Otitis media

Otitis media (OM) or middle ear inflammation is a spectrum of diseases, including acute otitis media (AOM), otitis media with effusion (OME; 'glue ear') and chronic suppurative otitis media (CSOM). OM is among the most common diseases in young children worldwide. Although OM may resolve spontaneously without complications, it can be associated with hearing loss and life-long sequelae. In developing countries, CSOM is a leading cause of hearing loss. OM can be of bacterial or viral origin; during 'colds', viruses can ascend through the Eustachian tube to the middle ear and pave the way for bacterial otopathogens that reside in the nasopharynx. Diagnosis depends on typical signs and symptoms, such as acute ear pain and bulging of the tympanic membrane (eardrum) for AOM and hearing loss for OME; diagnostic modalities include (pneumatic) otoscopy, tympanometry and audiometry. Symptomatic management of ear pain and fever is the mainstay of AOM treatment, reserving antibiotics for children with severe, persistent or recurrent infections. Management of OME largely consists of watchful waiting, with ventilation (tympanostomy) tubes primarily for children with chronic effusions and hearing loss, developmental delays or learning difficulties. The role of hearing aids to alleviate symptoms of hearing loss in the management of OME needs further study. Insertion of ventilation tubes and adenoidectomy are common operations for recurrent AOM to prevent recurrences, but their effectiveness is still debated. Despite reports of a decline in the incidence of OM over the past decade, attributed to the implementation of clinical guidelines that promote accurate diagnosis and judicious use of antibiotics and to pneumococcal conjugate vaccination, OM continues to be a leading cause for medical consultation, antibiotic prescription and surgery in high-income countries.

Comparison of performance by otolaryngologists, pediatricians, and general practioners on an otoendoscopic diagnostic video examination

OBJECTIVE

To compare the performance of United States, South African, and Greek otolaryngologists, pediatricians, and general practitioners in recognizing the otoscopic examination findings of acute otitis media (AOM) and otitis media with effusion (OME) as presented in an otoendoscopic video evaluation test.

DESIGN/SUBJECTS

Otolaryngologists, pediatricians, and general practitioners from the United States (n = 273, 2190, and 360 respectively), South Africa (n = 36, 36, and 206), and Greece (n = 58, 115, and 126) viewed nine different video-recorded otoscopic examinations, including pneumatic otoscopy of tympanic membranes. The ability to differentiate AOM, OME, and normal was ascertained.

RESULTS

Overall, the average +/- standard deviation correct diagnosis on the otoscopic video exam by otolaryngologists was superior to pediatricians and general practitioners in all three countries: from the United States, it was 74 +/- 16% for otolaryngologists versus 51 +/- 11% for pediatricians (p < 0.000l) and 46+/-21% for general practitioners (p < 0.0001); from South Africa, it was 72 +/- 16% versus 53 +/- 21% (p = 0.16) and 47 +/- 19% (p = 0.002); and from Greece, it was 61 +/- 15% versus 36 +/- 12% (p < 0.003) and 39 +/- 10% (p = 0.009).

CONCLUSIONS

A video-based otoscopy examination test may be a useful tool for evaluation of otoscopy-based diagnostic skills. Otolaryngologists performed significantly better than pediatricians in differentiating AOM, OME, and normal in such a test described here. However, all specialists who examine patients with AOM or OME may benefit from viewing video otoscopies to improve diagnostic accuracy.

Diagnosis and treatment of otitis media in dogs and cats

Otitis externa/media is commonly found in dogs with chronic ear diseases and in cats with upper respiratory disease and polyps. Diagnosis of otitis media requires attention to history and clinical signs, but it also requires other methods of determining disease within the bulla. If the integrity of the eardrum cannot be determined, assume that there is middle ear disease and proceed accordingly. It is prudent to take necessary precautions to avoid the use of potentially ototoxic ear cleaners or topical medications in suspected otitis media cases. Therapeutic success is possible using systemic and topical treatment within the cleaned bulla. Referral to a dermatology specialist or a radiologist for a CT scan may be indicated in some refractory cases. Surgical intervention may be required to cure these difficult cases.

Isolated malleus neck fracture

Isolated fracture of the malleus seems to be an extremely rare ossicular injury. All previously reported cases involved the handle of the malleus. This is the first reported case of fracture of the neck of the malleus. The diagnosis can easily be missed because the tympanic membrane remains intact. Furthermore, the history may not be suggestive. Surgical repair is particularly difficult.

The Use of Tympanometry and Pneumatic Otoscopy for Predicting Middle Ear Disease

Purpose: Otitis media is the most common condition diagnosed by pediatricians and is estimated to affect approximately 70% of the pediatric population. The goal of this study was to evaluate the effectiveness of otoscopy and multifrequency tympanometry (MFT) for diagnosis of otitis media in children.

Method: Twenty-one children, age 1 to 10 years, who were seeking medical treatment for suspected middle ear disease were selected to participate. Data were collected prior to myringotomy to determine the sensitivity and specificity rates of the following otologic and audiologic measures: (a) pneumatic otoscopy, (b) conventional tympanometry, and (c) MFT. For this study, the "gold standard," myringotomy, was used along with pneumatic otoscopy to determine the effectiveness, sensitivity, and specificity of conventional 226-Hz tympanometry, 678-Hz tympanometry, and 1000-Hz tympanometry to predict middle ear disease.

Results: The diagnoses provided with pneumatic otoscopy and tympanometry were both similar, agreeing in diagnosis 80%–100% of the time. The diagnoses from 678-Hz and 1000-Hz tympanometry were nearly equal and proved to detect abnormality at a higher rate.

Conclusions: MFT is recommended on a routine basis with children having a history of otitis media, or else abnormal or notched 226-Hz tympanograms. Further research with a larger sample size will illuminate the possible predictive potential of MFT in otitis media.

How helpful is pneumatic otoscopy in improving diagnostic accuracy?

BACKGROUND

Pneumatic otoscopy is believed to be helpful in optimally assessing the presence or absence of middle ear effusion (MEE). Although expert clinicians teach the importance of this diagnostic skill to trainees, evidence exists that many pediatric providers do not typically perform pneumatic otoscopy.

OBJECTIVE

To determine if the otoscopic accuracy within a group of clinicians improves with the pneumatic assessment when compared with the static assessment using videotaped otoendoscopic examinations (VOEs).

METHODS

Residents and faculty from 2 pediatric training programs served as subjects. All viewed a set of 50 video otoscopic examinations of tympanic membranes (TMs) from a validated VOE developed previously for training purposes. The video displays each TM in a static presentation and then in a pneumatic (mobile) presentation, followed by a final static presentation. Each subject first viewed the initial static presentation of each TM and responded "yes/no" to the presence of MEE, and then viewed the pneumatic presentation of the same TM and again responded "yes/no" to the presence of MEE. We compared the accuracy of assessment for both the static and the pneumatic tests.

RESULTS

Thirty-four pediatric residents and 6 clinical faculty participated. Accuracy (percent of total test items correct) on the pneumatic test was uniformly greater than accuracy on the static test. The mean absolute improvement in the accuracy from the static test (61%) to the pneumatic test (76%) was 15% (95% confidence interval [CI] = 12%-18%). The mean relative improvement in accuracy from the static test to the pneumatic test was 26% (95% CI = 19%-32%). Higher accuracy on the VOE was associated with greater absolute (r = 0.57) and greater relative (r = 0.47) improvement. The mean relative improvement in sensitivity and specificity from static viewing to pneumatic viewing was 24% (95% CI = 15%-33%) and 42% (95% CI = 27%-58%), respectively.

CONCLUSIONS

Using a video otoendoscopic test, we found that accurate identification of both the presence and the absence of MEE improved after pneumatic assessment of TM mobility. Providers who were more accurate at otoscopy, defined by higher video total test scores, benefited more from the pneumatic component than providers with lower scores.

Endoscopic transcanal stapedotomy: how I do it

Current paper presents a surgical technique and preliminary results of the first eight consecutive fully endoscopic transcanal stapedotomies. All eight procedures were performed under local anesthesia by the same surgeon using rigid endoscopes of 3-mm diameter, 14-cm length, 0° and 30°. A posterior tympanomeatal flap was elevated transmeatally with the 0° endoscope and then transposed anteriorly. Stapes fixation was confirmed, the stapes tendon was cut with curved micro-scissors, and the stapes was separated from the incus in the incudo-stapedial joint. The anterior and posterior stapedial crus were carefully fractured, and the superstructure was removed. The hole in the foot-plate was created with a Skeeter microdrill using a 0.5-mm-diameter diamond burr. A platinum/fluoroplastic piston prosthesis (0.4-mm diameter) was placed into this hole and fitted along the long process of the incus. The tympano-meatal flap was repositioned, and the external auditory canal was filled with Gelfoam(®). The chorda tympani nerve was preserved in all cases. A 4.5-mm prosthesis was used in six cases and a 4.75-mm prosthesis in two. Pure tone audiograms demonstrated improved air- and bone-conduction threshold averages across the three speech frequencies (0.5-1.2 kHz) 6 months after surgery (64 vs. 29.8 dB and 30.6 vs. 25.1 dB, respectively). The average postoperative air-bone gap was within 10 dB in six ears and between 10 and 15 dB in the other two ears. Our preliminary results indicate that transcanal fully endoscopic stapedotomy is a feasible and safe technique for surgical management of hearing loss associated with otosclerosis.

Otoscopic evaluation of the ear canal

Otoscopic evaluation of the external ear canal and tympanic membrane is the first diagnostic procedure that should be performed in animals presented with otitis externa. It is important to become familiar with the normal structures of the ear to identify any abnormalities. The video otoscope greatly enhances visualization of these structures as well as aiding in retrieval of foreign bodies, biopsy of masses, and performance of a myringotomy. In some cases, a complete otoscopic examination is not possible on the first visit, and the animal may require anti-inflammatory medications or otic flushing to visualize the entire ear canal as well as the tympanic membrane. The purpose of the otoscopic examination is to address the otitis by evaluating the condition of the ear, looking for any masses or foreign bodies; noting the presence, consistency, and color of any exudate; and evaluating the patency of the tympanic membrane. Once a complete otic evaluation has been performed, additional diagnostics as well as a treatment plan can be formulated.

Absent otoacoustic emissions predict otitis media in young Aboriginal children: a birth cohort study in Aboriginal and non-Aboriginal children in an arid zone of Western Australia

BACKGROUND

Otitis media (OM) is the most common paediatric illness for which antibiotics are prescribed. In Australian Aboriginal children OM is frequently asymptomatic and starts at a younger age, is more common and more likely to result in hearing loss than in non-Aboriginal children. Absent transient evoked otoacoustic emissions (TEOAEs) may predict subsequent risk of OM.

METHODS

100 Aboriginal and 180 non-Aboriginal children in a semi-arid zone of Western Australia were followed regularly from birth to age 2 years. Tympanometry was conducted at routine field follow-up from age 3 months. Routine clinical examination by an ENT specialist was to be done 3 times and hearing assessment by an audiologist twice. TEOAEs were measured at ages <1 and 1-2 months. Cox proportional hazards model was used to investigate the association between absent TEOAEs and subsequent risk of OM.

RESULTS

At routine ENT specialist clinics, OM was detected in 55% of 184 examinations in Aboriginal children and 26% of 392 examinations in non-Aboriginal children; peak prevalence was 72% at age 5-9 months in Aboriginal children and 40% at 10-14 months in non-Aboriginal children. Moderate-severe hearing loss was present in 32% of 47 Aboriginal children and 7% of 120 non-Aboriginal children aged 12 months or more. TEOAE responses were present in 90% (46/51) of Aboriginal children and 99% (120/121) of non-Aboriginal children aged <1 month and in 62% (21/34) and 93% (108/116), respectively, in Aboriginal and non-Aboriginal children at age 1-2 months. Aboriginal children who failed TEOAE at age 1-2 months were 2.6 times more likely to develop OM subsequently than those who passed. Overall prevalence of type B tympanograms at field follow-up was 50% (n = 78) in Aboriginal children and 20% (n = 95) in non-Aboriginal children.

CONCLUSION

The burden of middle ear disease is high in all children, but particularly in Aboriginal children, one-third of whom suffer from moderate-severe hearing loss. In view of the frequently silent nature of OM, every opportunity must be taken to screen for OM. Measurement of TEOAEs at age 1-2 months to identify children at risk of developing OM should be evaluated in a routine health service setting.

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.

In vivo detection of nanometer-scale structural changes of the human tympanic membrane in otitis media

Otitis media (OM) is a common ear infection and a leading cause of conductive hearing loss in the pediatric population. Current technologies such as otoscopy, pneumatic otoscopy, tympanometry, and acoustic reflectometry are used to diagnose OM, which can reasonably diagnose the infection with a sensitivity and specificity of 50-90% and 60-90%, respectively. However, these techniques provide limited information about the physical architecture of the tympanic membrane (TM), or what may lie behind it. Here, we report the detection of nanometer-scale structural changes of the TM using nano-sensitive optical coherence tomography (nsOCT). In total, an image dataset from 65 pediatric subjects from three different groups (normal, acute OM, and chronic OM) and with longitudinal image-based analysis of ear infections were included in this study. The nsOCT data were correlated with physician diagnosis and with OCT thickness measurements and were found to be in good agreement with these results. We report that nsOCT detects in vivo structural deformations of the TM earlier than OCT alone, and enhances the detection sensitivity of OCT measurements. This unique technique for early detection of nano-scale structural modifications in the TM has the potential to aid in our understanding of microbiological effects, and possibly for early diagnosis and more effective treatment of OM.

Tacrolimus: A New Option in Therapy-Resistant Chronic External Otitis

OBJECTIVE

To evaluate the efficacy of the novel topical immune modulator tacrolimus in chronic uninfectious otherwise therapy-resistant external otitis (EO).

STUDY DESIGN

Prospective clinical study.

PATIENTS AND METHODS

There were 53 patients aged 5 to 83 years. An ear wick containing 0.1% tacrolimus ointment (Protopic) was inserted into the external auditory canal every 2nd to 3rd day. Altogether, the wick was changed three times. The pre-, intra- and posttherapeutic state of the clinical parameters otalgia, edema, otorrhea, erythema, pruritus, and desquamation was rated by means of a 6-point score system. Treatment efficiency was evaluated on the basis of follow-up investigations at 3-month intervals, a standardized findings sheet, and photograph documentation.

RESULTS

The short-term results showed a clear improvement in 85% of the patients and significant reductions of the severity levels for all clinical parameters investigated (P < .001). Concerning the long-term results, a one-time treatment cycle led to complete healing in 46% of the patients throughout a follow-up of 10 to 22 months. Of the patients, 54% had recurrent EO events with significantly extended mean symptom-free intervals. Reapplied tacrolimus treatment patterns attenuated the relapsing course of disease and significantly reduced the number of EO episodes. Within the observation period, no relevant side effects were observed, except for a local feeling of heat, occasional skin burning, and itching.

CONCLUSIONS

The topical application of 0.1% tacrolimus ointment in the outer ear canal appears to be an effective and well-tolerated new option in corticosteroid-free treatment of chronic therapy-resistant EO.

Otologic Skills Training

This article presents a summary of the current simulation training for otologic skills. There is a wide variety of educational approaches, assessment tools, and simulators in use, including simple low-cost task trainers to complex computer-based virtual reality systems. A systematic approach to otologic skills training using adult learning theory concepts, such as repeated and distributed practice, self-directed learning, and mastery learning, is necessary for these educational interventions to be effective. Future directions include development of measures of performance to assess efficacy of simulation training interventions and, for complex procedures, improvement in fidelity based on educational goals.

Evaluation of outcome of otitis media after lavage of the tympanic bulla and long-term antimicrobial drug treatment in dogs: 44 cases (1998-2002)

OBJECTIVE

To evaluate the outcome of otitis media in dogs after video-otoscopic lavage of the tympanic bulla and long-term antimicrobial drug treatment.

DESIGN

Retrospective study.

ANIMALS

44 dogs with otitis media treated in an academic referral practice.

PROCEDURE

Medical records were reviewed for signalment, duration of ear canal disease, previous medical treatments, dermatologic diagnosis, results of cytologic examination and microbial culture of ear canal exudate, findings during video-otoscopy, medical treatment, days to resolution, and maintenance treatments prescribed. Four independent variables (age, duration of ear canal disease prior to referral, use of corticosteroids in treatment regimens, and infection with Pseudomonas aeruginosa) were evaluated statistically for potential influence on time to resolution.

RESULTS

Mean +/- SD (range) duration of ear canal disease prior to referral was 24.9 +/- 21.6 (3 to 84) months. Otitis media in 36 dogs resolved after lavage of the tympanic bulla and medical management; mean +/- SD (range) time to resolution was 117 +/- 86.7 (30 to 360) days. Time to resolution was not significantly influenced by any variable evaluated. Three dogs were lost to follow-up, and 4 dogs eventually required surgical intervention. Seven of 36 dogs in which otitis had resolved relapsed; 4 required additional lavage procedures.

CONCLUSIONS AND CLINICAL RELEVANCE

Results indicate that lavage of the tympanic bulla combined with medical management is an effective and viable option for treatment of otitis media in dogs.

Point Prevalence of Barotitis and Its Prevention and Treatment with Nasal Balloon Inflation: A Prospective, Controlled Study

INTRODUCTION

The most common cause of barotitis is pressure changes induced during descent in aviation. The incidence after air flight has been reported to vary from 8% to 17%.

OBJECTIVES

We conducted this study to estimate the incidence of barotitis after flight, to evaluate whether the incidence of barotitis can be reduced by nasal balloon inflation during descent, and, finally, to estimate the effect of nasal balloon inflation in case of negative middle ear pressure after landing.

STUDY DESIGN

Aircraft passengers were examined by otoscopy and tympanometry before and after flying and filled in a questionnaire inquiring about ear problems. On half of the flights, the passengers were asked to inflate a nasal balloon during descent, whereas the other half were control flights.

RESULTS

A total of 188 passengers filled in the questionnaire. Of these, 134 were examined before and after the flight. Otoscopic signs of barotitis were found in 15% of the ears in the control group compared with 6% in the balloon inflation group. In ears with a negative pressure after flying, the pressure could be equalized by Valsalva's maneuver in 46%. Passengers who were unable to equalize the pressure in this way inflated a nasal balloon, and in 69%, this maneuver cleared the middle ear pressure.

CONCLUSION

The incidence of barotitis in this study of aircraft passengers was 14%. This figure could be reduced to 6% in passengers who performed nasal balloon inflation during descent. We recommend nasal balloon autoinflation in aircraft passengers who have difficulty clearing their ears during and after flying.

Current challenges in diagnosis of acute otitis media

Diagnosis of acute otitis media is difficult: circumstances and equipment for diagnosis are often compromised, the child may be uncooperative, signs and symptoms of acute otitis media and those of the common cold are mostly the same, and parents appear to have strong opinions concerning correct diagnosis and treatment. Many clinicians have received inadequate pre- and postgraduate education about diagnosis. On the other hand, they are aware of the worldwide problem of antimicrobial resistance resulting from antibiotics unwisely prescribed for viral infections. We performed a systematic search to summarize what is known about diagnosis of acute otitis media and suggest ways to improve one's diagnostic skills. With the combination of appropriate and well-maintained diagnostic equipment for tympanometry and pneumatic otoscopy, strict diagnostic criteria, and open communication with each child's parents it is possible to increase accuracy in acute otitis media diagnosis. Recent public health campaigns both among clinicians and parents, plus increased knowledge of diagnostics reveal the possibility of significantly decreasing the number of acute otitis media diagnoses in children which will lead to reduced prescription of antibiotics.

Quantitative Pneumatic Otoscopy Using a Light-Based Ranging Technique

Otitis media is the leading cause of hearing loss in children. It is commonly associated with fluid in the ear, which can result in up to 45 dB of hearing loss for extended periods of time during a child's most important developmental years. Accurate assessment of middle ear effusions is an important part of understanding otitis media. Current technologies used to diagnose otitis media with effusion are pneumatic otoscopy, tympanometry, and acoustic reflectometry. While all of these techniques can reasonably diagnose the presence of an effusion, they provide limited information about the infection present behind the tympanic membrane.We have developed a technique based on low-coherence interferometry-a non-invasive optical ranging technique capable of sensing depth-resolved microscopic scattering features through the eardrum-to quantify eardrum thickness and integrity, as well as detect any effusion, purulence, or biofilm behind the tympanic membrane. In this manuscript, the technique is coupled with a pneumatic otoscope to measure minute deflections of the tympanic membrane from insufflation pressure stimuli. This results in quantitative measurements of tympanic membrane mobility, which may be used to gain a better understanding of the impact of infection on the membrane dynamics. A small pilot study of 15 subjects demonstrates the ability of pneumatic low-coherence interferometry to quantitatively differentiate normal ears from ears with effusions present. Analysis of the strengths and weaknesses of the technique, as well as focus areas of future research, is also discussed.

Video otoscopy: bringing otoscopy out of the "black box"

BACKGROUND

Several billion dollars are spent each year on otitis media, a diagnosis for which educational approaches and diagnostic skills are suboptimal. The Center for Disease Control has identified improvement in otoscopy skills as a key intervention to curb inappropriate antibiotic usage. Educators are looking for interventions to both improve and assess otoscopy skills. Video otoscopy (VO) uses endoscopic technology to project the image of the ear onto a monitor for all to see, offering unexplored educational opportunity. The objective of this study is to perform an evaluation of VO systems in medical education from a review of the literature and hands-on experience of available technology.

METHODS

The evaluation will focus on the technical acceptability (user requirements), clinical appropriateness (validity, reliability, feasibility), operational effectiveness (training requirements and implementation), and equipment selection.

RESULTS

The technical requirements in pediatric education exceed those available in some VO systems, specifically pneumatic capability, sophisticated cameras and optics, and pediatric-sized ear speculums. VO images are comparable to the conventional otoscopic and otomicroscopic examinations. VO is feasible in a primary care setting and can be integrated into resident and medical student education. The technology in VO systems is changing rapidly, necessitating comparison of systems before equipment is purchased.

CONCLUSIONS

VO is technically acceptable, clinically appropriate and can be integrated into the otoscopic education of residents and medical students. VO provides an opportunity to bring the pediatric ear examination out of the "black box," potentially improving diagnostic skills, quality of care, and reducing antibiotic overuse.

Otoscopic and tympanometric findings in acute otitis media yielding dry tap at tympanocentesis

BACKGROUND

The value of tympanometry in detection of middle ear effusion (MEE) has been widely studied in otitis media with effusion. There has been no direct comparison of tympanometric and tympanocentesis (TAP) findings in acute otitis media (AOM). We compared otoscopic, tympanometric and TAP findings in AOM including cases of AOM without effusion.

METHODS

In a study of AOM treatment of 90 children, a tympanogram was obtained, and TAP was performed before and after 5 days of treatment. Subjects were followed with otoscopy and tympanometry every 2 weeks for 3 months or until the MEE cleared.

RESULTS

In 130 AOM ears, otoscopic, tympanometric and TAP findings were available; MEE was obtained from 110 ears. Of 20 ears with a dry tap, 18 had abnormal tympanogram and otoscopic findings. With TAP findings as the standard, sensitivity and positive predictive value of type B tympanogram were 97 and 87%, respectively. Of 18 AOM ears yielding dry tap, 2 yielded MEE 5 days later, and 8 continued with evidence of MEE 5 days-12 weeks later. Five subjects with 8 AOM ears yielding dry tap were lost to follow-up; all had short duration of clinical symptoms.

CONCLUSIONS

Although otoscopic and tympanometric findings suggested the presence of MEE in AOM, MEE was unobtainable by TAP in 14% of cases. Dry tap cases likely represent early AOM before accumulation of detectable MEE. However, technical difficulty in obtaining small amounts of or highly viscous MEE could not be excluded. Sensitivity and positive predictive value of abnormal tympanograms in detection of MEE in AOM cases are comparable with those in otitis media with effusion.

Aberrant internal carotid artery causing objective pulsatile tinnitus and conductive hearing loss

Aberrant internal carotid artery (ICA) in the middle ear is a rare, dangerous vascular anomaly and conservative follow-up was usually adopted in most reported cases. Here we report the case of an 8-year-old girl with symptoms of objective pulsatile tinnitus and conductive hearing loss in the right ear. Otoscopic examination, computed tomography, and conventional angiography were performed. An aberrant ICA combined with a 'third mobile window' was suspected preoperatively and confirmed at exploratory surgery of the middle ear. The aberrant ICA was treated, and the pulsatile tinnitus disappeared and hearing recovered after the surgery. This case suggests that surgery is practical to relieve troublesome tinnitus and hearing loss in appropriate cases with aberrant ICA.

Otitis Techniques to Improve Practice

Successful management of otitis externa requires recognition of changes in the anatomy and physiology of the external and middle ear, as well as the adequate tools and examinations to detect changes from normal. Otoscopy and methods for assessing the normalcy of the tympanum, collection of samples for cytologic evaluation or culture, and myringotomy are diagnostic techniques important in practice. Treatment tubes and intralesional triamcinolone injections are techniques that improve the response in some cases.

Diffuse reflectance spectroscopy of the human tympanic membrane in otitis media

We have investigated if features in the diffuse reflectance spectra from in vivo spectroscopic measurements of the tympanic membrane could aid the diagnosis of otitis media in children. Diffuse reflectance spectroscopy, in the visible wavelength range, was used in 15 ears from children with otitis media with effusion before and after myringotomy and in 15 healthy ears as a reference. Two previously published erythema detection algorithms yielded numerical quantities of haemoglobin content. With a combination of the algorithms, induced erythema (after myringotomy) was distinguished from healthy ears using Student's t-test (p < 0.01). Otitis media with mucous effusion was distinguished from (1) otitis media with serous effusion, (2) induced erythema and (3) healthy ears, (p < 0.05) using Student's t-test for independent groups and the paired t-test for dependent groups. Our results imply that reflectance spectroscopy is a promising technique to be used for the diagnosis of otitis media.

A survey comparison of educational interventions for teaching pneumatic otoscopy to medical students

BACKGROUND

Though pneumatic otoscopy improves accurate diagnosis of ear disease, trainees lack proficiency. We evaluated the effect of three different training techniques on medical students' subsequent reported use of basic and pneumatic otoscopy in patient encounters.

METHODS

Pediatric clerkship students participated in an ear exam workshop with randomization to one of three educational interventions: task trainer (Life/form®, Fort Atkinson WI), instructional video, or peer practice. Each student received an insufflator bulb and logbook to record otoscopic exams and completed an 18-item anonymous survey at clerkship conclusion.

RESULTS

115 of 150 students (77%) completed the survey. There was no significant difference in number of basic or pneumatic otoscopic exams performed based on method of training. Most students (68-72%) felt more likely to perform pneumatic otoscopy after training. Though the majority of students performed basic otoscopy on patients when an ear exam was indicated, they used pneumatic otoscopy less than 10% of the time. Students reported significant barriers to otoscopy: time, access to equipment, cerumen impaction, patient hold, and anxiety. Student comments described a culture where insufflation was neither practiced nor valued by supervising physicians.

CONCLUSION

Training in pneumatic otoscopy can increase student comfort, but barriers exist to using the skill in clinical practice.

Nitrous oxide-oxygen inhalation for outpatient otologic examination and minor procedures performed on the uncooperative child

OBJECTIVE

Otomicroscopic examination with suctioning of ears or other procedures is frequently uncomfortable especially for children. Anxiety and pain with lack of cooperation may result in trauma to the ear, incompletion of the examination, delayed diagnosis and treatment and need for completion of the examination under general anesthesia. The purpose of this study was to evaluate the efficacy and safety of utilizing nitrous oxide-oxygen inhalation for sedation and analgesia in otologic examination and minor surgical procedures performed on the uncooperative child at the outpatient clinic.

METHODS

In a prospective pilot case series study conducted at the Pediatric Otolaryngology outpatient clinic of a tertiary medical center, nitrous oxide-oxygen inhalation was administered by the examining otolaryngologist and the assisting nurse. The study group included children over 2 years old, for which an accurate diagnosis of ear pathology could not be made or a minor surgical procedure could not be tolerated because of anxiety and lack of cooperation.

RESULTS

Completion of the indicated procedure was successful in 21 of 24 patients (88%). Full cooperation, where no restraint was necessary was achieved in 20 of 24 patients (83%). The mean rank pain scores, evaluated separately by the patient, parent and staff, were in the mild pain range using a 0-10 coding for Faces Pain Rating Scale. The mean procedure time was 8.9 min. An adverse reaction, vomiting, occurred in one patient. Twenty-one of 24 parents stated that they would repeat the procedure if necessary.

CONCLUSION

This pilot study shows the potential usefulness of nitrous oxide-oxygen inhalation administered by an otolaryngologist in the outpatient clinic. Alleviation of pain and anxiety and avoiding the need for physical restraint is an important goal that can be achieved with this form of sedation.