Tympanometry by nurses--can allocation of tasks be optimised?

An open randomised study of autoinflation in 4- to 11-year-old school children with otitis media with effusion in primary care

BACKGROUND

Otitis media with effusion (OME) is a very common problem in primary care, but one that lacks an evidence-based non-surgical treatment.

OBJECTIVE

To determine the clinical effectiveness of nasal balloon autoinflation for the treatment of OME in children.

DESIGN

A pragmatic, two-arm, open randomised controlled trial.

SETTING

Forty-three general practices from 17 UK primary care trusts recruited between January 2012 and February 2013.

PARTICIPANTS

School children aged 4-11 years with a history of OME symptoms or related concerns in the previous 3 months, and a type B tympanogram, diagnostic of a middle ear effusion, in one or both ears.

INTERVENTION

Three hundred and twenty children were randomised, 160 to each group, using independent web-based computer-generated randomisation (with minimisation based on age, sex and baseline severity of OME) to either nasal balloon autoinflation performed three times per day for 1-3 months plus usual care, or usual care alone.

MAIN OUTCOME MEASURES

The proportion of children demonstrating clearance of middle ear fluid in at least one ear (with normal tympanograms) at 1 and 3 months, assessed blind to treatment. An ear-related measure of quality of life (QoL) [a 14-point questionnaire on the impact of OME (OMQ-14)], weekly diary recorded symptoms, compliance and adverse events were all secondary outcomes.

RESULTS

At 1 month, the proportion of children with normal tympanograms was 47.3% (62/131) in those allocated to autoinflation and 35.6% (47/132) in those receiving usual care [adjusted relative risk (RR) 1.36, 95% confidence interval (CI) 0.99 to 1.88]. At 3 months, the proportions were 49.6% (62/125) and 38.3% (46/120), respectively (adjusted RR 1.37, 95% CI 1.03 to 1.83; number needed to treat = 9). The change in OMQ-14 also favoured the intervention arm (adjusted global score difference -0.42; p = 0.001). Reported compliance was good: 89% in the first month and 80% in months 2 and 3. Adverse events included otalgia in 4% of treated children compared with 1% in the control group. Minor nosebleeds (14% vs. 15%) and respiratory tract infections (18% vs. 13%) were noted.

CONCLUSION

We found the use of autoinflation in young children with OME to be feasible in primary care and effective in both clearing effusions and improving child and parent ear-related QoL and symptoms. This method has scope to be used more widely. Further research is needed for very young children, and to inform prudent use in different health settings.

Can nurses exclude middle-ear effusion without otoscopy in young asymptomatic children in primary care?

OBJECTIVE

Scandinavian guidelines recommend controlling middle-ear effusion (MEE) after acute otitis media. The study aim was to determine whether nurses without otoscopic experience can reliably exclude MEE with tympanometry or spectral gradient acoustic reflectometry (SG-AR) at asymptomatic visits.

DESIGN

Three nurses were taught to perform examinations with tympanometry and SG-AR. Pneumatic otoscopy by the study physician served as the diagnostic standard.

SETTING

Study clinic at primary health care level.

PATIENTS

A total of 156 children aged 6-35 months.

MAIN OUTCOME MEASURES

Predictive values (with 95% confidence interval) for tympanometry and SG-AR, and the clinical usefulness, i.e. the proportion of visits where nurses obtained the exclusive test result from both ears of the child.

RESULTS

At 196 visits, the negative predictive value of type A and C1 tympanograms (tympanometric peak pressure > -200 daPa) was 95% (91-97%). Based on type A and C1 tympanograms, the nurse could exclude MEE at 81/196 (41%) of visits. The negative predictive value of SG-AR level 1 result was 86% (79-91%). Based on SG-AR level 1 results, the nurse could exclude MEE at 29/196 (15%) of visits.

CONCLUSION

Tympanograms with tympanometric peak pressure > -200 daPa (types A and C1) obtained by nurses are reliable test results in excluding MEE. However, these test results were obtained at less than half of the asymptomatic visits and, thus, the usefulness of excluding MEE by nurses depends on the clinical setting.

Can trained nurses exclude acute otitis media with tympanometry or acoustic reflectometry in symptomatic children?

OBJECTIVE

Since acute otitis media (AOM) is the most prevalent bacterial infection in young children, the reliable exclusion of AOM by nurses might save physicians' time for other duties. The study aim was to determine whether nurses without otoscopic experience can reliably use tympanometry or spectral gradient acoustic reflectometry (SG-AR) to exclude AOM.

DESIGN

Three nurses were trained, who performed examinations with tympanometry and SG-AR. Pneumatic otoscopy by the study physician served as the diagnostic standard.

SETTING

Study clinic at primary health care level.

PATIENTS

281 children 6-35 months of age.

MAIN OUTCOME MEASURES

Predictive values (with 95% confidence interval) for tympanometry and SG-AR, and the clinical usefulness, i.e. the proportion of visits where nurses obtained the exclusive test result from both ears of the child.

RESULTS

At 459 visits, the negative predictive value of type A and C1 tympanograms (tympanometric peak pressure >-200 daPa) was 94% (91-97%). Based on type A and C1 tympanograms, the nurse could exclude AOM at 94/459 (20%) of visits. The negative predictive value of SG-AR level 1 result (>95°) was 94% (89-97%). Based on the SG-AR level 1 result, the nurse could exclude AOM at 36/459 (8%) of visits.

CONCLUSION

Type A and C1 tympanograms and SG-AR level 1 results obtained by nurses are reliable test results in excluding AOM. However, the clinical usefulness of these test results is limited by their rarity. Type A and C1 tympanograms were obtained by nurses from both ears of the child only at one-fifth of the symptomatic visits. Key Points Acute otitis media (AOM) is the most prevalent bacterial infection in young children. Nurses' role in excluding AOM is unknown. Type A and C1 tympanograms (tympanometric peak pressure >-200 daPa) obtained by nurses are reliable test results in excluding AOM. With type A and C1 tympanograms, nurses could exclude AOM only at one-fifth of the symptomatic visits. The clinical usefulness of the exclusion of AOM performed by nurses seems to be limited.

Tympanometry in general practice: use, problems and solutions

OBJECTIVES

The diagnosis in children with middle ear symptoms is often difficult. Tympanometry is recommended as a supplementary diagnostic tool with a high predictive value for fluid or no fluid in the middle ear. The aim of this study was to examine how tympanometry was used in Danish general practice in 2009, to report common problems general practitioners (GPs) and GP nurses encounter in tympanometry and to evaluate the effect of a practical and theoretical course.

METHODS

A 1-year registration of the use of tympanometry in the Danish National Health Service Register in two regions with 40% of all Danish GPs and a survey among 197 participants in a course on diagnosis of otitis media and tympanometry in children were used. The Danish National Health Insurance covers 100% of GPs because they administer reimbursement for their activities, including tympanometry.

RESULTS

During the year 2009, 1433 GPs in 702 clinics were on the list. A total of 417 clinics performed 35 529 tympanometries. Some 285 clinics (40.6%) did not perform tympanometry in 2009. The active clinics performed 42 tympanometries per GP. A 1-day course improved the knowledge and practical skills of the participating GPs and nurses. A majority (70%) stated in a self-reported questionnaire that tympanometry often provided important information, especially about middle ear fluid, and 48% reported that tympanometry several times during the past 2 weeks had changed their management of a middle ear problem. Few had not used their tympanometer during the 2 weeks preceding the survey. The response rate was 72%.

CONCLUSIONS

The use of tympanometry is very skewed. A 6-hour course could improve GPs' care of patients with middle ear problems by using tympanometry.