EvidenceEvidence Based Practice PresentationBased Practice Presentation

Does the assessment of tympanic Does the assessment of tympanic

membrane mobility using pneumatic membrane mobility using pneumatic

otoscopy reduce the diagnosis of Acute otoscopy reduce the diagnosis of Acute

otitisotitis media & media & otitisotitis media with effusion media with effusion

in children ?in children ?

Ashley PhillipsAshley Phillips

Ambulatory Care 2Ambulatory Care 2

May 2010May 2010

Rationale For QuestionRationale For QuestionTo establish if pneumatic otoscopy is more effective than otosTo establish if pneumatic otoscopy is more effective than otoscopy copy and as effective as tympanometry when diagnosing AOM and OME. and as effective as tympanometry when diagnosing AOM and OME.

At Tayside ChildrenAt Tayside Children’’s Hospital SSAA in s Hospital SSAA in NinewellNinewell’’ss pneumatic pneumatic otoscopy is not routinely carried out by medical staff or traineotoscopy is not routinely carried out by medical staff or trainee nurse e nurse practitioners.practitioners.

Ear examinations are predominantly carried out by plain otoEar examinations are predominantly carried out by plain otoscopy scopy and diagnosis is generally made through visualisation of the and diagnosis is generally made through visualisation of the tympanic membrane. The tympanic membrane. The insufflatorinsufflator is not routinely used.is not routinely used.

Medical staff have little or no experience of pneumatic otoscopyMedical staff have little or no experience of pneumatic otoscopy and and its uses. If tympanic membrane mobility is to be assessed in theits uses. If tympanic membrane mobility is to be assessed in theShort stay assessment area in Short stay assessment area in NinewellsNinewells Hospital a referral is made Hospital a referral is made to ENT clinic for to ENT clinic for tympanometrytympanometry However, this referral is extremely However, this referral is extremely rare and diagnosis of AOM and OME is done solely on how the rare and diagnosis of AOM and OME is done solely on how the tympanic membrane looks.tympanic membrane looks.

AOM and OME are common conditions which are referred to AOM and OME are common conditions which are referred to Tayside ChildrenTayside Children’’s Hospital.s Hospital.

Facts relating to Acute Facts relating to Acute OtitisOtitis Media Media

(A0M)(A0M)

Incidence:Incidence: Acute Acute otitisotitis media is a common condition with a high media is a common condition with a high morbidity and low mortality rate. In the United Kingdom about 30morbidity and low mortality rate. In the United Kingdom about 30% % of children aged under 3 years visit their GP with acute of children aged under 3 years visit their GP with acute otitisotitis media media each year, and 97% receive antimicrobial treatment. (each year, and 97% receive antimicrobial treatment. (FroomFroom 1997) 1997) About 1 in 10 children will have an episode of acute About 1 in 10 children will have an episode of acute otitisotitis media by 3 media by 3 months of age. It is the most common reason for outpatient months of age. It is the most common reason for outpatient antimicrobial treatment in the United States. (Froom1997)antimicrobial treatment in the United States. (Froom1997)

Aetiology: Aetiology: The most common bacterial causes for acute The most common bacterial causes for acute otitisotitis media media are Streptococcus are Streptococcus pneumoniaepneumoniae, , HaemophilusHaemophilus influenzaeinfluenzae, and , and MoraxellaMoraxella catarrhaliscatarrhalis. (. (FroomFroom 1997)1997)

Prognosis:Prognosis: In about 80% of children the condition resolves without In about 80% of children the condition resolves without antibiotic treatment in about three days. Complications are rareantibiotic treatment in about three days. Complications are rare but but include hearing loss, include hearing loss, mastoiditismastoiditis, meningitis, and recurrent attacks. , meningitis, and recurrent attacks. ((FroomFroom 1997)1997)

Facts relating to Facts relating to OtitisOtitis Media with Media with

effusioneffusionIncidence : Incidence : Otitis media with effusion (OME) is a common condition of early childhood (Nice 2008). OME has a prevalence of about 20% of children at 2 years of age. OME remains common up to the age of 7 at which the the prevalence reduces to between 3% and 8%.(Butler 2003)

.

Aetiology: OME may be overlooked because of the insidious nature of the condition (Nice 2008). It is not clear why or how OME develops. Low grade infection, poor eustachian tube function, local inflammatory reaction and adenoidal infection or hypertrophy have all been indicated. (Butler 2003)

.

Prognosis: In most cases of OME symptoms resolve spontaneously and no treatment is required as the fluid disperses. Hearing can be affected The hearing loss is usually transient and self-limiting over several weeks, but may be more persistent if the fluid in the middle ear does not disperse thus may lead to educational, language andbehavioural problems. So needs careful observation. (Nice 2008)

Spot the difference !Spot the difference !

Image at Image at meddean.luc.edumeddean.luc.edu

Image at ganfyd.org

Acute Acute OtitisOtitis Media (AOM): Media (AOM): The rapid onset of The rapid onset of

signs and symptoms such as signs and symptoms such as otalgiaotalgia and fever. and fever.

(Bluestone 2007). Clinical features include (Bluestone 2007). Clinical features include

middlemiddle--ear effusion, evidence of ear pain and /or ear effusion, evidence of ear pain and /or

marked redness, fullness and bulging of the marked redness, fullness and bulging of the

tympanic membrane. (tympanic membrane. (PeltonPelton 1998).1998).

OtitisOtitis media with effusion (OME): media with effusion (OME): Inflammation of Inflammation of

the middle ear with a collection of fluid in the middle the middle ear with a collection of fluid in the middle

ear space. The signs and symptoms differ from ear space. The signs and symptoms differ from

AOM as evidence of acute infection is absent and AOM as evidence of acute infection is absent and

there is no TM perforation. (Bluestone 2007). there is no TM perforation. (Bluestone 2007).

OME may result from the aftermath of AOM or OME may result from the aftermath of AOM or

as a consequence of as a consequence of eustachianeustachian tube obstruction or tube obstruction or

due to another cause, such as an upper respiratory due to another cause, such as an upper respiratory

tract infection. Children who are subjected to tract infection. Children who are subjected to

smoking have a high risk of developing OME. smoking have a high risk of developing OME.

((AgiusAgius 1995)1995)

Pneumatic Otoscopy and OtoscopyPneumatic Otoscopy and Otoscopy

An An otoscopeotoscope is a handis a hand--held instrument held instrument with a tiny light and a funnelwith a tiny light and a funnel--shaped shaped attachment called an ear speculum, attachment called an ear speculum, which is used to examine the ear canal which is used to examine the ear canal and eardrum. The pneumatic and eardrum. The pneumatic otoscopeotoscopediffers slightly from the plain differs slightly from the plain otoscopeotoscope as as it has an extra attachment, a small bulb it has an extra attachment, a small bulb also known as an also known as an insufflatorinsufflator..

(Davidson 2006)(Davidson 2006)

By pressing the By pressing the insufflatorinsufflator gently the gently the otoscopeotoscope produces a small puff of air produces a small puff of air which vibrates the eardrum (pneumatic which vibrates the eardrum (pneumatic otoscopy). Pneumatic otoscopy is an otoscopy). Pneumatic otoscopy is an examination that allows determination of examination that allows determination of the mobility of a patientthe mobility of a patient’’s tympanic s tympanic membrane (TM) in response to pressure membrane (TM) in response to pressure changes. The normal tympanic changes. The normal tympanic membrane moves in response to membrane moves in response to pressure. Immobility may be a result of pressure. Immobility may be a result of fluid in the middle ear.fluid in the middle ear.

TympanometryTympanometry / / MyringotomyMyringotomy

Image at Image at www.actscc.co.za/tympanometerwww.actscc.co.za/tympanometer--lsmlsm--300./html300./html

Image at Image at www.entdocwww.entdoc--crc.comFAQs.htmcrc.comFAQs.htm

Tympanometry is a test which Tympanometry is a test which measures the function of the measures the function of the middle ear. It works by varying the middle ear. It works by varying the pressure within the ear canal and pressure within the ear canal and measuring the movement of the measuring the movement of the tympanic membrane. The test also tympanic membrane. The test also measures the ears response to measures the ears response to sound. The sound. The tympanometertympanometer then then records the results.records the results.

MyringotomyMyringotomy is a procedure which is a procedure which involves an incision being made involves an incision being made into the tympanic membrane into the tympanic membrane which allows fluid to be drained which allows fluid to be drained from the ear sometimes a small from the ear sometimes a small plastic tube (grommet or Pressure plastic tube (grommet or Pressure equilizationequilization tube) can be inserted tube) can be inserted into the incision to allow further into the incision to allow further drainage.drainage.

Research QuestionResearch Question

PICO FormatPICO Format

Accurate diagnosis of AOM or OME Accurate diagnosis of AOM or OME OutcomeOutcome

Visualisation of tympanic membrane by Visualisation of tympanic membrane by

otoscopy / otoscopy / tympanometrytympanometry / / myringotomymyringotomyComparisonComparison

Pneumatic otoscopy / tympanic Pneumatic otoscopy / tympanic

membrane mobilitymembrane mobilityInterventionIntervention

Children under 15 years Children under 15 years Patient GroupPatient Group

Does the assessment of tympanic membrane Does the assessment of tympanic membrane mobility using pneumatic otoscopy, reduce the mobility using pneumatic otoscopy, reduce the diagnosis of acute diagnosis of acute otitisotitis media & media & otitisotitis media with media with effusion in children ?effusion in children ?

Search StrategySearch StrategySearch termsSearch terms

Children <15 years Children <15 years

Pneumatic otoscopyPneumatic otoscopy

TympanometryTympanometry / / myringotomymyringotomy

Tympanic membrane mobilityTympanic membrane mobility

Otoscopy Otoscopy

Visualisation of tympanic membrane Visualisation of tympanic membrane

Accurate diagnosis of AOM Accurate diagnosis of AOM

Accurate diagnosis of OME Accurate diagnosis of OME

Inclusion CriteriaInclusion Criteria

All articles written in the English Language.All articles written in the English Language.

Articles available electronically via Scottish eArticles available electronically via Scottish e--library / Athens.library / Athens.

Articles available at University of Dundee Medical and Nursing lArticles available at University of Dundee Medical and Nursing library.ibrary.

Exclusion CriteriaExclusion Criteria

Articles written prior to 2000.Articles written prior to 2000.

Articles which include adults in study.Articles which include adults in study.

TympanocentesisTympanocentesis

AccousticAccoustic reflectometryreflectometry

Video Video otoendoscopicotoendoscopic examination examination

Databases Searched and Databases Searched and ResultsResults

18 articles18 articles2000 2000 –– Week 4 2010Week 4 2010EmbaseEmbase

0 articles0 articlesAll articlesAll articlesCochrane libraryCochrane library

0 articles0 articles2000 2000 -- Week 4 2010Week 4 2010Joanna Briggs InstituteJoanna Briggs Institute

217 articles217 articles2000 2000 -- Feb 2010Feb 2010Google ScholarGoogle Scholar

20 articles20 articles20002000-- Week 4 2010Week 4 2010EbscoEbsco CinahlCinahl

7 articles7 articles2000 2000 -- Week 4 2010Week 4 2010Ovid MedlineOvid Medline

ResultsResultsArticles Dated FromArticles Dated FromDatabase searchedDatabase searched

2 articles were selected. 2 articles were selected.

Other articles were disregarded due to: Other articles were disregarded due to:

Inclusion of other diagnostic tests.Inclusion of other diagnostic tests.

Inclusion of adults in study.Inclusion of adults in study.

Articles published prior to 2000.Articles published prior to 2000.

Articles not published in the English language Articles not published in the English language

Articles not available through Scottish eArticles not available through Scottish e--library/Athens, LJMU or Dundee University library/Athens, LJMU or Dundee University Medical / Nursing library.Medical / Nursing library.

Research ArticleResearch Article SelectedSelected

A Diagnostic study carried out from November 2002 A Diagnostic study carried out from November 2002 –– February 2003. February 2003.

51 children were included in the study aged < 10 years with susp51 children were included in the study aged < 10 years with suspected ected

OME. OME.

The studyThe study’’s aim was to determine the accuracy of pneumatic s aim was to determine the accuracy of pneumatic otoscopyotoscopy , ,

tympanometrytympanometry and and otomicroscopyotomicroscopy when diagnosing OME. The 3 when diagnosing OME. The 3

diagnostic tests were carried out prior to diagnostic tests were carried out prior to myringotomymyringotomy. The . The myringotomymyringotomy

results were used to confirm the accuracy of the other 3 tests.results were used to confirm the accuracy of the other 3 tests.

Article 1Article 1

HEEHEE--DONG L, and SANGDONG L, and SANG--WON Y. (2004) Clinical diagnostic accuracy of WON Y. (2004) Clinical diagnostic accuracy of OtitisOtitis

Media with Effusion in Children and significance of Media with Effusion in Children and significance of MyringotomyMyringotomy: Diagnostic or : Diagnostic or

Therapeutic. Therapeutic. Journal of Korean Medical ScienceJournal of Korean Medical Science 2004 19 pp7392004 19 pp739--743. 743.

Research Article SelectedResearch Article Selected

A diagnostic test study carried out on 21 children aged between A diagnostic test study carried out on 21 children aged between 1 to 10 1 to 10

years who had suspected middle ear disease. The study was carrieyears who had suspected middle ear disease. The study was carried out d out

prior to prior to myringotomymyringotomy and insertion of PE tubes.and insertion of PE tubes.

The physician examined the mobility of the TM with a pneumatic The physician examined the mobility of the TM with a pneumatic otoscopeotoscope

and classified the mobility and appearance of the TM,S. MFT and and classified the mobility and appearance of the TM,S. MFT and

conventional conventional tympanographytympanography was then carried out. Following this the was then carried out. Following this the

myringotomymyringotomy was carried out and the presence or absence of fluid in the was carried out and the presence or absence of fluid in the

TM was reported. TM was reported.

The study then discussed the findings and compared the pneumaticThe study then discussed the findings and compared the pneumatic and and

tympanometry results with the surgical findings.tympanometry results with the surgical findings.

Article 2Article 2

HARRIS, P.K et al., 2005. The use of Tympanometry and Pneumatic HARRIS, P.K et al., 2005. The use of Tympanometry and Pneumatic

Otoscopy for Predicting Middle Ear Disease.Otoscopy for Predicting Middle Ear Disease.

American Journal of Audiology American Journal of Audiology June 2005; 14 pp 3June 2005; 14 pp 3--13.13.

Critical Appraisal ToolCritical Appraisal Tool

Critical appraisal skills programme (CASP) tool Critical appraisal skills programme (CASP) tool

(2004). (2004).

((http://http://www.phru.nhs.uk/Pages/PHD/resources.hwww.phru.nhs.uk/Pages/PHD/resources.h

tmtm))

The articles were critically appraised using The articles were critically appraised using

the diagnostic test critical appraisal tool. the diagnostic test critical appraisal tool.

12 questions to help make sense of a diagnostic 12 questions to help make sense of a diagnostic

study.study.

Article 1Article 1

Yes.Yes. 118 patients were selected 118 patients were selected

for study but only 51 patients were for study but only 51 patients were

included due to exclusion data included due to exclusion data

such as non compliance for such as non compliance for

myringotomymyringotomy, perforated TM , , perforated TM ,

failed failed tympanogramstympanograms and and

discharging ears.discharging ears.

Yes.Yes. MyringotomyMyringotomy was carried out was carried out

without anaesthesia (without anaesthesia (emlaemla cream cream

was applied to TM) to confirm the was applied to TM) to confirm the

results of the 3 diagnostic tests.results of the 3 diagnostic tests.

Yes. Yes. To determine the accuracy of To determine the accuracy of

3 diagnostic tools in diagnosis of 3 diagnostic tools in diagnosis of

OME pneumatic OME pneumatic otoscopyotoscopy, ,

tympanometrytympanometry and and otomicroscopyotomicroscopy. .

Article 2Article 2

Yes. Yes. 21 children participated in the 21 children participated in the

study. However only 35 of the 42 ears study. However only 35 of the 42 ears

had completed Pneumatic had completed Pneumatic otoscopyotoscopy

myringotomymyringotomy and and tympanogramstympanograms due due

to patent PE tubes and occluding to patent PE tubes and occluding

cerumencerumen. 2 false negative . 2 false negative

examinations were excluded. So 7 examinations were excluded. So 7

ear exams were excluded from study ear exams were excluded from study

Yes.Yes. The The ““gold standardgold standard””

myringotomymyringotomy under anaesthesia was under anaesthesia was

used to assess the accuracy of the used to assess the accuracy of the

results. results.

Yes.Yes. To measure the effectiveness of To measure the effectiveness of

pneumatic otoscopy and pneumatic otoscopy and

tympanometry for tympanometry for dagnosisdagnosis of AOM.of AOM.

3. Did all 3. Did all

patients get the patients get the

diagnostic test diagnostic test

and the and the

reference reference

standard?standard?

2. Was there a 2. Was there a

comparison comparison

with an with an

appropriate appropriate

reference reference

standard? standard?

1. Was there a 1. Was there a

clear question clear question

for the study to for the study to

address?address?

Diagnostic Test Critical Appraisal ToolDiagnostic Test Critical Appraisal Tool

Diagnostic Test Critical Appraisal ToolDiagnostic Test Critical Appraisal Tool

4. Could the results 4. Could the results

of the test of of the test of

interest have been interest have been

influenced by the influenced by the

results of the results of the

reference reference

standard ? standard ?

No. No. Blinding of staff was not Blinding of staff was not

possible due to the nature of the possible due to the nature of the

diagnostic tests. Pneumatic diagnostic tests. Pneumatic

otoscopyotoscopy and and tympanometrytympanometry was was

carried out prior to carried out prior to myringotomymyringotomy..

Article 2Article 2

5. Is the disease 5. Is the disease

status of the tested status of the tested

population clearly population clearly

described ?described ?

No. No. Blinding of staff was not Blinding of staff was not

possible due to the nature of the possible due to the nature of the

diagnostic tests. Pneumatic diagnostic tests. Pneumatic

otoscopyotoscopy, , tympanometrytympanometry and and

otomicroscopyotomicroscopy were carried out were carried out

and results noted prior to the and results noted prior to the

myringotomymyringotomy..

Article 1Article 1

No. No. Article states all children Article states all children

aged <10years old with aged <10years old with

suspected OME included in suspected OME included in

study. No reference is made to study. No reference is made to

stages of disease, presenting stages of disease, presenting

symptoms or date of onset .symptoms or date of onset .

Yes. Yes. 21 new patients seen by the 21 new patients seen by the

otolaryngologist aged between 1 otolaryngologist aged between 1

to 10 years who were seeking to 10 years who were seeking

treatment for middle ear disease.treatment for middle ear disease.

6. Were the

methods of

performing the test

described in

sufficient detail ?

Yes.Yes. Article clearly states how Article clearly states how

each diagnostic test was carried each diagnostic test was carried

out. The same method is used for out. The same method is used for

each patient. each patient.

YesYes. Article explains in depth . Article explains in depth

when and how each diagnostic when and how each diagnostic

test was carried out. The same test was carried out. The same

method is used for each patientmethod is used for each patient

Diagnostic Test Critical Appraisal ToolDiagnostic Test Critical Appraisal Tool

7. What are the 7. What are the

results ? results ? Sensitivity and specificity of each Sensitivity and specificity of each

test clearly presented in table form test clearly presented in table form

and explanation given in article. and explanation given in article.

Each diagnostic test was compared Each diagnostic test was compared

with with myringotomymyringotomy result. Pneumatic result. Pneumatic

otoscopyotoscopy had a sensitivity of 95% had a sensitivity of 95%

and specificity of 54%. The results and specificity of 54%. The results

showed that pneumatic showed that pneumatic otoscopyotoscopy

was significant in diagnosis of MEE. was significant in diagnosis of MEE.

(p.000)(p.000)

TympanometryTympanometry was carried out was carried out

using three using three diffferentdiffferent typanometerstypanometers

with different with different frequencysfrequencys. .

226 226 hzhz had a sensitivity of 80 and had a sensitivity of 80 and

specificity of 54%. This low specificity of 54%. This low

frequency frequency tympanometertympanometer was poor was poor

at accurately predicting middle ear at accurately predicting middle ear

fluid . The 678hz & 1000hz fluid . The 678hz & 1000hz

tympanometerstympanometers had a sensitivity of had a sensitivity of

95% & 100% with a specificity of 95% & 100% with a specificity of

54%.54%.

Article 2Article 2

Sensitivity and specificity of each Sensitivity and specificity of each

test are clearly presented.test are clearly presented.

Sensitivity of pneumatic Sensitivity of pneumatic otoscopyotoscopy

was 97.2% specificity was 38.5%. was 97.2% specificity was 38.5%.

Sensitivity of Sensitivity of tympanographytympanography was was

87.5% specificity 0%.87.5% specificity 0%.

OtomicroscopyOtomicroscopy was most accurate was most accurate

with sensitivity of 100% and with sensitivity of 100% and

specificity of 61.5%.specificity of 61.5%.

McnemersMcnemers test showed that there test showed that there

was no significant difference in the was no significant difference in the

ability of each of the diagnostic ability of each of the diagnostic

tests.tests.

Pneumatic Pneumatic otoscopyotoscopy and and

myringotomymyringotomy p=0.109. p=0.109.

Article 1Article 1

Diagnostic Test Critical Appraisal ToolDiagnostic Test Critical Appraisal Tool

9. Can the results be 9. Can the results be

applied to your patients/ applied to your patients/

the population of the population of

interest ? interest ?

8. How sure are we 8. How sure are we

about the results?about the results?

Yes.Yes.ResultsResults can be applied to can be applied to

the SSAA at Tayside the SSAA at Tayside

childrenchildren’’s Hospital at s Hospital at

NinewellsNinewells. Similar patients . Similar patients

were used in the study which were used in the study which

would present to the SSAA. would present to the SSAA.

Results are accurate Results are accurate

confidence levels are confidence levels are

documented for each documented for each

diagnostic test.diagnostic test.

Study has 95% confidence Study has 95% confidence

limits.limits.

Peer reviewed journal.Peer reviewed journal.

However study size small only However study size small only

21 patients included in the 21 patients included in the

study.study.

Article 2Article 2

Yes. Yes. Results can be applied to Results can be applied to

the SSAA at Tayside childrenthe SSAA at Tayside children’’s s

Hospital at Hospital at NinewellsNinewells. Similar . Similar

patients were used in the study patients were used in the study

which would present to the which would present to the

SSAA. SSAA.

Results are accurate Results are accurate

confidence levels are confidence levels are

documented for each documented for each

diagnostic test.diagnostic test.

Study has 95% confidence Study has 95% confidence

limits.limits.

International peer reviewed International peer reviewed

journal.journal.

However study size is small However study size is small

only 51 patients included in the only 51 patients included in the

study. study.

Article 1Article 1

Diagnostic Test Critical Appraisal ToolDiagnostic Test Critical Appraisal Tool

11. Were all 11. Were all

outcomes important outcomes important

to the individual or to the individual or

population population

considered ?considered ?

10. Can the test be 10. Can the test be

applied to your applied to your

patient or population patient or population

of interest ?of interest ?

Yes. Yes. The test proves that The test proves that

pneumatic pneumatic otoscopyotoscopy is a is a

valuable tool in reducing the valuable tool in reducing the

diagnosis of AOM and OME. diagnosis of AOM and OME.

By introducing pneumatic By introducing pneumatic

otoscopyotoscopy into practice the over into practice the over

prescribing of antibiotics prescribing of antibiotics

should be reduced.should be reduced.

Yes.Yes. Pneumatic Pneumatic otoscopyotoscopy can can

be carried out in Tayside be carried out in Tayside

childrenchildren’’s hospital SSAA as s hospital SSAA as

we have access we have access otoscopesotoscopes

with insufflators. These are with insufflators. These are

currently not used due to lack currently not used due to lack

of understanding by staff of of understanding by staff of

there benefits in diagnosing there benefits in diagnosing

AOM and OME.AOM and OME.

Article 2Article 2

Yes. Yes. The test The test proovesprooves that that

pneumatic pneumatic otoscopyotoscopy is a is a

valuable tool in reducing the valuable tool in reducing the

diagnosis of AOM and OME. diagnosis of AOM and OME.

By introducing pneumatic By introducing pneumatic

otoscopyotoscopy into practice the over into practice the over

prescribing of antibiotics prescribing of antibiotics

should be reduced.should be reduced.

Yes.Yes. Pneumatic Pneumatic otoscopyotoscopy can can

be carried out in Tayside be carried out in Tayside

childrenchildren’’s hospital SSAA as s hospital SSAA as

we have access we have access otoscopesotoscopes

with insufflators. These are with insufflators. These are

currently not used due to lack currently not used due to lack

of understanding by staff of of understanding by staff of

there benefits in diagnosing there benefits in diagnosing

AOM and OME.AOM and OME.

Article 1Article 1

Diagnostic Test Critical Appraisal ToolDiagnostic Test Critical Appraisal Tool

..

Reduction in the diagnosis of AOM and OME. Reduction in the diagnosis of AOM and OME.

Number of antibiotics prescribed would reduce. Number of antibiotics prescribed would reduce.

A saving for the trust in cost of antibiotics. A saving for the trust in cost of antibiotics.

Reduced referrals for Reduced referrals for tympanometrytympanometry..

Overall a more precise accurate diagnosis of AOM and OME. Overall a more precise accurate diagnosis of AOM and OME.

12, Impact of using this test on patients in 12, Impact of using this test on patients in NinewellsNinewells HospitalHospital

AnswerAnswer

Does the assessment of tympanic membrane Does the assessment of tympanic membrane

mobility using pneumatic reduce the diagnosis mobility using pneumatic reduce the diagnosis

of Acute of Acute otitisotitis media & media & otitisotitis media with media with

effusion in children ?effusion in children ?

YESYES

Implication of Study Results on Implication of Study Results on

PracticePractice

These studies have highlighted that pneumatic These studies have highlighted that pneumatic otoscopyotoscopyis an accurate diagnostic test when it comes to is an accurate diagnostic test when it comes to diagnosing AOM and OME. Confidence is lacking with diagnosing AOM and OME. Confidence is lacking with health professional in the SSAA as they have never health professional in the SSAA as they have never been taught the value of pneumatic been taught the value of pneumatic otoscopyotoscopy. Education . Education of professionals is required to increase the accuracy of of professionals is required to increase the accuracy of AOM and OME diagnosis in Tayside childrenAOM and OME diagnosis in Tayside children’’s hospital.s hospital.

Clinical practice should change to avoid children Clinical practice should change to avoid children

becoming becoming resisitantresisitant to antibiotics due to over prescribingto antibiotics due to over prescribing. .

As an APNP It is my duty to implement change in my As an APNP It is my duty to implement change in my area and educate staff of new practice and its benefits.area and educate staff of new practice and its benefits.

Any Questions ?Any Questions ?

ReferencesReferences

AGIUS, A.M. et al., 1995. Smoking and middle ear ciliary beat frequency in otitis media with effusion. Acta-Oto-Laryngologica, 115 (1), pp. 44-49.

BLUESTONE, C.D. and O. Klein J., 2007. Otitis media in infants and children. 4th ed. Italy: BC Decker inc, 2007, pp. 2.

BUTLER, C.C. and WILLIAMS, R.G., 2003. The etiology, pathophysiology, and management of otitis media with effusion. Current Infectious Disease Reports, 5 (3), pp.205-212.

CASP, 2006. 12 Questions to help you make sense of a diagnostic CASP, 2006. 12 Questions to help you make sense of a diagnostic test test study. study. Oxford:PublicOxford:Public Health Resource Unit.Health Resource Unit.http://http://www.phru.nhs.uk/pages/PHD/resources.htmwww.phru.nhs.uk/pages/PHD/resources.htm (Accessed on25/02/10.)(Accessed on25/02/10.)

DAVIDSON, T. and EDGREN, A., 2006. Gale Encyclopedia of Children’s Health : Infancy through Adolescence. http://www.encyclopedia.com/doc/1G2-3447200205.html (Accessed on 22/02/2010).

FROOM, J. et al., 1997. Antimicrobials for acute otitis media? A review from the International Primary Care Network. BMJ, 315, pp. 98-102.

ReferencesReferences

HARRIS, P.K. et al., 2005. The use of tympanometry and pneumatic otoscopy for predicting middle ear disease. American Journal of Audiology,

14, pp. 3-13.

HEE DONG, and SANG-WON W., 2004 Clinical diagnostic accuracy of otitis media with effusion in children and significance of myringotomy: diagnostic or therapeutic. Journal of Korean Medical Science, 19, pp. 739-743

NICE CLINICAL GUIDELINES 60, 2008. Surgical management of otitismedia with effusion in children. NICE Online.http://www.nice.org.uk/nicemedia/pdf/CG60NICEguidline.pdf (Accessed on 22/2/2010).

O’NEILL, P. 1999. Acute otis media. BMJ, 319 (7213), pp. 833-835.

PELTON, S.I. 1998. Otoscopy for the diagnosis of otitis media. Paediatric Infectious Diseases Journal, 17, pp. 540-543.