
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Steele KM, Carreiro JE, Viola JH, Conte JA, Ridpath LC. Effect of osteopathic manipulative treatment on middle ear effusion following acute otitis media in young children: a pilot study. J Osteopath Med 2015; 114:436-47. [PMID: 24917631 DOI: 10.7556/jaoa.2014.094] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/24/2022]
Abstract
CONTEXT Childhood acute otitis media (AOM) is highly prevalent. Its usual sequela of middle ear effusion (MEE) can lead to conductive hearing loss, for which surgery is commonly used. OBJECTIVE To evaluate the efficacy of an osteopathic manipulative treatment (OMT) protocol on MEE resolution following an episode of AOM. The authors hypothesized that OMT provided adjunctively to standard care for young children with AOM would reduce the duration of MEE following the onset of AOM. METHODS We compared standard care only (SCO) and standard care plus OMT (SC+OMT) for the duration of MEE following AOM. Patients were aged 6 months to 2 years. The SC+OMT group received OMT during 3 weekly visits. Weekly tympanometric and acoustic reflectometer (AR) readings were obtained from all patients. RESULTS There were 52 patients enrolled, with 43 completing the study and 9 dropping out. No demographic differences were noted. Only ears from each patient with abnormal tympanograms at entry were included. There were 76 ears in the tympanogram analysis (38 from SCO; 38 from SC+OMT) and 61 ears in the AR data analysis (31 from SCO; 30 from SC+OMT). Dependence of bilateral ear disease noted in AR readings was accounted for in statistical analysis. Tympanogram data demonstrated a statistically significant improvement in MEE at visit 3 in patients in the SC+OMT group (odds ratio, 2.98; 95% confidence interval, 1.16, 7.62; χ(2) test for independence, P=.02). The AR data analysis showed statistically significant improvement at visit 3 for the SC+OMT group (z=2.05; P=.02). There was no statistically significant change in MEE before or immediately after the OMT protocol. CONCLUSION A standardized OMT protocol administered adjunctively with standard care for patients with AOM may result in faster resolution of MEE following AOM than standard treatment alone. (ClinicalTrials.gov number NCT00520039.).
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Affiliation(s)
- Karen M Steele
- From the Department of Osteopathic Medical Education (Dr Steele) and the Department of Assessment and Educational Development (Mr Ridpath) at the West Virginia School of Osteopathic Medicine (WVSOM) in Lewisburg; the Department of Osteopathic Manipulative Medicine (OMM) at the University of New England College of Osteopathic Medicine in Biddeford, Maine (Dr Carreiro); the Department of Emergency Medicine at Duke University in Durham, North Carolina (Dr Viola); and the Maine Dartmouth Family Medicine Residency in Augusta, Maine (Dr Conte). Dr Steele is now retired from WVSOM as professor emerita and has established a private OMM practice
| | - Jane E Carreiro
- From the Department of Osteopathic Medical Education (Dr Steele) and the Department of Assessment and Educational Development (Mr Ridpath) at the West Virginia School of Osteopathic Medicine (WVSOM) in Lewisburg; the Department of Osteopathic Manipulative Medicine (OMM) at the University of New England College of Osteopathic Medicine in Biddeford, Maine (Dr Carreiro); the Department of Emergency Medicine at Duke University in Durham, North Carolina (Dr Viola); and the Maine Dartmouth Family Medicine Residency in Augusta, Maine (Dr Conte). Dr Steele is now retired from WVSOM as professor emerita and has established a private OMM practice
| | - Judith Haug Viola
- From the Department of Osteopathic Medical Education (Dr Steele) and the Department of Assessment and Educational Development (Mr Ridpath) at the West Virginia School of Osteopathic Medicine (WVSOM) in Lewisburg; the Department of Osteopathic Manipulative Medicine (OMM) at the University of New England College of Osteopathic Medicine in Biddeford, Maine (Dr Carreiro); the Department of Emergency Medicine at Duke University in Durham, North Carolina (Dr Viola); and the Maine Dartmouth Family Medicine Residency in Augusta, Maine (Dr Conte). Dr Steele is now retired from WVSOM as professor emerita and has established a private OMM practice
| | - Josephine A Conte
- From the Department of Osteopathic Medical Education (Dr Steele) and the Department of Assessment and Educational Development (Mr Ridpath) at the West Virginia School of Osteopathic Medicine (WVSOM) in Lewisburg; the Department of Osteopathic Manipulative Medicine (OMM) at the University of New England College of Osteopathic Medicine in Biddeford, Maine (Dr Carreiro); the Department of Emergency Medicine at Duke University in Durham, North Carolina (Dr Viola); and the Maine Dartmouth Family Medicine Residency in Augusta, Maine (Dr Conte). Dr Steele is now retired from WVSOM as professor emerita and has established a private OMM practice
| | - Lance C Ridpath
- From the Department of Osteopathic Medical Education (Dr Steele) and the Department of Assessment and Educational Development (Mr Ridpath) at the West Virginia School of Osteopathic Medicine (WVSOM) in Lewisburg; the Department of Osteopathic Manipulative Medicine (OMM) at the University of New England College of Osteopathic Medicine in Biddeford, Maine (Dr Carreiro); the Department of Emergency Medicine at Duke University in Durham, North Carolina (Dr Viola); and the Maine Dartmouth Family Medicine Residency in Augusta, Maine (Dr Conte). Dr Steele is now retired from WVSOM as professor emerita and has established a private OMM practice
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Erkkola-Anttinen N, Laine MK, Tähtinen PA, Ruohola A. Parental role in the diagnostics of otitis media: can layman parents use spectral gradient acoustic reflectometry reliably? Int J Pediatr Otorhinolaryngol 2015; 79:1516-21. [PMID: 26183005 DOI: 10.1016/j.ijporl.2015.06.040] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/05/2015] [Revised: 06/25/2015] [Accepted: 06/27/2015] [Indexed: 11/28/2022]
Abstract
OBJECTIVE Spectral gradient acoustic reflectometry (SG-AR) can be used to detect middle ear effusion (MEE). Since both families and primary health care systems carry the burden of otitis media, our aim was to determine whether layman parents could be taught to use the SG-AR reliably. METHODS We enrolled 359 children (age 6-35 months) whose parents were willing to use SG-AR at home. The parents were asked to perform bilateral SG-AR daily on their child. In this study, we included children who had undergone successful parental home SG-AR examination performed on the same day that a physician had also performed successful SG-AR examination and pneumatic otoscopy at the study clinic. We compared the parental and study physician SG-AR examination results to the study physicians' pneumatic otoscopy, which served as the diagnostic standard. RESULTS We analyzed 571 successful parental home SG-AR examinations performed on the same day that a study physician had performed a successful SG-AR examination and pneumatic otoscopy at the study clinic. None of the evaluated SG-AR level combinations resulted in both high sensitivity and specificity. For symptomatic visits, the negative predictive value of a parental SG-AR level 1 to detect MEE was 64%. For parental SG-AR levels 4-5, the positive predictive value to detect MEE was 88%. However, for asymptomatic visits, the negative predictive value of a parental SG-AR level 1 to detect MEE was 83%. CONCLUSION This study showed that layman parents are able to use the SG-AR technically successfully. In symptomatic children, parentally obtained SG-AR level 1 examination is not adequate to exclude MEE. However, parentally obtained SG-AR levels 4-5 do indicate the presence of MEE. At the same time, in asymptomatic children, parentally obtained SG-AR level 1 examination seems to indicate a healthy middle ear. From the perspective of primary care, the implementation of parental SG-AR examinations in the diagnostic chain of otitis media would be intriguing. This study showed that the possibilities lie in the follow up of the resolution of MEE after an episode of OM in asymptomatic children. However, it seems that currently, the SG-AR technique is an obstacle for wider clinical implementation.
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Affiliation(s)
- Nora Erkkola-Anttinen
- Department of Paediatrics and Adolescent Medicine, Turku University Hospital, Turku, Finland; City of Turku Welfare Division, Primary Healthcare Services, Turku, Finland.
| | - Miia K Laine
- Department of Medical Microbiology and Immunology, University of Turku, Turku, Finland
| | - Paula A Tähtinen
- Department of Paediatrics and Adolescent Medicine, Turku University Hospital, Turku, Finland
| | - Aino Ruohola
- Department of Paediatrics and Adolescent Medicine, Turku University Hospital, Turku, Finland; University of Turku, Turku, Finland
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13
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Abstract
Acute otitis media (AOM) is diagnosed based on visualization of a full or bulging tympanic membrane with middle ear effusion. The distribution of bacteria causing AOM in North America under the influence of pneumococcal conjugate vaccination and antibiotic selection pressure has resulted in a predominance of β-lactamase-producing Haemophilus influenzae followed by penicillin-resistant Streptococcus pneumoniae. Although guidelines continue to endorse amoxicillin as the preferred treatment, amoxicillin/clavulanate in high dosage would be the preferred treatment based on the otopathogen mix currently. Antibiotic prophylaxis has fallen into disfavor as a preventative strategy for AOM recurrences.
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Affiliation(s)
- Michael E Pichichero
- Center for Infectious Diseases and Immunology, Rochester General Hospital Research Institute, Rochester General Hospital, Rochester, NY 14621, USA.
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14
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Diagnosis and treatment of acute otitis media: review. The Journal of Laryngology & Otology 2012; 126:976-83. [PMID: 22809689 DOI: 10.1017/s0022215112001326] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/07/2022]
Abstract
BACKGROUND Acute otitis media is very common, but diagnostic criteria and treatment recommendations vary considerably. METHODS Medline, the Cochrane Database of Systematic Reviews and the Cochrane Central Register of Controlled Trials were searched using the key words 'acute otitis media' AND 'diagnosis' OR 'diagnostic criteria' OR 'definition', and by combining the terms 'acute otitis media' AND 'guidelines'. PubMed was searched using the key words 'mastoiditis' and 'prevalence'. RESULTS The 11 most recently published guidelines unanimously agreed that adequate analgesia should be prescribed in all cases. The majority recommended that routine antibiotic prescription should be avoided in mild to moderate cases and when there was diagnostic uncertainty in patients two years and older. Antibiotics were recommended in children two years and younger, most commonly a 5-day course of amoxicillin (or a macrolide in patients allergic to penicillin). CONCLUSION Level 1A evidence shows that selected cases of acute otitis media benefit from antibiotic prescription.
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Valente MH, Escobar AMDU, Grisi SJFE. Aspectos diagnósticos da otite média com derrame na faixa etária pediátrica. REVISTA BRASILEIRA DE SAÚDE MATERNO INFANTIL 2010. [DOI: 10.1590/s1519-38292010000200003] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/21/2022]
Abstract
OBJETIVOS: apresentar e discutir aspectos diagnósticos da otite média com derrame (OMD) na prática clínica da atenção primária à saúde. MÉTODOS: foram pesquisadas as bases de dados Medline, Lilacs e SciELO (1994-2004). Identificados 523 artigos, dos quais 30 foram considerados para o presente trabalho. RESULTADOS: os estudos revelaram disparidade entre as definições, inconsistência no quadro clínico e falta de padronização dos critérios diagnósticos. Isto contribuiu para a inadequação diagnóstica da OMD. As evidências que levaram ao diagnóstico de efusão foram: a) pelo menos duas anormalidades do tímpano relacionadas à coloração, opacificação e mobilidade; e/ou b) membrana timpânica (MT) tipicamente retraída, côncava, e com alteração da coloração; e/ou c) mobilidade reduzida ou ausente na otoscopia pneumática (OP). A OP mostrou ser mais acurada que a otoscopia simples (OS), sendo considerada como método de escolha para o diagnóstico clínico da OMD. Quando houver dúvida na otoscopia pneumática, pode-se indicar a timpanometria, que aumenta a acurácia deste diagnóstico. CONCLUSÕES: na prática clínica, o diagnóstico da OMD deve ser realizado, primariamente pela otoscopia pneumática, em toda criança com suspeita de OMD. Em caso de dúvida deve-se indicar a timpanometria.
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Teppo H, Revonta M. Consumer acoustic reflectometry by parents in detecting middle-ear fluid among children undergoing tympanostomy. Scand J Prim Health Care 2009; 27:167-71. [PMID: 19565410 PMCID: PMC3413189 DOI: 10.1080/02813430903072165] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/20/2022] Open
Abstract
OBJECTIVE This study aimed at evaluating the diagnostic accuracy of a consumer model acoustic reflectometer in the hands of parents in the detection of middle-ear fluid among children. DESIGN Prospective diagnostic study according to STARD guidelines. Acoustic reflectometry recorded by the parents was compared with otomicroscopic myringotomy with suction in general anaesthesia, performed immediately afterwards. SETTING Secondary care (Kanta-Hame Central Hospital, Finland). PATIENTS Pre-school (<7 years) children undergoing otomicroscopic myringotomy due to recurrent acute otitis media or suspicion of glue ear. MAIN OUTCOME MEASURES Sensitivity, specificity, and positive and negative predictive values of acoustic reflectometry. RESULTS Consumer model acoustic reflectometry performed by parents reached sensitivity of 94% (95% confidence interval 88-100%) and negative predictive value of 92% (83-100%) with result 1 (green colour) on a scale of 1-5. On the other hand, the method was not very specific and positive predictive value was poor. CONCLUSIONS The negative screening result was very reliable. Thus, home screening of otitis among otitis-prone children and home follow-up of resolution of middle-ear fluid afterwards deserves to be studied in the home setting in the future.
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Affiliation(s)
- Heikki Teppo
- Department of Otorhinolaryngology, Kanta-Hame Central Hospital, Hameenlinna, Finland.
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Teppo H, Revonta M. Comparison of old, professional and consumer model acoustic reflectometers in the detection of middle-ear fluid in children with recurrent acute otitis media or glue ear. Int J Pediatr Otorhinolaryngol 2007; 71:1865-72. [PMID: 17904648 DOI: 10.1016/j.ijporl.2007.08.013] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/26/2007] [Revised: 08/17/2007] [Accepted: 08/17/2007] [Indexed: 10/22/2022]
Abstract
OBJECTIVE Acoustic reflectometry is an alternative method of determining the probability of middle-ear fluid. Its sensitivity and specificity are comparable to those of pneumatic otoscopy and tympanometry. The relative superiority between the first-generation model and second-generation spectral gradient acoustic reflectometers (introduced for both professional and consumer use) has not been studied. This study aimed to assess the diagnostic performance of three different acoustic reflectometry devices, and to evaluate the intercorrelation of the results. METHODS Fifty children (100 ears) aged <7 years undergoing ambulatory otomicroscopic myringotomy in anesthesia were examined with three different acoustic reflectometers, and the results were compared to the myringotomy findings (gold standard method). Specificity, sensitivity and positive and negative predictive values of each instrument in detecting middle-ear fluid were determined. The intercorrelations between the three devices were assessed descriptively (percentage agreement) and statistically (kappa correlation). RESULTS Second-generation professional and consumer spectral gradient acoustic reflectometers performed equally well in detecting middle-ear fluid (specificities 84 and 85%, sensitivities 83 and 77%, respectively) and were superior to the old model. Accordingly, the results obtained with professional and consumer models correlated well with each other (kappa 0.60) but not with those of the first-generation device. Acoustic reflectometry is not reliable when performed in anesthesia with the patient lying down. CONCLUSIONS Newer spectral gradient acoustic reflectometers perform better than the older first-generation model. In this study, the consumer model gave the same information as professional model, but its diagnostic validity in the hands of layman consumers needs to be confirmed.
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Affiliation(s)
- Heikki Teppo
- Department of Otorhinolaryngology, Kanta-Hame Central Hospital, FIN-13530 Hameenlinna, Finland.
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Lindén H, Teppo H, Revonta M. Spectral gradient acoustic reflectometry in the diagnosis of middle-ear fluid in children. Eur Arch Otorhinolaryngol 2006; 264:477-81. [PMID: 17102956 DOI: 10.1007/s00405-006-0206-8] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/26/2006] [Accepted: 10/19/2006] [Indexed: 10/23/2022]
Abstract
Diagnosis of otitis media is based on detection of middle-ear fluid (MEF) and is both important and difficult to achieve. Also non-infectious MEF is important to detect, since it can compromise hearing. In this prospective, blinded study, spectral gradient acoustic reflectometry (SG-AR) was evaluated as an indicator of MEF among children. Sensitivity, specificity and positive and negative predictive values of SG-AR in detecting MEF were calculated in children undergoing ambulatory surgery for recurrent or secretory otitis media using otomicroscopic myringotomy as the reference method of confirming middle-ear status. Final study material consisted of 376 ears. Pattern recognition of SG-AR curves reached the best combination of sensitivity and specificity (69 and 97%, respectively), and the best combination of positive (PPV) and negative (NPV) predictive values (93 and 83%, respectively), in detection of MEF. With a spectral gradient value of <80 degrees , the sensitivity was 75% and specificity 71%. With <50 degrees , PPV was 78%, and with >or=100 degrees , NPV was 86%. The diagnostic power of SG-AR was comparable to that reported with pneumatic otoscopy and tympanometry. It was equally effective in detecting both MEF cases and healthy ears. Pattern recognition seems to improve its performance. We recommend the use of pattern recognition of SG-AR as a screening method for MEF among children.
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Affiliation(s)
- Henriikka Lindén
- Department of Otorhinolaryngology, Kanta-Hame Central Hospital, Hameenlinna, Finland.
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Teppo H, Revonta M, Lindén H, Palmu A. Detection of middle-ear fluid in children with spectral gradient acoustic reflectometry: a screening tool for nurses? Scand J Prim Health Care 2006; 24:88-92. [PMID: 16690556 DOI: 10.1080/02813430600699997] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/24/2022] Open
Abstract
OBJECTIVE To evaluate the validity of spectral gradient acoustic reflectometry (SG-AR) in the hands of nurses in screening children for middle-ear fluid (MEF). DESIGN Prospective, blinded study. SETTING A satellite study within the Finnish Otitis Media Vaccine Trial in primary care in 1995-99. PATIENTS Some 739 ear examinations among a cohort of 271 children under the age of 2 years during different healthcare contacts (acute sick visits, check-up visits after otitis media, and scheduled healthy control visits at 24 months of age). MAIN OUTCOME MEASURES Specificity, sensitivity and positive and negative predictive values of SG-AR performed by nurses in detecting MEF using pneumatic otoscopy by trained physicians as a reference. RESULTS SG-AR was successful in 585 (79%) ears. None of the cut-off points assessed resulted in both excellent sensitivity and specificity. Nevertheless, at the sick visits, positive predictive values at 50 and 60 degrees were as high as 94% and 89%, respectively. However, negative predictive value for the cut-off point of 100 degrees was considerably lower, at 75%. At the non-acute visits, negative predictive values were excellent. CONCLUSION SG-AR is a useful device for nurses in screening MEF among children. It detects ears with both very high and very low probability of MEF and is especially effective in detecting MEF during sick visits and in ruling out MEF among non-acute patients. We recommend the use of the SG-AR cut-off point of 60 degrees as a sign of MEF when screening sick children, and the cut-off point of 100 degrees as a sign of a healthy ear among non-symptomatic patients.
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Affiliation(s)
- Heikki Teppo
- Department of Otorhinolaryngology, Kanta-Hame Central Hospital, Hameenlinna, Finland.
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Abstract
The management of otitis media with effusion (OME) has received much attention recently as a result of, among other factors, the development of resistant bacteria and the finding of less long-term impact of middle-ear effusion (MEE) on development than previously believed. Guidelines have recently been published for the management of OME promoting more accurate diagnosis, particularly distinguishing acute otitis media from OME, and recommending the 'judicious' use of antibacterials. Today, more emphasis is being placed on prevention of disease by reducing risk factors and the development of vaccines. The identification of susceptibility genes may lead to better understanding of the pathogenesis of otitis media, which in turn may lead to the development of more innovative and satisfactory methods for prevention and treatment.
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Affiliation(s)
- Ellen M Mandel
- ENT Research Center, Children's Hospital of Pittsburgh, Pittsburgh, Pennsylvania 15213, USA.
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Shiao AS, Guo YC. A comparison assessment of videotelescopy for diagnosis of pediatric otitis media with effusion. Int J Pediatr Otorhinolaryngol 2005; 69:1497-502. [PMID: 16168494 DOI: 10.1016/j.ijporl.2005.03.041] [Citation(s) in RCA: 22] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/15/2004] [Revised: 03/03/2005] [Accepted: 03/19/2005] [Indexed: 11/23/2022]
Abstract
OBJECTIVES A correct diagnosis of pediatric otitis media with effusion (OME) is imperative for instituting an appropriate treatment. The aim of this study was to compare the diagnostic efficacies of videotelescopy, pneumatic otoscopy, and tympanometry for detecting the presence or absence of pediatric OME, and thereby, to recommend a standardized procedure for assessing possible OME in the outpatient setting of a referral center. STUDY DESIGN Prospective study. METHODS Between November 1999 and May 2002, 104 children were enrolled in this comparison study of diagnostic methods for OME. Based on a presumptive diagnosis of OME or atelectasis of the eardrum, patients under 12 years of age were admitted to the ward for ventilation-tube insertion. In the 2 days prior to surgery, videotelescopy, pneumatic otoscopy, and tympanometry were performed. Myringotomies were subsequently conducted under general anesthesia to confirm the presence or absence of OME. Type B tympanograms were accepted as positive results for ears with effusion. RESULTS : Of the 201 ears assessed in the study, middle-ear effusion was detected in 179, while the remaining 22 ears were found to be dry on myringotomy. It was demonstrated that videotelescopy had the highest sensitivity (97.8%), specificity (100%), and accuracy (98.0%), reflecting significantly better results than those for pneumatic otoscopy and tympanometry. CONCLUSIONS In our study, videotelescopy seemed to be better than pneumatic otoscopy and tympanometry for diagnosis of pediatric OME. It may be has the potential to become the standard diagnostic and teaching procedure for pediatric OME in the outpatient setting of a referral center, and for validation of pneumatic otoscopy.
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Affiliation(s)
- An-Suey Shiao
- Department of Otolaryngology, Taipei Veterans General Hospital, National Yang-Ming University School of Medicine, No. 201 Shih-Pai Road, Sec. 2, Taipei 112, Taiwan, ROC.
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Abstract
The clinical practice guideline on otitis media with effusion (OME) provides evidence-based recommendations on diagnosing and managing OME in children. This is an update of the 1994 clinical practice guideline "Otitis Media With Effusion in Young Children," which was developed by the Agency for Healthcare Policy and Research (now the Agency for Healthcare Research and Quality). In contrast to the earlier guideline, which was limited to children 1 to 3 years old with no craniofacial or neurologic abnormalities or sensory deficits, the updated guideline applies to children aged 2 months through 12 years with or without developmental disabilities or underlying conditions that predispose to OME and its sequelae. The American Academy of Pediatrics, American Academy of Family Physicians, and American Academy of Otolaryngology-Head and Neck Surgery selected a subcommittee composed of experts in the fields of primary care, otolaryngology, infectious diseases, epidemiology, hearing, speech and language, and advanced-practice nursing to revise the OME guideline. The subcommittee made a strong recommendation that clinicians use pneumatic otoscopy as the primary diagnostic method and distinguish OME from acute otitis media. The subcommittee made recommendations that clinicians should 1) document the laterality, duration of effusion, and presence and severity of associated symptoms at each assessment of the child with OME, 2) distinguish the child with OME who is at risk for speech, language, or learning problems from other children with OME and more promptly evaluate hearing, speech, language, and need for intervention in children at risk, and 3) manage the child with OME who is not at risk with watchful waiting for 3 months from the date of effusion onset (if known) or diagnosis (if onset is unknown). The subcommittee also made recommendations that 4) hearing testing be conducted when OME persists for 3 months or longer or at any time that language delay, learning problems, or a significant hearing loss is suspected in a child with OME, 5) children with persistent OME who are not at risk should be reexamined at 3- to 6-month intervals until the effusion is no longer present, significant hearing loss is identified, or structural abnormalities of the eardrum or middle ear are suspected, and 6) when a child becomes a surgical candidate (tympanostomy tube insertion is the preferred initial procedure). Adenoidectomy should not be performed unless a distinct indication exists (nasal obstruction, chronic adenoiditis); repeat surgery consists of adenoidectomy plus myringotomy with or without tube insertion. Tonsillectomy alone or myringotomy alone should not be used to treat OME. The subcommittee made negative recommendations that 1) population-based screening programs for OME not be performed in healthy, asymptomatic children, and 2) because antihistamines and decongestants are ineffective for OME, they should not be used for treatment; antimicrobials and corticosteroids do not have long-term efficacy and should not be used for routine management. The subcommittee gave as options that 1) tympanometry can be used to confirm the diagnosis of OME and 2) when children with OME are referred by the primary clinician for evaluation by an otolaryngologist, audiologist, or speech-language pathologist, the referring clinician should document the effusion duration and specific reason for referral (evaluation, surgery) and provide additional relevant information such as history of acute otitis media and developmental status of the child. The subcommittee made no recommendations for 1) complementary and alternative medicine as a treatment for OME, based on a lack of scientific evidence documenting efficacy, or 2) allergy management as a treatment for OME, based on insufficient evidence of therapeutic efficacy or a causal relationship between allergy and OME. Last, the panel compiled a list of research needs based on limitations of the evidence reviewed. The purpose of this guideline is to inform clinicians of evidence-based methods to identify, monitor, and manage OME in children aged 2 months through 12 years. The guideline may not apply to children more than 12 years old, because OME is uncommon and the natural history is likely to differ from younger children who experience rapid developmental change. The target population includes children with or without developmental disabilities or underlying conditions that predispose to OME and its sequelae. The guideline is intended for use by providers of health care to children, including primary care and specialist physicians, nurses and nurse practitioners, physician assistants, audiologists, speech-language pathologists, and child-development specialists. The guideline is applicable to any setting in which children with OME would be identified, monitored, or managed. This guideline is not intended as a sole source of guidance in evaluating children with OME. Rather, it is designed to assist primary care and other clinicians by providing an evidence-based framework for decision-making strategies. It is not intended to replace clinical judgment or establish a protocol for all children with this condition and may not provide the only appropriate approach to diagnosing and managing this problem.
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Abstract
This evidence-based clinical practice guideline provides recommendations to primary care clinicians for the management of children from 2 months through 12 years of age with uncomplicated acute otitis media (AOM). The American Academy of Pediatrics and American Academy of Family Physicians convened a committee composed of primary care physicians and experts in the fields of otolaryngology, epidemiology, and infectious disease. The subcommittee partnered with the Agency for Healthcare Research and Quality and the Southern California Evidence-Based Practice Center to develop a comprehensive review of the evidence-based literature related to AOM. The resulting evidence report and other sources of data were used to formulate the practice guideline recommendations. The focus of this practice guideline is the appropriate diagnosis and initial treatment of a child presenting with AOM. The guideline provides a specific definition of AOM. It addresses pain management, initial observation versus antibacterial treatment, appropriate choices of antibacterials, and preventive measures. Decisions were made based on a systematic grading of the quality of evidence and strength of recommendations, as well as expert consensus when definitive data were not available. The practice guideline underwent comprehensive peer review before formal approval by the partnering organizations. This clinical practice guideline is not intended as a sole source of guidance in the management of children with AOM. Rather, it is intended to assist primary care clinicians by providing a framework for clinical decision-making. It is not intended to replace clinical judgment or establish a protocol for all children with this condition. These recommendations may not provide the only appropriate approach to the management of this problem.
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Takata GS, Chan LS, Morphew T, Mangione-Smith R, Morton SC, Shekelle P. Evidence assessment of the accuracy of methods of diagnosing middle ear effusion in children with otitis media with effusion. Pediatrics 2003; 112:1379-87. [PMID: 14654613 DOI: 10.1542/peds.112.6.1379] [Citation(s) in RCA: 105] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/24/2022] Open
Abstract
OBJECTIVES We report the findings of an evidence assessment on the accuracy of methods of diagnosing middle ear effusion in children with otitis media with effusion (OME). METHODS We searched Medline (1966-January 2000), the Cochrane Library (through January 2000), and Embase (1980-January 2000) and identified additional articles from reference lists in proceedings, published articles, reports, and guidelines. Excluded were nonhuman studies; case reports; editorials; letters; reviews; practice guidelines; non-English-language publications; and studies on patients with immunodeficiencies, craniofacial anomalies (including cleft palate), primary mucosal disorders, or genetic conditions. From each eligible study, we calculated the sensitivity, specificity, positive predictive value, negative predictive value, accuracy, and prevalence of OME in the cohort. We determined the number of studies for each comparison of a diagnostic method and a reference standard listed within the scope of our assessment. For comparisons with 3 or more studies, we derived random effects estimates of sensitivity, specificity, and prevalence rate. Using the pooled estimates, we plotted the performance of each diagnostic test in terms of sensitivity and (1 - specificity) and identified the best performer among the tests included in the comparison. RESULTS Among 8 diagnostic methods, pneumatic otoscopy had the best apparent performance with a sensitivity of 94% (95% confidence interval: 92%-96%) and a specificity of 80% (95% confidence interval: 75%-86%). However, examiner qualifications were reported inconsistently, and training was not specified. CONCLUSIONS The finding that pneumatic otoscopy can do as well as or better than tympanometry and acoustic reflectometry has significant practical implications. For the typical clinician, pneumatic otoscopy should be easier to use than other diagnostic methods. The important question may be what degree of training will be needed for the clinician to be as effective with pneumatic otoscopy as were the examiners in the studies reviewed in this report.
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Affiliation(s)
- Glenn S Takata
- Division of General Pediatrics, Childrens Hospital Los Angeles, Los Angeles, California 90027, USA.
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Klaudt MR, Steinbach WJ, Sectish TC. Clinical considerations in the diagnosis of otitis media. Curr Allergy Asthma Rep 2003; 3:313-20. [PMID: 12791208 DOI: 10.1007/s11882-003-0091-9] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/23/2022]
Abstract
Acute otitis media and otitis media with effusion are commonly encountered by both general practitioners and specialists. The diagnosis of otitis media requires a focused history and accurate physical examination. Unfortunately, many practitioners are either unaware of the criteria needed to make the diagnosis, or they incorrectly perform or misinterpret the physical examination. We review the pertinent historical and physical examination findings needed to accurately diagnose otitis media. Additionally, we examine the accessory tests that might help make the correct diagnosis in difficult cases. Finally, we address the issues involved in ensuring that both current and future physicians are appropriately trained in the diagnosis of this common illness.
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Affiliation(s)
- Monte R Klaudt
- Division of General Pediatrics, Department of Pediatrics, Stanford University School of Medicine, 750 Welch Road, Palo Alto, CA 94304, USA.
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Matz PS. Acute otitis media. PEDIATRIC CASE REVIEWS (PRINT) 2002; 2:209-19. [PMID: 12865669 DOI: 10.1097/00132584-200210000-00003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
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Butler CC, MacMillan H. Does early detection of otitis media with effusion prevent delayed language development? Arch Dis Child 2001; 85:96-103. [PMID: 11466181 PMCID: PMC1718883 DOI: 10.1136/adc.85.2.96] [Citation(s) in RCA: 14] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/04/2022]
Abstract
OBJECTIVE To consider whether earlier detection of otitis media with effusion (OME) in asymptomatic children in the first 4 years of life prevents delayed language development. METHODS MEDLINE and other databases were searched and relevant references from articles reviewed. Critical appraisal and consensus development were in accordance with the methods of the Canadian Task Force on Preventive Health Care. RESULTS No randomised controlled trials assessing the overall screening for OME and early intervention to prevent delay in acquiring language were identified, although one trial evaluated treatment in a screened population and found no benefit. The "analytic pathway" approach was therefore used, where evidence is evaluated for individual steps in a screening process. The evidence supporting the use of tools for early detection such as tympanometry, microtympanometry, acoustic reflectometry, and pneumatic otoscopy in the first 4 years of life is unclear. Some treatments (mucolytics, antibiotics, steroids) resulted in the short term resolution of effusions as measured by tympanometry. Ventilation tubes resolved effusions and improved hearing. Ventilation tubes in children with hearing loss associated with OME benefited children in the short term, but after 18 months there was no difference in comparison with those assigned to watchful waiting. Most prospective cohort studies that evaluated the association between OME and language development lacked adequate measurement of exposure or outcome, or suffered from attrition bias. Findings with regard to the association were inconsistent. CONCLUSIONS There is insufficient evidence to support attempts at early detection of OME in the first 4 years of life in the asymptomatic child to prevent delayed language development.
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Affiliation(s)
- C C Butler
- Department of Family Medicine, McMaster University, Faculty of Health Sciences, 1200 Main Street West, HSC 2V14, Hamilton, Ontario L8N 3Z5, Canada.
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Barnett ED, Cabral HJ, Klein JO. Home monitoring of the middle ear system with spectral gradient acoustic reflectometry: distinguishing acute otitis media from upper respiratory infection. Pediatr Infect Dis J 2000; 19:360-2. [PMID: 10783033 DOI: 10.1097/00006454-200004000-00023] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Affiliation(s)
- E D Barnett
- Maxwell Finland Laboratory for Infectious Diseases, Boston Medical Center, MA, USA
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Block SL, Pichichero ME, McLinn S, Aronovitz G, Kimball S. Spectral gradient acoustic reflectometry: detection of middle ear effusion in suppurative acute otitis media. Pediatr Infect Dis J 1999; 18:741-4. [PMID: 10462354 DOI: 10.1097/00006454-199908000-00024] [Citation(s) in RCA: 17] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Affiliation(s)
- S L Block
- Kentucky Pediatric Research, Inc., Bardstown 40004, USA
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Abstract
Acute otitis media (AOM) has become increasingly difficult to treat in the 1990s, the decade of drug-resistant pneumococcus. Throughout the world, drug-resistant strains of this pathogen are being recovered from 20 to 50% of cases of initial untreated AOM, and from 45 to 90% of refractory AOM. Almost as alarming is that beta-lactamase-producing strains of Haemophilus influenzae are currently being isolated in 40 to 50% of cases of AOM in the US. Clinicians can no longer expect 'Pollyanna-like' high rates of clinical resolution for this disease. It is now imperative that they become aware of the regional prevalence of these drug-resistant bacteria and, just as importantly, their patterns of antibacterial resistance. Although some authors would hold that any antibacterial, or even placebo, should be adequate for most cases of AOM, clinical practice appears to suggest otherwise. Amoxicillin, still the first-line therapeutic choice for initial nonrefractory AOM, will often fail. The real dilemma begins when clinicians search for clinical data to select an antibacterial for therapeutic failures--few data are available. Thus, to give optimal treatment to a child who has failed antibacterial therapy--the true actual indication for all second-line antibacterials--they must instead become familiar with the following in vivo and in vitro data: 1. 'In vivo sensitivity data': otherwise known as bacteriological efficacy, in which repeat tympanocentesis is performed in mid-therapy. This reveals the bacterial 'Achilles heel' or weakness for the individual antibacterial agents. 2. Clinical efficacy data: analysis of rates of clinical resolution after therapy in comparative trials which use a single tympanocentesis initially and a 'gold standard' comparator antibacterial. 3. 'Bug to drug' data: comparison of reported middle ear concentrations for each individual antibacterial agent relative to the respective minimum inhibitory concentrations of isolates, particularly drug-resistant pneumococcus and H. influenzae (if possible, obtained from the paediatric respiratory tract). The selection of an antibacterial agent for AOM in any particular case should not be merely a random process. It involves awareness of the pathogens most likely to be observed: with co-infections; after failure with a particular antibacterial (the bacterial 'Achilles heel' of the drug); and at different points in time, whether initially or after therapeutic failures (e.g. first-line versus fourth-line failure).
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Affiliation(s)
- S L Block
- Kentucky Pediatric Research, Incorporated, Bardstown 40004, USA
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Kimball S. Acoustic reflectometry: spectral gradient analysis for improved detection of middle ear effusion in children. Pediatr Infect Dis J 1998; 17:552-5; discussion 580. [PMID: 9655559 DOI: 10.1097/00006454-199806000-00034] [Citation(s) in RCA: 25] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Affiliation(s)
- S Kimball
- MDI Instruments, Inc., Woburn, MA 01801-6397, USA
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Barnett ED, Klein JO, Hawkins KA, Cabral HJ, Kenna M, Healy G. Comparison of spectral gradient acoustic reflectometry and other diagnostic techniques for detection of middle ear effusion in children with middle ear disease. Pediatr Infect Dis J 1998; 17:556-9; discussion 580. [PMID: 9655560 DOI: 10.1097/00006454-199806000-00035] [Citation(s) in RCA: 39] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Affiliation(s)
- E D Barnett
- Maxwell Finland Laboratory, Boston Medical Center, MA 02118, USA.
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