Consistency of diagnostic criteria for acute otitis media: a review of the recent literature

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.

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.

A simple scoring system to improve clinical assessment of acute otitis media

OBJECTIVE

To evaluate an easy to use 10-point scoring system in clinical assessment of acute otitis media (AOM). Study design. Symptoms of AOM observed by validated otoscopists were tabulated and scored with a 10-point and a 30-point system at acute onset of illness and at the test-of-cure (TOC) 3 weeks later.

RESULTS

A total of 330 children (mean age = 13.1 months) with AOM were studied. At AOM onset, the mean 10-point and 30-point scores; were highly correlated (P < .001). At TOC, 256 children were cured, 69 failed, and 5 were lost to follow-up. The 10-point scores were 0.5 and 4.4 for children with cure and failure. The 10-point score had a sensitivity of 87%, specificity of 98%, positive predictive value of 91%, and negative predictive value of 97% compared with the diagnosis by validated otoscopists.

CONCLUSION

A simple, easy-to-use 10-point AOM scoring system was shown to discriminate AOM cure and failure at TOC.

Clinical spectrum of acute otitis media complicating upper respiratory tract viral infection

BACKGROUND

acute otitis media (AOM) often occurs as a complication of upper respiratory tract infection (URI).

OBJECTIVE

to describe otoscopic findings during URI, the full clinical spectrum of AOM, and outcome of cases managed with watchful waiting.

METHODS

: In a prospective study of 294 healthy children (6 months-3 years), characteristics of AOM complicating URI were studied. Otoscopic findings were categorized by tympanic membrane (TM) position, color, translucency, and mobility. Otoscopic score was assigned based on McCormick otoscopy scale (OS)-8 scale.

RESULTS

during days 1 to 7 of URI, otoscopic findings at 1114 visits were consistent with AOM in 22%; myringitis (inflamed TM, no fluid) was diagnosed in 7%. In AOM episodes diagnosed within 28 days of URI onset, TM position was described as: nonbulging (19%), mild bulging (45%), bulging (29%), and TM perforation occurred in (6%). OS-8 scale showed mild TM inflammation (OS, 2-3) in 6%, moderate (OS, 4-5) in 59%, and severe (OS, 6-8) in 35%. In 54% of 126 bilateral AOM episodes, inflammation of both TMs was at different stages. Of 28 cases of nonsevere AOM managed with watchful waiting, 4 progressed and 3 later required an antibiotic.

CONCLUSIONS

AOM is a spectrum of infection that may present at various stages, even in the same child with bilateral disease. During URI, otoscopic changes are observed from the first day of onset. Understanding the wide clinical spectrum of AOM is needed to help with future clinical trial design and development of a scoring system to establish treatment criteria that will minimize antibiotic use.

Serum intercellular adhesion molecule 1 variations in young children with acute otitis media

Acute otitis media (AOM) is an inflammatory reaction in the middle ear, most often occurring in young children. Streptococcus pneumoniae, nontypeable Haemophilus influenzae, and Moraxella catarrhalis are the most common bacteria isolated. Intercellular adhesion molecule 1 (ICAM-1) is involved in the innate immune response to infection by microorganisms, in effective antigen presentation, and in subsequent T-cell activation. Here we prospectively studied levels of serum soluble ICAM-1 (sICAM-1) before, at the time of, and after antimicrobial treatment of AOM in a group of 138 children ages 6 to 30 months. Middle ear fluids were collected by tympanocentesis to identify otopathogens. We found that (i) serum levels of sICAM-1 were significantly higher in S. pneumoniae-, nontypeable H. influenzae-, and M. catarrhalis-infected children than in well children (P < 0.001), confirming that a systemic inflammatory response occurs during AOM; (ii) sICAM-1 levels varied from no elevation (110 ng/ml) to elevation to high levels (maximum, 1,470 ng/ml) among children with AOM; (iii) in paired samples, sICAM-1 levels increased 4- to 20-fold when children developed AOM compared to their sICAM-1 levels before infection; and (iv) the level of sICAM-1 returned to the pre-AOM level at the convalescent stage of AOM after successful antimicrobial therapy. We conclude that AOM often causes a systemic inflammatory reaction, as measured by elevation of the serum sICAM-1 level, and that a high variability in sICAM-1 responses occurs with the presence of otopathogens during AOM.

Diagnostic inaccuracy and subject exclusions render placebo and observational studies of acute otitis media inconclusive

BACKGROUND

Diagnostic accuracy and appropriate inclusion/exclusion criteria representative of children at greatest risk is of paramount importance in trials to evaluate placebo or observation as an option for acute otitis media (AOM) management.

METHODS

Twelve observational studies spanning the time frame 1958-2005 and 13 natural history studies spanning the time frame 1968-2006 were evaluated for the diagnostic criteria, inclusion criteria, and exclusion criteria applied within the study design.

RESULTS

Although a bulging or full tympanic membrane (TM) with effusion is the best indication of a diagnosis of bacterial AOM based on tympanocentesis findings, few observational and natural history studies required a bulging TM. Examination of subject inclusion criteria showed that many subjects did not have AOM but rather had no middle ear disease at all or they had otitis media with effusion. Exclusion criteria of subjects were also remarkable. Frequently children <2 years old were excluded; mean age among the studies reflected an older age group, unlike the true epidemiology of AOM. Otitis prone children, those with severe disease, with a bulging TM, with fever, with a definite need for antibiotics, with recent antibiotic treatment, with recent AOM, or with perforation of the TM were often excluded.

CONCLUSIONS

Guidelines and some authorities have overlooked or discounted the importance of the issues of inaccurate diagnosis on study entry, broad inclusion criteria, and the creation of bias in exclusion criteria among placebo/natural history trials in AOM. The current data favoring observation of children with AOM should be reconsidered until better studies are conducted.

Laterality of acute otitis media: different clinical and microbiologic characteristics

BACKGROUND

A large individual patient data meta-analysis recently showed that children aged less than 2 years with bilateral, as compared with unilateral, acute otitis media (AOM) were at higher risk for persistent symptoms without antibiotic treatment. Prior studies have shown a propensity for children with bilateral AOM to be infected with bacterial pathogens, specifically Haemophilus influenzae. The objectives of this study were to further characterize risk factors for bilateral AOM and to assess the propensity for specific viral and bacterial pathogens to predispose to bilateral versus unilateral AOM.

METHODS

We performed a secondary data analysis on 1216 cases of AOM diagnosed and treated at our institution: 566 subjects underwent tympanocentesis and middle ear fluid (MEF) culture. We compared subjects with bilateral and unilateral AOM for demographic characteristics, clinical findings, parent/clinician perception of AOM severity, and MEF study results for bacteria and viruses.

RESULTS

When compared with children who have unilateral AOM, children with bilateral AOM were more likely to be younger (P < 0.001), have H. influenzae isolated from one or both MEFs (P < 0.0001), and have more severe inflammation of the tympanic membrane on otoscopic examination (P < 0.0001).

CONCLUSION

Compared with children who have unilateral AOM, children with bilateral AOM are more likely to have bacteria in the MEF and have more severe inflammation of the tympanic membrane. This may help explain why children with bilateral AOM are more likely to experience persistent symptoms without antibiotic treatment. Laterality of AOM should be considered when discussing treatment options with parents.

Diagnosis and Treatment of Acute Otitis Media: Evaluating the Evidence

Acute otitis media (AOM) is one of the most common illnesses for which children in the United States receive an antimicrobial agent. Of the six recommendations offered in recent guidelines for treatment of AOM, only one, the assessment and treatment of pain with analgesics, is based on strong evidence. This article reviews the diagnosis of AOM and the accuracy of various signs and symptoms in indicating a bacterial origin, the data on the effect of antimicrobial agents compared with placebo in the treatment of AOM, and the gaps in knowledge that should be addressed by future research and clinical trials.