Healthy Baby Practical advice for treating newborns and toddlers.

Improving the Diagnosis of Acute Media: “Seeing Is Believing” Stan L. Block, MD, FAAP

cute (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 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 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.

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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 , 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 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 : 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

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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. Our vs. translucent (normal) techs pre-soften the cerumen by instill- A ing several drops of peroxide for about 5 Mostly or entirely cloudy / purulent minutes. Often, young children can merely (green, pale yellow sit on a parent’s lap during the process of or non-scarring gentle irrigation until the tech perceives white fluid) or Discoloration B marked hyperemia that the wax has been flushed into the ir- Images courtesy of Stan L. Block, MD, FAAP. rigation basin. The tech has to be keenly Figure 4. Two instruments for flushing the ceru- indicates AOM vs. aware, however, and stop if the child seems men filled canal. (A) Waterpik [Water Pik, Inc.] gray (normal) or electric device. Bottom: 20-cc, hand-held manu- amber / orange to really be in pain — not just fussing — al-pump 20 cc syringe with a cut-off, large-bore (OME). during the flushing process, as very rarely, plastic IV catheter. AOM = acute otitis media; OME = otitis media with a hidden perforation or patent tube may be effusion; TM = tympanic membrane. present. matic experience will often pay off, with Data from Block7 quicker and more compliant future exami- Feistiness and Pushback by the Child nations of all body parts. infrequently absent.”7 The current AOM This is truly the art of pediatrics. You For those “ballistic” children, accept definition is now mostly synchronous with must decide how much restraint, pressure, your losses for the TM examination and my previous delineations of AOM diagno- and calm reassurance to administer to each routinely place them on the exam table as sis over the last decade (Table 1). However, child. My preference for most “non-ballis- described above. I suggest keeping your according to the AAP guidelines, presence tic” children aged older than 6 months is stethoscope in your when examining a of significant fever (102.2° F) or signifi- to allow them to sit comfortably sideways “screamer” as, over time, this will prevent cant ear complaints will place the child on the parent’s lap while I firmly press the damage to your hearing, and this may also into different categories of AOM severity, child’s head against the parent’s chest. You make you less likely rush your TM exam at which will have implications as to how to should tell the parent to sit firmly back hand due to your own “ear pain.” approach antibiotic therapy. against the chair, to keep the child’s feet Most pediatricians in practice can read- hanging off the chair or his or her leg, and TM CHARACTERISTICS OF AOM ily ascertain fullness or bulging of the TM to not be alarmed by the child’s likely re- Fortunately, the 2013 AAP guidelines within a clear ear canal. It is this positive sistance. You should not “box” the ear, but on AOM now emphasize the diagnostic pressure upon the TM that foremost as- rather use the gentle force of your thumb importance of purulent or cloudy middle sures the diagnosis of AOM, even as es- against the pinna and the child’s skull to ear effusion (MEE), along with severe poused by the new AOM guidelines. apply mild upward traction. Novices also redness or new-onset otorrhea. Symptoms Interestingly, the “true” mobility of the tend to force the speculum too far into the plus a non-purulent MEE are no longer TM (a very difficult process for most of us canal, when it often only requires inserting considered evidence for the diagnosis of to determine) or ascertaining the severity of a few millimeters or so. Being gentle but AOM. AOM symptoms in young children otalgia rarely ever changes the diagnosis of firm must be finessed. A minimally trau- “are mostly non-specific, variable, and not AOM, as shown by the data from Shaikh

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A

A B C Images courtesy of Alejandro Hoberman, MD. Figure 6. Obvious diagnostic tympanic membrane (TM) findings regardless of TM mobility and patient symptoms. (A) and (B) Examples of bulging, infected TM. (C) An example of a normal TM.

B

A B C D

C

E F G Images courtesy of Alejandro Hoberman, MD. Figure 7. The subtler and more difficult diagnostic tympanic membrane (TM) findings, regardless of TM mobil- ity or patient symptoms. Each one has an element of middle ear effusion: infected/treatment-worthy or not?

et al.9 Seven U.S. experts in AOM assessed reliable in children aged younger than 6 945 middle ear images; out of all AOM months due to the elasticity and tininess of cases, bulging TM and marked redness the ear canal in this age group. alone was present in 93% and 2%, respec- The simplest and cheapest method is tively. Otherwise, knowing the presence or to use the handheld insufflator shown in absence of TM mobility altered their di- Figure 5A. However, this inexpensive agnosis of AOM in only three of 945 TM auxiliary part also requires much evaluations. Of these three cases, one each bimanual dexterity, as well as the sufficient was changed from AOM to OME (otitis restraint of the child for a period of several media with effusion), one from AOM to “eternal” arduous seconds. This time may D

Images courtesy of Stan L. Block, MD, FAAP. normal, and one from normal to AOM. be better spent in pursuing the accurate Figure 5. (A) Hand-held otoscopic insufflator to Furthermore, knowing the presence or ab- position and color of the TM in the often help determine tympanic membrane (TM) mo- sence of “otalgia” changed the diagnosis of unruly child. Also, if you are not careful, bility when using the otoscope. (B) Tympanom- etry machine for detecting middle ear fluid and OME to AOM in seven (10%) of otalgia this blowing process and “jamming” the mobility by the curve’s appearance, as well as cases, and from AOM to OME in seven speculum into the canal to create a seal can patency of pressure equalization tubes or pres- ence of a TM perforation by the volume reading (0.8%) of non-otalgia cases. be quite uncomfortable for the child, thus of the entire ear canal space versus the entire For those who wish to pursue TM jeopardizing future cooperation with this middle ear. (C) Close-up of the schematic of po- tential readings and their interpretation. A print- mobility, one primary and two ancillary and other simple examinations. out of the TM findings is available. (D). EarCheck instruments are available, as shown in Two other options for the indirect as- device (Innnovia Medical), or spectral gradient acoustic reflectometry, for consumer use. Among Figure 5. Note that each of these instru- sessment of MEE are the use of the tym- other things, the professional, more advanced ments requires a fairly clean ear canal. panometry (Figure 5B) and spectral- EarCheck Pro device (not shown) provides an ad- The latter two are also not likely to be very gradient acoustic reflectometry (SGAR) ditional feature of a printout of the TM findings.

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A B C

D E F Images courtesy of Alejandro Hoberman, MD. Figure 8. The subtler and more difficult diagnostic tympanic membrane (TM) findings, regardless of TM mobility or patient symptoms. Each one has an ele- ment of purulent middle ear effusion: infected/treatment-worthy or not?

(Figure 5C) machines. However, neither The diagnosis of normal TM and bulg- initially presented with significant symp- instrument will differentiate AOM from ing TM is relatively straight-forward, as toms of URI, fever, or fussiness. Over the OME, and the sensitivity for either machine seen in the first three middle ear samples decades, having performed tympanocente- in predicting merely MEE ranges from 80% (Figure 6). However, it is those TMs with sis in numerous similar-appearing, mildly to 90%.9,10 SGAR is cheaper, portable, does more subtle findings, as shown in the re- infected TMs (simultaneous with a contra- not require a seal, and is simpler to use. By mainder of TM photos, that create the di- lateral bulging TM) as those in Figure 8, contrast, is a stand-alone agnostic dilemma for all of us in pediatrics. we nearly always observed the recovery of machine in a separate room and requires a My evaluations for each of these TMs were an identical bacterial pathogen from both canal-to-instrument tip seal. However, it is corroborated by and totally harmonious ears. However, we would also not treat any also considered the only adequate supple- with each of my three astute, highly experi- asymptomatic children in Figures 8C, 8D, mental measure to determine MEE within enced otoscopist general pediatric partners, and 8F if they had recently finished antibi- the 2013 AAP AOM guidelines.1 James Hedrick, MD, Ron Tyler, MD, and otics within the last few weeks. We readily Dan Finn, MD. acknowledge both the common persistence TM Characteristics for AOM In the group of TMs in Figure 7, the TM of some MEE after an episode of AOM and The best way to learn about the defin- photographs in A to E were each consid- the “post-antibiotic effect” or persistent ing characteristics of AOM versus OME ered by us to be definitive cases of OME, low-level antibiotic concentrations after a versus normal is to examine a plethora of and therefore not treated with antibiotics. recent course of antibiotics. Because of the variations on TM findings with oversight Photographs F and G were considered as fullness or mild bulging that we perceived from a qualified mentor. An excellent ini- cases of OME with early superimposed in- in Figures 8A, 8B, and 8E, we would pro- tiation and training CME program for dif- fection due to the “fullness” in F, and the ceed with further antibiotic therapy. Only ferentiation of the TM findings has been notable hyperemia and fullness of the pars one of us thought that the findings on insuf- developed by the otolaryngology experts at flaccida in G. Thus, we would prescribe flation of these particular TMs would pos- the University of Pittsburgh. The website is antibiotics for them. sibly change our mind. located at www.pedsed.pitt.edu under sub- Each of the TMs in Figure 8 was con- With all due respect to the AAP 2013 heading: Enhancing proficiency in otitis sidered to have a purulent air-fluid level guidelines, the concept of “otalgia” and media (eprom). and, therefore, we would treat them, if they “ear tugging” or direct ear pain is much

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too infrequently observed, too vague, criteria for the diagnosis of AOM: posi- 5. Block SL. Management of acute otitis media too non-specific, and too unreliable to tion, opacification, and discoloration. The in afebrile neonates. Pediatr Ann. 2012;41:(6) 225-228. be of much use in the infant or child plethora of subtle variations in TM find- 6. Block SL. Accurately diagnosing acute otitis aged younger than 36 months.12 And far ings when MEE is present will continue media: “dispose of the disposables.” Pediatr too many young children with normal to challenge the diagnostic skills of every Infect Dis J. 1998;17(12):1179-1180. 7. Paradise JL, Hoberman A, Rockette HE, Shai- TMs constantly tug at their ears during otoscopist, as well. kh N. Treating acute otitis media in young chil- any illness. dren: what constitutes success? Pediatr Infect ACKNOWLEDGMENT Dis J. 2013;32(7):745-747 8. Block, SL Diagnosing acute otitis media: CONCLUSION Special thanks to Alejandro Hober- it’s what you see, not what you hear. Post- The diagnosis of AOM continues to man, MD, of the University of Pittsburgh, grad Med. 2005;118(6 Supplement Emerg- remain almost exclusively “what you see, for allowing me to use his magnificent ing);32-33, 5-12. not what you hear.” New, improved 2013 diverse photographs of actual tympanic 9. Shaikh N, Hoberman A, Kaleida PH, et al. Oto- scopic signs of otitis media. Pediatr Infect Dis AAP guidelines for management of AOM membranes. J. 2011;30(10):822-826. have refined the physical diagnostic cri- 10. Laine MK, Tähtinen PA, Helenius KK, Luoto teria for AOM without providing many REFERENCES R, Ruohola A. Acoustic reflectometry in dis- crimination of otoscopic diagnoses in young 1. Lieberthal AS, Carroll AE, Chonmaitree T, et specifics about diagnostic techniques. ambulatory children. Pediatr Infect Dis J. al. The diagnosis and management of acute oti- 2012;31(10):1007-1011. Practitioners need to use the optimal in- tis media. Pediatrics. 2013;131(3):e964-999. 11. Block SL, Pichichero M, McKlinn S, Arono- struments and approaches, particularly 2. Block SL, Harrison C, Hendrick J, et al. Re- vitz G, Kimball S. Spectral-gradient acoustic stricted use of antibiotic prophylaxis for recur- in infants and younger children, when at- reflectometry: detection of middle ear effusion rent acute otitis media in the era of pencillin tempting to differentiate AOM from OME in suppurative acute otitis media. Pediatr Infect non-susceptible Streptococcus pneumonia. Int Dis J. 1999;18(8):741-744. and normal. With all the physical and time J Pedicatr Otorhinolarynol. 2001;61(1):47-60. 12. Laine MK, Tähtinen PA, Ruuskanen O, obstacles, as well as the major difficulties 3. Shaikh N, Hoberman A. Update: acute otitis Huovinen P, Ruohola A.. Symptoms or media. Pediatr Ann. 2010;39(1):28-33. encountered while examining TMs of symptom-based scores cannot predict acute 4. Block S, Harrison CJ. Diagnosis and Manage- otitis media at otitis-prone age. Pediatrics. young children, I recommend a simpli- ment of Acute Otitis Media. Third edition. Cad- 2010;125(5):e1154-1161. fied and quick approach using my three do, OK: Professional Publications, Inc. 2005.

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