Diagnosis of Middle Ear Disease using Tympanograms and Digital Imaging

The reliability of video otoscopy recordings and still images in the asynchronous diagnosis of middle-ear disease

OBJECTIVE

To compare the asynchronous assessment of video otoscopic still images to recordings by an audiologist and ear, nose and throat surgeon (ENT) for diagnostic reliability and agreement in identifying middle-ear disease.

DESIGN

A prospective cross-sectional study, asynchronously assessing video otoscopy, tympanometry and case history (Dx1). A subset was re-diagnosed (Dx2).

STUDY SAMPLE

Video otoscopy and data from 146 children recruited at two public community events; a sub-set of 47 were re-assessed.

RESULTS

The intra-rater diagnostic agreement between Dx1 and Dx2 was moderate (k = 0.445-0.552) for the ENT surgeon, and almost-perfect (k = 0.928) for the audiologist, in both procedures. The agreement between the two procedures was substantial (k = 0.624) and moderate (k = 0.416) for the ENT surgeon in Dx1 and Dx2 respectively, and almost-perfect for the audiologist (k = 0.854-0.978) in both rounds. In Dx1, the inter-rater agreement between the clinicians was substantial using still images (k = 0.672) and moderate using recordings (k = 0.593); in Dx2 it was moderate using both procedures (k = 0.477-0.488).

CONCLUSION

Both video otoscopic procedures, in addition to tympanometry and case history information, can be reliably used for asynchronous diagnosis of childhood middle-ear disease. An audiologist has a potential role in triaging children with middle-ear abnormalities and, therefore, improving access to ear-health services.

Clinician-rated quality of video otoscopy recordings and still images for the asynchronous assessment of middle-ear disease

INTRODUCTION

Video otoscopy plays an important role in improving access to ear health services. This study investigated the clinician-rated quality of video otoscopy recordings and still images, and compared their suitability for asynchronous diagnosis of middle-ear disease.

METHODS

Two hundred and eighty video otoscopy image-recording pairs were collected from 150 children (aged six months to 15 years) by an ear, nose, and throat (ENT) specialist, audiologists, and trained research assistants, and independently rated by an audiologist and ENT surgeon. On a five-point scale, clinicians rated the cerumen amount, field of view, quality, focus, light, and gave an overall rating, and asked whether they could make an accurate diagnosis for both still images and recordings.

RESULTS

More video otoscopy recordings were rated as 'good' or 'excellent' compared to still images across all domains. The mean difference between the two otoscopic procedures ratings was significant across almost all domains (p < 0.05), except 'cerumen amount'. The suitability to make a diagnosis significantly improved when using recordings (p<0.05). Younger participant age was found to have a significant, negative impact on the ratings across all domains (p < 0.03). The role of the tester conducting video otoscopy did not have a significant impact on the ratings.

DISCUSSION

Video otoscopy recordings were found to provide clearer views of the tympanic membrane and increase the ability to make diagnoses, compared to still images, for both audiologists and ENT surgeons. Research assistants with limited practice were able to obtain video otoscopy images and recordings that were comparable to the ones obtained by clinicians.

Telemedicine in Audiology. Best practice recommendations from the French Society of Audiology (SFA) and the French Society of Otorhinolaryngology-Head and Neck Surgery (SFORL)

Objectives

Access to diagnosis and treatments for auditory disorders and related pathologies has regressed in France during the COVID-19 pandemic, posing a risk to the patient's chance of recovery. This best practice recommendations guide aims to list the existing technological solutions for the remote examination of a patient with hearing complaint, and to outline their benefits and, where applicable, their limitations.

Methods

The recommendations were developed both from the clinical experience of the medical experts who drafted the guide, and from an extensive review of the literature dealing with clinical practice recommendations for tele-audiology. Tele-audiometry solutions were identified on the basis of a search engine query carried out in April 2020, prior to verification of their availability on the European market.

Results

Video otoscopy solutions allow for the teletransmission of images compatible with a high-quality diagnosis, either by connecting via internet to a tele-health platform or using a smartphone or a tablet with an iOS or Android operating system. Using the same telecommunication methods, it is possible to remotely conduct a pure-tone audiometry test in accordance with standard practice, a speech-in-quiet or a speech-in-noise audiometry test, as well as objective measures of hearing. Clinical and paraclinical examinations can be accessed by the physician to be interpreted on a deferred basis (asynchronous tele-audiology). Examinations can also be conducted in real time in a patient, at any age of life, as long as a caregiver can be present during the installation of the transducers or the acoumetry. Tele-audiology solutions also find application in the remote training of future healthcare professionals involved in the management of deafness and hearing impairment.

Conclusion

Under French law, tele-otoscopy is a medical procedure that is either a tele-expertise (asynchronous adive) or a teleconsultation act (synchronous advice). Subjective and objective evaluation of the patient's hearing functions can be done remotely provided that the listed precautions are respected.

Cytomegalovirus infection during pregnancy: state of the science

Cytomegalovirus is the most common congenital infection, affecting 0.5-2% of all live births and the main nongenetic cause of congenital sensorineural hearing loss and neurological damage. Congenital cytomegalovirus can follow maternal primary infection or nonprimary infection. Sensorineurological morbidity is confined to the first trimester with up to 40-50% of infected neonates developing sequelae after first-trimester primary infection. Serological testing before 14 weeks is critical to identify primary infection within 3 months around conception but is not informative in women already immune before pregnancy. In Europe and the United States, primary infection in the first trimester are mainly seen in young parous women with a previous child younger than 3 years. Congenital cytomegalovirus should be evoked on prenatal ultrasound when the fetus is small for gestation and shows echogenic bowel, effusions, or any cerebral anomaly. Although the sensitivity of routine ultrasound in predicting neonatal symptoms is around 25%, serial targeted ultrasound and magnetic resonance imaging of known infected fetuses show greater than 95% sensitivity for brain anomalies. Fetal diagnosis is done by amniocentesis from 17 weeks. Prevention consists of both parents avoiding contact with body fluids from infected individuals, especially toddlers, from before conception until 14 weeks. Candidate vaccines failed to provide more than 75% protection for >2 years in preventing cytomegalovirus infection. Medical therapies such as cytomegalovirus hyperimmune globulins aim to reduce the risk of vertical transmission but 2 randomized controlled trials have not found any benefit. Valaciclovir given from the diagnosis of primary infection up to amniocentesis decreased vertical transmission rates from 29.8% to 11.1% in the treatment group in a randomized controlled trial of 90 pregnant women. In a phase II open-label trial, oral valaciclovir (8 g/d) given to pregnant women with a mildly symptomatic fetus was associated with a higher chance of delivering an asymptomatic neonate (82%), compared with an untreated historical cohort (43%). Valganciclovir given to symptomatic neonates is likely to improve hearing and neurological symptoms, the extent of which and the duration of treatment are still debated. In conclusion, congenital cytomegalovirus infection is a public health challenge. In view of recent knowledge on diagnosis and pre- and postnatal management, health care providers should reevaluate screening programs in early pregnancy and at birth.

The use of telehealth services to facilitate audiological management for children: A scoping review and content analysis

Approximately 32 million children globally present with disabling hearing loss. Despite evidence describing the negative consequences of hearing loss, there is still a lack of hearing screening programmes in South Africa. Audiologists have been exploring the use of information and communication technologies (tele-audiology) to provide services to children and it is currently being evaluated to determine its feasibility.

Aims

We aim to describe tele-audiology services conducted to facilitate audiological management for children in both the rural and urban context and to determine the strengths, challenges and clinical implications of such services.

Methods

A scoping review was conducted by searching for peer-reviewed publications from five databases. Inclusion criteria and search strategies were outlined.

Results

Of the 23 studies that met the inclusion criteria, reliability of automated testing was comparable to conventional testing; however, these studies were based primarily on screening programmes. Eight (35%) of the 23 papers were concordance studies evaluating feasibility and validity of tele-audiology systems when compared with conventional testing, while one study (4%) evaluated a tele-audiology service. A further four studies (17%) evaluated the feasibility of introducing telehealth methods to evaluate middle ear pathology. Tele-auditory brainstem response was investigated in three studies (13%) and another five (22%) used smartphone and/or iPad technology to screen hearing. Only two studies (9%) evaluated the feasibility of providing intervention through telehealth methods. All included studies demonstrated improved access to and coverage of rural areas. Services such as video otoscopy and synchronous (online) hearing testing in remote areas were successfully implemented. Challenges included lack of diagnostic studies, inadequate training of staff and the need to standardize protocols and procedures in order to ensure that tele-audiology services are provided in a standardized and valid manner.

Conclusion

Tele-audiology services are feasible and can be useful in identifying auditory pathology for children in rural and remote areas.

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.

Video-otoscopy recordings for diagnosis of childhood ear disease using telehealth at primary health care level

We studied the diagnoses made by an otologist and general practitioner (GP) from video-otoscopy recordings on children made by a telehealth facilitator. The gold standard was otomicroscopy by an experienced otologist. A total of 140 children (mean age 6.4 years; 44% female) were recruited from a primary health care clinic. Otomicroscopic examination was performed by an otologist. Video-otoscopy recordings were assigned random numbers and stored on a server. Four and eight weeks later, an otologist and a GP independently graded and made a diagnosis from each video recording. The otologist rated the quality of the video-otoscopy recordings as acceptable or better in 87% of cases. A diagnosis could not be made from the video-otoscopy recordings in 18% of ears in which successful onsite otomicroscopy was conducted. There was substantial agreement between diagnoses made from video-otoscopy recordings and those from onsite otomicroscopy (first review: otologist κ = 0.70 and GP κ = 0.68; second review: otologist κ = 0.74 and GP κ = 0.75). There was also substantial inter-rater agreement (κ = 0.74 and 0.74 at the two reviews) and intra-rater agreement (κ = 0.77 and 0.74 for otologist and GP, respectively). A telehealth facilitator, with limited training, can acquire video-otoscopy recordings in children for asynchronous diagnosis. Remote diagnosis was similar to face-to-face diagnosis in inter- and intra-rater variability.

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.

Digital imaging and telemedicine as a tool for studying inflammatory conditions in the middle ear--evaluation of image quality and agreement between examiners

OBJECTIVE

To evaluate digital imaging of the tympanic membrane by telemedicine technology and study interpersonal agreement in assessing image quality.

METHODS

In an open consecutive study, 64 children aged 2-16 years who attended three rural health care centres in Northern Sweden with otalgia were examined with video endoscopic photography of their tympanic membrane in a telemedical environment. One hundred and twenty-four images were stored in a central database and later assessed independently regarding image quality by an ENT specialist, a general practitioner and a registrar in general practice. The overall image quality was graded (0-2) regarding assessment of signs of tympanic membrane inflammation. All images were also assessed regarding 8 different components, four image-related components and four anatomically related components.

RESULTS

Overall image quality was good, with 82.3% of acceptable or excellent quality. The position and thickness of the TM were found to be the most important factors of the images to be able to assess inflammatory disease. Image quality tended to be higher later in the study as a sign of improved skills of examiners. Interpersonal agreement between examiners was acceptable. Overall grade showed kappa 0.56, 0.49 and 0.66 respectively, and focus, light and existence of obscuring objects were the components with the highest agreement.

CONCLUSIONS

The image quality of video endoscopy of the tympanic membrane was good overall. Interpersonal agreement in evaluating image quality was acceptable but not excellent. The use of digital imaging of good quality in clinical studies can offer an objective clinical evaluation of the TM in retrospect by independent reviewers using strict criteria.

Otomicroscopic findings and systemic interleukin-6 levels in relation to etiologic agent during experimental acute otitis media

The aim of the present study was to explore whether it was possible to differentiate the clinical course and the otomicroscopic appearance of acute otitis media (AOM) caused by common otitis pathogens in an animal model. Systemic interleukin (IL)-6 levels as early markers for bacterial AOM were also studied. Four groups of rats were inoculated with either Streptococcus pneumoniae, Streptococcus pyogenes, non-typeable Haemophilus influenzae or Moraxella catarrhalis. The animals were monitored by otomicroscopy, photos of the tympanic membrane, cultures and IL-6 detection in serum the following 4 days. The gram-positive S. pneumoniae and S. pyogenes induced severe AOM with opaque effusion behind the tympanic membrane, pronounced dilation of the vessels and spontaneous perforations. The gram-negative H. influenzae and M. catarrhalis induced a less severe infection with cloudy, sometimes foamy effusion, and no spontaneous perforations. With the otomicroscopic findings it was possible to distinguish between infections induced by gram-positive bacteria and gram-negative bacteria. Detection of interleukin-6 in serum appeared to be of limited use for all infections except the pneumococcal AOM, but this needs to be further investigated.