Clinical/otologic score before and during treatment of acute otitis media

Remote evaluation of video-otoscopy recordings in an unselected pediatric population with an otitis media scale

BACKGROUND

A recently validated image-based grading scale for acute otitis media (OMGRADE) can be used to assess tympanic membrane (TM) status. The aim of this study was to evaluate the validity and reliability of this scale for remote assessments of TM status using video-otoscopy recordings in an unselected pediatric population.

METHOD

Children 2-16 years attending a South African primary health clinic were offered an ear examination by an otologist using otomicroscopy. An ear and hearing telehealth facilitator then made video-otoscopy recordings (9-33s) of the ears and uptakes were uploaded to a secure server for remote assessments in Sweden by an otologist and general practitioner at four- and eight-weeks post onsite assessment. TM appearance was judged according to the OMGRADE scale. Concordance between onsite otomicroscopy and asynchronous assessments of video-otoscopy recordings was calculated together with intra- and inter-rater agreements.

RESULTS

One hundred and eighty ears were included. Concordance of TM classifications using the OMGRADE scale was found to be substantial (weighted kappa range 0.66-0.79). Intra- and inter-rater agreement (test-retest) was found to be substantial to almost perfect (weighted kappa range 0.85-0.88 and 0.69-0.72, respectively).

CONCLUSION

The OMGRADE scale can be used to accurately assess the normal TM and secretory otitis media (SOM) remotely using video-otoscopy recordings in an unselected pediatric population.

Panel 7: Treatment and comparative effectiveness research

BACKGROUND AND OBJECTIVES

Otitis media (OM) is one of the most common reasons for antibiotic treatment in children. Controversies regarding antibiotic treatment for OM have accumulated in the past decade, and there seem to be more dilemmas than certainties. The objectives of this article are to provide the state-of-the art review on achievements in treatment of all different stages of OM, including acute otitis media (AOM), otitis media with effusion (OME), and chronic suppurative otitis media, and to outline the future research areas.

DATA SOURCES

PubMed, Ovid Medline, the Cochrane Database, and Clinical Evidence (BMJ Publishing).

REVIEW METHODS

All types of articles related to OM treatment published in English between January 2007 and June 2011 were identified. A total of 286 articles related to OM treatment were reviewed by the panel members; 114 relevant quality articles were identified and summarized.

RESULTS

New evidence emerged on beneficial results of antibiotic treatment, compared with observation of AOM in young children who were diagnosed based on stringent criteria. In OME, the main results were related to a nonsignificant benefit of adenoidectomy versus tympanostomy tube placement alone in the treatment of chronic OME in younger children. Other modalities of OM treatment were studied and described herein.

CONCLUSIONS AND IMPLICATIONS FOR PRACTICE

Significant progress has been made in advancing the knowledge on the treatment of OM. Areas of potential future research have been identified and outlined.

Development and validation of a new grading scale for otitis media

BACKGROUND

Grading of acute otitis media (AOM) is important in clinical situations as well as in research. Current grading scales for AOM have used a 6 to 9 point scoring system primarily based on variation of redness and bulging of the tympanic membrane (TM). This study aimed to develop and validate a new scale for grading AOM.

METHOD

The scale was developed in 3 stages based on 32 patients with images taken of the TM when a child attended healthcare centre with othalgia and at follow-up visits. Content validity was used as the method for the first 2 stages. An expert panel reviewed the scale and repeated the process on a revised scale. Reliability was tested with a different expert panel that used the final scale on a sample of TM images in a test-retest and inter-rater and intra-rater agreements were calculated.

RESULTS

The scale was developed in 3 steps using expert committees. During the process the description of vascularization was judged to be of insufficient importance for our scale. Inter-rater agreement was moderate (κ = 0.52) and intra-rater agreement was good (κ = 0.66 to 0.89) in the test-retest of the final scale.

CONCLUSIONS

The developed AOM image-based grading scale demonstrates substantial inter- and intra-rater reliability with potential use in clinical research and telemedicine applications. Furthermore, the parameter "redness of TM" is of less importance in our scale as compared with other available grading systems.

Challenges in reducing the burden of otitis media disease: an ENT perspective on improving management and prospects for prevention

Acute otitis media (AOM) is a major public health concern. This frequent disease of childhood is a leading cause of physician visits, a major component of paediatric healthcare burden, and a key contributor to antibiotic resistance. An international expert group comprising mainly ear, nose, and throat physicians met in June 2008 to discuss the optimal management of AOM, particularly with regards to unmet needs in diagnosis and management. Current guidelines do not help identify which patients are most at risk for severe or complicated AOM. Diagnosis of AOM is also complicated by a lack of correlation between clinical signs and symptoms and responsible pathogens. Consequently, treatment of AOM is not always appropriate, and the long-term overuse of antibiotics in AOM reduces the effectiveness of treatment and places children at risk for drug-resistant infections. There is a need for educational and research initiatives to improve diagnostic accuracy and management of AOM. Because there is currently no ideal treatment, vaccination is an attractive additional approach for managing AOM and reducing its burden.

Clinical outcome in children with culture-negative acute otitis media

BACKGROUND

Culture-negative AOM is often milder and associated with lower local/systemic inflammatory responses than culture-positive AOM.

STUDY OBJECTIVES

To compare the clinical outcome of culture-negative AOM with that of culture-positive AOM children.

PATIENTS AND METHODS

Children aged 3 to 35 months with AOM were enrolled in 11 double-tympanocentesis antibiotic efficacy studies documenting both bacteriologic (days 4-6 of treatment) and clinical outcome (days 11-14, end of treatment). Univariate analysis (age, gender, ethnicity, previous AOM history, and antibiotic treatment) between culture-negative and culture-positive AOM patients was performed by Student t test, ANOVA, or chi2 test. Those found to be significant were further submitted to multivariable regression analysis.

RESULTS

A total of 1088 patients (mean age, 11.95 +/- 5.96 months, 209 culture-negative and 879 culture-positive AOM) were enrolled. No differences were recorded between culture-negative AOM and culture-positive AOM patients in age, gender, ethnicity and number of previous episodes. Seventy-four percent (650/879) culture-positive AOM patients achieved bacteriologic eradication within 3 to 5 days. Successful outcome (cured + improved) was recorded in 90% (189/209) culture-negative AOM patients versus 86% (758/879) in culture-positive AOM (P = 0.086). Successful clinical outcome was more frequent in culture-negative than in culture-positive AOM without bacteriologic eradication (90% vs. 67% [154/229], P < 0.001). No difference in successful clinical outcome was found between culture-negative versus culture-positive AOM patients with bacterial eradication (90% vs. 93% [604/650], P = 0.24). Overall, the inclusion of culture-negative AOM patients in the evaluation of clinical failures rates in study patients decreased the total clinical failure rate by 9%. We present a hypothetical antibiotic efficacy study enrolling 300 patients in whom 2 drugs with different bacteriologic efficacy rates (A-90% and B-60%) were used. When the culture-negative cases (5% clinical failure) enrolled increased from 50/300 (16.7%) to 150/300 (50%), the overall clinical failure rate decreased by 36% (from 17.4% to 11.2%, P = 0.08) for the less efficacious drug, while remaining unmodified for the more efficacious drug (9.6% and 8.8%, respectively).

CONCLUSIONS

(1) Clinical outcome in culture-negative AOM was similar to that of culture-positive AOM with bacteriologic eradication and both were superior to that of culture-positive AOM without eradication; (2) Inclusion of culture-negative AOM patients in series aiming at antibiotic efficacy may falsely improve the clinical outcome for antibiotics with reduced ability to eradicate AOM pathogens.

Potential contribution by nontypable Haemophilus influenzae in protracted and recurrent acute otitis media

BACKGROUND

Characterization of acute otitis media (AOM) caused by nontypable Haemophilus influenzae (NTHi) is important, particularly in view of the efforts to develop vaccines against NTHi. To characterize NTHi AOM a large database of culture-positive AOM cases was analyzed.

METHODS

All culture-positive AOM episodes (NTHi, Streptococcus pneumoniae, Moraxella catarrhalis, and Streptococcus pyogenes) in children <5 years old from 1999 through 2006, processed in our center were included. One isolate was counted per episode (< or = 30 days). Demographic and clinical data were retrieved from charts or by telephone interviews. Multivariable regression analysis models were used.

RESULTS

Twelve thousand eight hundred twenty-three (8145 culture-positive) episodes were included. NTHi was recovered in 4928 episodes; S. pneumoniae in 4399 episodes, M. catarrhalis in 499, and S. pyogenes in 447 episodes. Independent risk factors for NTHi AOM (in culture-positive episodes) were: winter (odds ratio [OR]: 1.2, 95% confidence interval [CI]: 1.05-1.33, P = 0.006); bilateral AOM (OR: 1.26, 95% CI: 1.12-1.42, P < 0.001); >3 previous AOM episodes (OR: 1.27, 95% CI: 1.11-1.47, P = 0.001); and antibiotic consumption in previous month (OR: 1.3, 95% CI: 1.15-1.46, P < 0.001). ORs for these variables remained significant when the analysis was conducted on single-pathogen AOM only. For both NTHi and S. pneumoniae, risk factors for mixed episodes were older age and bilateral AOM.

CONCLUSION

NTHi AOM is characterized by higher occurrence in winter, bilaterality, recurrence, and previous antibiotic treatment compared with that caused by S. pneumoniae. These findings are in agreement with data associating NTHi with protracted or recurrent morbidity. The finding that S. pneumoniae and NTHi mixed episodes are more likely to occur in older children and in bilateral AOM suggests that interaction between these 2 pathogens contributes to chronicity or complexity of AOM.