Improving the Diagnosis of Acute Otitis Media: “Seeing Is Believing” Stan L
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Healthy Baby Practical advice for treating newborns and toddlers. Improving the Diagnosis of Acute Otitis Media: “Seeing Is Believing” Stan L. Block, MD, FAAP cute otitis media (AOM) should in 94% of all children in a non-inner city remain an entirely visual di- population by the age of 24 months.2 So, A agnosis for all of us. A much- one would assume that probably the most improved guideline on the diagnosis and important aspect in the entire discussion of management of AOM was recently pub- AOM and its treatment would be how to lished in Pediatrics.1 The new diagnostic correctly diagnose AOM and the optimal emphasis in AOM is now the presence of methods needed to obtain its diagnosis; infected middle ear effusion (MEE), as it however, one would be mistaken. Shaikh appears with different levels of a bulging and Hoberman3 briefly addressed this A or convex tympanic membrane (TM). In problem in 2010. the guidelines, the child with moderate to We are all painfully aware of how poor- severe bulging TM or otorrhea is definitely ly diagnosed or misdiagnosed AOM can considered to have AOM, whereas the often be. Just ask any otolaryngologist or child with mild bulging TM (once termed general pediatrician who sees patients in “fullness”) should also have concomitant follow-up from many of their own less- recent ear pain or intense TM erythema. experienced health providers, community Remember that straight-forward otitis me- emergency rooms, urgent care centers, and dia with effusion, or serous otitis, should even from other too-busy pediatric offices. not be treated with antibiotics, but rather Unfortunately, for such an everyday B C followed up over several months. problem, the amount of time spent on As every pediatrician is keenly aware, teaching the correct diagnoses and man- AOM is the most common reason for pre- agement of AOM in medical school is scribing antibiotics in every general clinical negligible. Even in most pediatric and fam- practice. In fact, before routine PCV7/13 ily practice training programs, training is vaccination, an AOM episode developed minimal. So, why do we give such short shrift to such an important, ubiquitous pe- Stan L. Block, MD, FAAP, is Professor of Clinical diatric assessment that must be ascertained D Pediatrics, University of Louisville, and University of in nearly every young pediatric patient’s Images courtesy of Stan L. Block, MD, FAAP. Kentucky, Lexington, KY; President, Kentucky Pedi- well or sick visit? Figure 1. Welch-Allyn otoscopic heads and a atric and Adult Research Inc.; and general pediatri- Do not kid yourself; this is one of the handle. (A) This is the “Macroview” (preferred). (B) This is the less expensive “standard” oto- cian, Bardstown, KY. most technically difficult tasks to perform scopic head. (C) This is the Welch-Allyn “sur- Address correspondence to Stan L. Block, MD, on young children within a general pedi- gical” head with green round speculum. (D) FAAP, via email: [email protected]. atric practice. It requires a confident, firm Otoscopic handle (top): the lithium ion battery (preferred); otoscopic handle (bottom): the Disclosure: Dr. Block has no relevant financial parent to restrain the child, as well as your nickel cadmium battery — just not as bright relationships to disclose. own extreme diligence, patience, a lot of or long lasting, and as the battery wears, the light becomes subtly and almost imperceptibly doi: 10.3928/00904481-20131122-05 upper arm strength, and a stable eye to duller for quite awhile. PEDIATRIC ANNALS 42:12 | DECEMBER 2013 Healio.com/Pediatrics | 485 Healthy Baby fort to obtain the correct diagnosis — hard for all children younger than age 4 years.6 to do in busy office practice! These specula are longer in order to get For example, each of the following ob- past the bend of the ear canal, more ta- stacles may become glaringly manifest as pered, have a critically wider aperture, and you examine the TMs of young children: reflect light better from the plastic onto the • Inadequate instrumentation. TM. You will need to wipe them down with • Tiny ear canals. an alcohol pad after each visit, and they • Too much ear cerumen. sometimes require cleaning of the aperture • Too much feistiness and pushback with a cotton swab. The little bit of extra ef- from the child toward either the parent or fort is well worth it, as the shorter, stubbier Images courtesy of Stan L. Block, MD, FAAP. Figure 2. Original manufacturer non-disposable the pediatrician. disposable specula are simply inadequate specula: 4-mm, 3-mm, and 2.5-mm sizes. Better for • Poor practitioner training in assess- for younger children. children younger than 4 years old, these longer more tapered specula are highly preferred over the ment of TM markers of bona fide AOM. Occasionally, you may encounter a shorter stubbier disposable 2.5-mm speculum. The remainder of this article addresses child with such tiny ear canals that they each of these issues from my point of view may preclude the entrance of even the as a U.S. Food and Drug Administration 2.5-mm speculum. Some may even have preferred clinical investigator of AOM. I atretic canals, and you will need to con- have previously written many treatises on sider otolaryngology referral and probably the management of AOM, most recently a CT scan of the middle ear space to see touching on the diagnosis of AOM in the if any functional TM remains. For the rest A neonate in the June 2012 issue of Pedi- of these rarely encountered patients, the atric Annals5 and in the third edition of Welch-Allyn surgical otoscopic head and our book, Diagnosis and Management of its 2-mm green speculum (Figure 1C) will Acute Otitis Media.4 For the last 31 years, I frequently allow you to visualize the TM have examined bilateral TMs in more than until it enlarges enough for the routine oto- 3,000 patients annually, performed tympa- scope as the child matures over time. nocentesis in more than 400 patients with severe AOM, and been a principal investi- Ear Cerumen gator in nearly 50 clinical trials involving You will often encounter children with B Images courtesy of Stan L. Block, MD, FAAP. AOM and approximately 10 clinical trials significant amounts of cerumen obstructing Figure 3. (A) Assortment of tympanic membrane involving TM instrumentation. the ear canal, challenging your adequate curettes: colored curettes (Bionix Medical Tech- visualization of the TM. It is important to nologies)are plastic and more bendable, and pre- ferred by the less experienced otoscopists due THE STUMBLING BLOCKS TO make sure that the debris is not pus and/or to its lower likelihood of scratching the canal. (B) ACCURATE TM ASSESSMENT blood from otorrhea. The larger, black-handled curette is metal, and is preferred by many experienced otoscopists; Inadequate Instrumentation Cleaning the cerumen ear canals is the the bottom “Farrell” curette should only be used One of the most important and most bane of pediatrics, without a doubt. You along with a wrap-around corner of a piece of overlooked areas of assessing the TM will need one or several of the curettes alcohol swab to “wet mop” the remaining softer debris in the ear canal. is the use of optimal instruments. Fig- shown in Figure 3. Personally, I prefer the ures 1A and 1B display the primary op- stiffer metal curettes like the dark-handled tions for otoscopes: the Welch-Allyn one shown in Figure 3B, but it can pose the perform this task in most children younger MacroView and the standard head. I much potential hazard of scratching the canal and than 24 months and in many children up prefer the new version MacroView be- causing subsequent secondary brief bleed- to 4 years old. To compound the technical cause of its crisper optics and longer-last- ing; however, this can be tamponaded with difficulties, the TMs in nearly 80% of chil- ing, brighter lithium battery. It is worth the a portion of cotton ball. dren under age 12 months are partially or price differential. Just be sure to line up or The key is the gentle but firm restraint totally obscured by wax.4 You may never adjust the green line according to your own of the child by the parent or, rarely, by adequately see the TMs in most of these visual needs. your nurse. When cleaning ear canals in children without some manner of cleaning I cannot emphasize enough the criti- infants or obstreperous young children, I the debris from the ear canals. Thus, it can cal importance of using the original non- now always use the technique of laterally often take a great deal of extra time and ef- disposable specula as shown in Figure 2 positioning the child upon the exam table 486 | Healio.com/Pediatrics PEDIATRIC ANNALS 42:12 | DECEMBER 2013 Healthy Baby with the parent firmly restraining the arms TABLE 1. while lying on the lower trunk and legs; I can then restrain the head with one hand. The Three Criteria for TM cleaning often takes up to a few minutes, as Physical Diagnosis of AOM well as patience and gentle strength on the (without Otorrhea) part of the physician, as most of us know. Bulging or “full” This positioning technique especially pays always means acute otitis media (AOM) off in children aged younger than 6 months. Position The less we aggravate the child, the easier vs. neutral (normal) or retracted (serous the exam will usually be the next time. otitis media, or OME) For those children who are too difficult Absence of or too compacted with cerumen, ancillary bony landmarks, personnel are needed when resorting to the completely opaque, instruments shown in Figure 4; however, Opacification opaque air-fluid make sure the child does not have a history level (AOM or OME) of recent PE tubes or TM perforation.