National quality evaluation of peri-surgical hearing care for pediatric otitis media with effusion.

OBJECTIVE: Otitis media with effusion (OME) is a common disease among children that can lead to grave sequelae with respect to hearing. Thus, when treating OME, appropriate hearing care should be provided; ventilation tube insertion (VTI), a standard approach for treating OME, is no exception. This study examined hearing care for VTI and its associated factors, especially at the national level. DESIGN: Retrospective database analysis. SETTING: Taiwan's National Health Insurance Research Database. PARTICIPANTS: One thousand one hundred and fifty-nine patients who received VTI (age ≤12 years; 2011-12). INTERVENTION: No intervention. MAIN OUTCOME MEASURES: Compliance to guidelines: sufficient observation time (OBS), tympanogram before VTI (TYM-B) and hearing tests before and after VTI (HEAR-B and HEAR-A, respectively). RESULTS: The national proportions of completion for each procedure were 30.1% for OBS, 84.4% for TYM-B, 74.3% for HEAR-B and 36.0% for HEAR-A; those of OBS and HEAR-A were extremely low. Age, nasal allergy and even geographic area were associated with differences across completion patterns. Regression revealed some notable patterns. Compared with non-teaching hospitals, teaching hospitals administered HEAR-B most successfully (odds ratio [OR: 3.20, 95% CI: 1.06-9.63) and the smallest hospital group performed HEAR-B most successfully (OR: 2.92, 95% CI: 1.14-7.46). CONCLUSION: Several findings surfaced concerning VTI-related hearing care and its association with many clinical and socioeconomic factors in this national study. These findings could serve as a map for improving hearing care quality among children with OME.

Seasonal differences of tympanogram and middle ear findings in children.

BACKGROUND: It is a known fact that bacterial or viral acute otitis media occurs more frequently in the winter months. Only a few older studies on seasonal differences in middle ear findings are available. These studies are based solely on tympanography, without correlation to intraoperative middle ear findings. This study addresses the question of whether seasonal differences can be found in the preoperative tympanogram and in the corresponding intraoperative findings in children with chronic middle ear problems. PATIENTS AND METHODS: This retrospective study included patients who had undergone myringotomy with or without tympanostomy tube insertion at the Charité-Universitätsmedizin Berlin between January and December 2011. Corresponding to the catarrhal phases, winter months were defined as those from November to April; summer months from May to October. The preoperative tympanogram and the documented intraoperative middle ear finding were statistically analyzed for seasonal differences. RESULTS: A total of 654 ears from 206 male and 127 female patients with mean age 3.7 ± 2.5 years were analyzed. In the majority of cases, a type B tympanogram was found (n = 376; 57.5%), whereas the middle ear was filled with air in 19.1% of cases. No significant seasonal differences were found for either the intraoperative middle ear findings or the preoperative tympanograms (p > 0.05). CONCLUSION: For children with a typical history of chronic otitis media without effusion and chronic tube ventilation dysfunction, myringotomy with or without tympanostomy tube insertion is indicated independently of the season. The results indicate that a wait-and-see approach with hope of improvement during the summer months is not rational.

Effects of consecutive trials and test-retest reliability of 1000-Hz tympanometry in adults.

OBJECTIVE: To investigate the effect of consecutive 1000-Hz tympanometry testing on admittance measures, and examine test-retest reliability. DESIGN: Repeated measures with eight trials of 1000-Hz Y(a) and B(a)/G(a) tympanometry, respectively, in two ears of each subject, followed by repeated 226-Hz tympanometry. STUDY SAMPLE: Twenty-seven normal-hearing young adults. RESULTS: For single-peak tympanograms, peak Y(tm) and G(tm) systematically increased across trials with a mean change of 8% and 15% at Trial 8, respectively, whereas B(tm) increased marginally. For notched tympanograms, peak Y(tm) and B(tm) decreased by 23% and 162% at Trial 8, and G(tm) in two cases also decreased (10% on average). Trial 2 and 3 contributed 50% to 70% of the total changes. Test-retest differences of subsequently acquired 1000- and 226-Hz tympanograms were smaller than previously reported. CONCLUSIONS: Consecutive testing significantly alters middle-ear admittance in 1000-Hz tympanometry. The outcome is contingent on tympanogram pattern and admittance component: Increase of peak Y(tm) and G(tm) in single-peak tympanograms and decrease of all measures in notched tympanograms. The present results complement previous studies on our understanding of the mechanism underlying this effect: a decrease of middle-ear stiffness. The effect of repetitive tympanometry should be accounted for in research involving sequential testing.

Factors that introduce intrasubject variability into ear-canal absorbance measurements.

Wideband immittance measures can be useful in analyzing acoustic sound flow through the ear and also have diagnostic potential for the identification of conductive hearing loss as well as causes of conductive hearing loss. To interpret individual measurements, the variability in test­retest data must be described and quantified. Contributors to variability in ear-canal absorbance­based measurements are described in this article. These include assumptions related to methodologies and issues related to the probe fit within the ear and potential acoustic leaks. Evidence suggests that variations in ear-canal cross-sectional area or measurement location are small relative to variability within a population. Data are shown to suggest that the determination of the Thévenin equivalent of the ER-10C probe introduces minimal variability and is independent of the foam ear tip itself. It is suggested that acoustic leaks in the coupling of the ear tip to the ear canal lead to substantial variations and that this issue needs further work in terms of potential criteria to identify an acoustic leak. In addition, test­retest data from the literature are reviewed.

Tympanometry in general practice: use, problems and solutions.

OBJECTIVES: The diagnosis in children with middle ear symptoms is often difficult. Tympanometry is recommended as a supplementary diagnostic tool with a high predictive value for fluid or no fluid in the middle ear. The aim of this study was to examine how tympanometry was used in Danish general practice in 2009, to report common problems general practitioners (GPs) and GP nurses encounter in tympanometry and to evaluate the effect of a practical and theoretical course. METHODS: A 1-year registration of the use of tympanometry in the Danish National Health Service Register in two regions with 40% of all Danish GPs and a survey among 197 participants in a course on diagnosis of otitis media and tympanometry in children were used. The Danish National Health Insurance covers 100% of GPs because they administer reimbursement for their activities, including tympanometry. RESULTS: During the year 2009, 1433 GPs in 702 clinics were on the list. A total of 417 clinics performed 35 529 tympanometries. Some 285 clinics (40.6%) did not perform tympanometry in 2009. The active clinics performed 42 tympanometries per GP. A 1-day course improved the knowledge and practical skills of the participating GPs and nurses. A majority (70%) stated in a self-reported questionnaire that tympanometry often provided important information, especially about middle ear fluid, and 48% reported that tympanometry several times during the past 2 weeks had changed their management of a middle ear problem. Few had not used their tympanometer during the 2 weeks preceding the survey. The response rate was 72%. CONCLUSIONS: The use of tympanometry is very skewed. A 6-hour course could improve GPs' care of patients with middle ear problems by using tympanometry.

[Pediatric OSAS and otitis media with effusion]. / Kindliches OSAS und Seromukotympanon.

BACKGROUND: Adenotonsillar hyperplasia is considered as a possible cause for two frequent ENT disorders in children: pediatric obstructive sleep apnea syndrome (OSAS) and otitis media with effusion (OME). The present study analyzes whether a link between pediatric OSAS and OME can also be presumed. METHODS: Polysomnographic data of 186 children with suspected OSAS were correlated to middle ear ventilation assessed by tympanometry. Tympanograms were classified according to Jerger. RESULTS: In a Kruskal Wallis test, children with an apnea-hypopnea index < 1 (exclusion of OSA by tight criteria), 1-5 or > 5 (definitively pathological value) did not statistically significantly differ in the prevalence of normally ventilated ears and OME. Accordingly, the Mann-Whitney U test showed that children with normally ventilated ears did not have a statistically different apnea-hypopnea, apnea, hypopnea or snoring index or varying minimal oxygen saturation to children suffering from OME. CONCLUSIONS: In the present study, no link was detected between pediatric OSAS and OME.

Promoting diagnostic accuracy in general practitioner management of otitis media in children: findings from a multimodal, interactive workshop on tympanometry and pneumatic otoscopy.

AIM: Previous research has shown that general practitioners (GPs) rarely use pneumatic otoscopy or tympanometry as recommended by best practice guidelines for diagnosing otitis media. The purpose of this study was to determine whether a multimodal, interactive training workshop on the techniques of pneumatic otoscopy and tympanometry would improve the confidence of GPs for the diagnosis of otitis media with effusion (OME) and acute otitis media (AOM), and for using pneumatic otoscopy and tympanometry. Additionally, we sought to determine whether this training could change GPs' intentions for using pneumatic otoscopy and tympanometry in their practices. METHODS: Twenty-three GPs participated in a three-hour training workshop led by an ear, nose and throat (ENT) surgeon, a paediatrician and an audiologist. Prior to and following the workshop, GPs completed questionnaires indicating their previous use and beliefs about the usefulness of pneumatic otoscopy and tympanometry, confidence for diagnosing AOM and OME, confidence for using pneumatic otoscopy and tympanometry, and intention to use pneumatic otoscopy and tympanometry in the future. RESULTS: There were no differences (P > 0.05) from pre- to post-workshop in GP confidence for diagnosing AOM. There were increases in GP confidence for diagnosis of OME (pre: 4.5 ± 0.9, post: 4.9 ± 0.4, P < 0.01) and confidence for using pneumatic otoscopy (pre: 3.6 ± 1.6, post: 4.8 ± 1.0, P < 0.01) and tympanometry (pre: 3.3 ± 1.5, post: 5.0 ± 0.7, P < 0.01), but no change (P > 0.05) in intention to use pneumatic otoscopy or tympanometry in their practices in the future. CONCLUSION: These results suggest that a multimodal, interactive workshop can significantly increase the confidence of GPs for diagnosis of OME and also for using pneumatic otoscopy and tympanometry. It is likely, however, that GPs will need follow-up and further practice with these techniques to implement them in their practices.

Predictors of Conservative Treatment Outcomes for Adult Otitis Media with Effusion.

OBJECTIVES: Conservative treatments are usually the preferred choices for newly diagnosed adult otitis media with effusion (OME). This study was performed to explore the efficacy of conservative treatments, including medication and eustachian tube auto-inflation (ETA), for treating OME in adults and to analyze its predictors. MATERIALS AND METHODS: A total of 107 adult patients with OME were included. All patients completed two weeks of conservative treatments including medication alone or the combination of medication and ETA. RESULTS: The numbers of patients with only one and both ears affected were 79 and 28, respectively, and therefore, 135 affected ears were included. After treatment, 75 affected ears were classified as responders (55.6%), while 60 ears were classified as nonresponders (44.4%). Four predictive factors, including age, air-bone gap (ABG), tubomanometry value (TMM), and the treatment plan (all p<0.05) were found in treatment outcomes. Patients with age ≤50 years (vs. age>50 years), ABG <17 dB (vs. ABG≥17dB), TMM values of 2-6 (vs. TMM values of 0-1), and patients who received combined treatments, including medication and ETA (vs. patients who received medication only), were more likely to be responders (all p<0.05). CONCLUSION: For OME in adult patients, younger age, smaller ABG, higher TMM value, and combined treatment including medication and ETA are good predictors for treatment success.

Effect of age, electrode array, and time on cochlear implant impedances.

Objectives: To determine the impact of age, electrode array, and time on impedance patterns in cochlear implant (CI) patients. Methods: A retrospective case review was performed on 98 patients implanted with the CI24RE perimodiolar (PM) and CI422 lateral wall (LW) arrays between 2010 and 2014 to assess impedances at the 1 week and 3-6 month visit after initial stimulation (IS). Results: With respect to age, impedances were higher in young patients compared to older patients in the middle and apical turns. With time, there were significant reductions in impedances across most electrodes. Electrode array type also had a significant impact on impedance measurements with PM and LW arrays having higher impedances in the basal turn and apical turns, respectively. Furthermore, PM arrays demonstrated significantly lower impedances in the middle and apical turn with time, when compared to LW arrays. Conclusions: Age, electrode array, and time can independently affect CI impedances. Moreover, we show that PM arrays may be advantageous to LW arrays, due to demonstrated lower impedances in the middle and apical turns long term. Understanding the impact of impedance on speech discrimination and determining the intracochlear processes that contribute to differences in impedance are future research directions.

Wideband tympanometry and absorbance measurements in otosclerotic ears.

OBJECTIVES: This study aimed to assess absorbance using a thorough analysis of individual points of its plot in ears with intraoperatively confirmed otosclerosis. To the best of our knowledge, until recently no analyses have been performed that concerned the shape of an absorbance plot and a detailed analysis of its individual points. This study is the first to undertake such an issue. METHODS: A total of 77 otosclerotic ears were included in the study. Pure tone audiometry, low frequency tympanometry, and wide band tympanometry including absorbance were performed preoperatively. The average patients' age in the group was 43.49 years (standard deviation = 10.44). Individual points of absorbance plot were thoroughly analyzed. Parameters were analyzed, such as resonance frequency; number of peaks; maximum absorbance (Height); and plot Width at the following Heights: 1/3, 1/2, and 2/3 (Width1/3, Width1/2, Width2/3, respectively), as well as associated absorbance parameters and frequencies. RESULTS: Data analysis revealed five different types of absorbance plots. Numerous statistically significant differences regarding the parameters of individual points of the plots were found among the distinguished types. CONCLUSIONS: There are five types of absorbance plots in otosclerotic ears: type I, characterized by two distinct peaks, closely resembling normal ear absorbance plot; type II with a single distinct peak reaching high values of absorbance; type III with reduced absorbance for frequencies <2000 Hz; type IV with reduced absorbance for all frequencies; and type V with reduced absorbance for frequencies >2000 Hz. Absorbance measurements may play an important role in the diagnostics of otosclerosis; however, further research is necessary in this area. LEVELS OF EVIDENCE: 4 Laryngoscope, 129:E365-E376, 2019.

The role of bacteriotherapy in the prevention of adenoidectomy.

OBJECTIVE: Adenoidectomy is a surgical procedure with potential adverse events. Effective nonsurgical therapy could reduce patient risk and harm. The aim of this study was to evaluate the role of bacteriotherapy to reduce the necessity of adenoid surgery. PATIENTS AND METHODS: This experimental study was conducted as an open study in 44 children (30 males and 14 females, mean age 4.9 years) who were candidates for adenoidectomy and tympanocentesis as treatment for adenoidal hypertrophy and otitis media with effusion. Twenty-two children were treated with Streptococcus salivarius 24SMB and Streptococcus oralis 89a nasal spray, administered as 2 puffs per nostril twice a day for a week for 3 months (study group). The other half of the children was treated with hypertonic saline nasal lavage on the same schedule (control group). Tympanometry and adenoid size assessment were evaluated throughout the intervention period. RESULTS: In the study group, 6/22 children required surgery, compared to 20/22 children in the study group (p<0.0001). The clinical change in the treated children was a significant reduction of adenoid size (p<0.0001) and improvement of middle ear effusion measured with tympanometry (p<0.0001). CONCLUSIONS: Bacteriotherapy with Streptococcus salivarius 24SMB and Streptococcus oralis 89a nasal spray could significantly reduce the need for adenoid surgery.

Tympanostomy tube insertion practice in under-18-year-olds in the South African private healthcare sector insured by Discovery Health.

BACKGROUND: The reported rates of tympanostomy tube insertion (TTI) in children vary significantly internationally. Lack of adherence to evidence-based clinical guidelines may contribute to these differences. OBJECTIVES: To study the rates of TTI in South Africa (SA) in children ≤18 years old in the private healthcare sector, both nationally and regionally, to compare these with international TTI rates, and to determine the use of preoperative audiometry and tympanometry. METHODS: A retrospective analysis was done of data obtained from the Discovery Health database. Rates of TTI were analysed nationally and regionally and in different age groups, as was the use of tympanometry and audiograms. RESULTS: The SA TTI rates were much higher than published international rates except for the 0 - 1-year age group in Canada and Denmark and the 0 - 15-year age group in Denmark. There was a statistically significant regional variation in TTI rates as well as in the use of preoperative audiometry and tympanometry. CONCLUSIONS: SA private sector TTI rates are high by international standards. Significant regional variations may indicate over- or underservicing in certain regions. Further investigation of causes for the high TTI rate and regional variations is recommended. Education of healthcare professionals on recognised indications for TTI may improve patient selection.

Sources of variability in reflectance measurements on normal cadaver ears.

OBJECTIVES: The development of acoustic reflectance measurements may lead to noninvasive tests that provide information currently unavailable from standard audiometric testing. One factor limiting the development of these tests is that normal-hearing human ears show substantial intersubject variations. This work examines intersubject variability that results from measurement location within the ear canal, estimates of ear-canal area, and variations in middle-ear cavity volume. DESIGN: Energy reflectance (ER) measurements were made on nine human-cadaver ears to study three variables. (1) ER was measured at multiple ear-canal locations. (2) The ear-canal area at each measurement location was measured and the ER was calculated with the measured area, a constant area, and an acoustically estimated area. (3) The ER was measured with the middle-ear cavity in three conditions: (1) normal, (2) the mastoid widely opened (large air space), and (3) the mastoid closed off at the aditus ad antrum (small air space). RESULTS: Measurement-location effects are generally largest at frequencies below about 2000 Hz, where in some ears reflectance magnitudes tend to decrease systematically as the measurement location moves away from the tympanic membrane but in other ears the effects seem minimal. Intrasubject variations in reflectance due to changes in either measurement location within the ear canal or differences in the estimate of the ear-canal area are smaller than variations produced by large variations in middle-ear cavity air volume or intersubject differences. At frequencies below 2000 Hz, large increases in cavity volume systematically reduce the ER, with more variable changes above 2000 Hz. CONCLUSIONS: ER measurements depend on all variables studied: measurement location, ear-canal cross-sectional area, and middle-ear cavity volume. Variations within an individual ear in either measurement location or ear-canal cross-sectional area result in relatively small effects on the ER, supporting the notion that diagnostic tests (1) need not control for measurement location and (2) can assume a constant ear-canal area across most subjects. Variations in cavity volume produce much larger effects in ER than measurement location or ear-canal area, possibly explaining some of the intersubject variation in ER reported among normal ears.

Using impedance measurements to detect and quantify the effect of air leaks on the attenuation of earplugs.

The impedance of a simple artificial ear occluded with an earplug and bypassed with narrow air leaks was measured along with the attenuation of sound through the air leaks. A lumped element model is suggested for the simple occluded artificial ear with an air leak. The suggested model was adapted to the impedance measurements and the attenuation was predicted from the model. The attenuation predictions were compared to the attenuation measurements and were found to be within [-3.5,+3] dB of the measured attenuation over the frequency range of 50-1000 Hz and an attenuation range of -2-38 dB. The average difference between the measured and predicted attenuation for four different leaks in the frequency range of 50-1000 Hz was -0.7 dB, indicating a very slight underestimation of the attenuation.

Detection of modiolar proximity through bipolar impedance measurements.

OBJECTIVES: To test the hypothesis that bipolar electrical impedance measurements in perimodiolar cochlear implants (CIs) may be used to differentiate between perimodiolar insertion technique favoring proximity to the modiolus or lateral wall. STUDY DESIGN AND METHODS: Bipolar impedances are a measure of electrical resistance between pairs of electrode contacts in a CI. Stimulation is through biphasic pulses at fixed frequency. Impedance measurements were made in real time through sequential sampling of electrode pairs. Perimodiolar electrodes were inserted in temporal bones using one of two techniques: 1) In the standard insertion technique (SIT), the electrode array slides along the lateral wall during insertion. 2) In the Advance Off Stylet (Cochlear Ltd. Sydney) technique (AOS), the electrode maintains modiolar contact throughout the insertion process. A set of 22 insertions were performed in temporal bone specimens using perimodiolar electrode arrays with both AOS and SIT. Buffered saline was used as a substitute for natural perilymph based on similar electrical conductivity properties. Impedance with and without stylet removal were recorded with a 30-second sampling window at final insertion depth. RESULTS: There is a significant difference in bipolar impedance measures between AOS and SIT, with impedances rising in measurements with stylet removal. Evaluation was based on two-sided analysis of variance considering technique and electrode with P < 0.025. CONCLUSION: Bipolar electrical impedance can be used to detect relative motion toward the modiolus inside the cochlea. This detection method has the potential to optimize intraoperative placement of perimodiolar electrode arrays during implantation. We anticipate that this will result in lower excitation thresholds and improved hearing outcome. LEVEL OF EVIDENCE: NA. Laryngoscope, 127:1413-1419, 2017.

A simple diagnostic scale based on the analysis and screening of clinical parameters in paediatric obstructive sleep apnoea hypopnea syndrome.

OBJECTIVE: This study aimed to develop a simple and accurate method to diagnose paediatric obstructive sleep apnoea hypopnea syndrome. METHODS: A total of 311 children with suspected paediatric obstructive sleep apnoea hypopnea syndrome were included in the study. Multiple clinical parameters, including sex, age, body mass index, history of snoring or gasping, history of nasal obstruction, history of running nose, palatine tonsil size, adenoid to nasopharynx ratio, and tympanogram type, were compared with polysomnography results using relevant correlation and regression analyses. A diagnostic scale was established using the regression equation and the correlation between the polysomnography result and scale result was determined. RESULTS: The apnoea-hypopnea index correlated significantly with a history of snoring or gasping, palatine tonsil size, and tympanogram type. Stepwise logistic regression analysis revealed that the polysomnography result correlated significantly with a history of snoring or gasping, palatine tonsil size, and the adenoid to nasopharynx ratio. The percentage correlation between the scale and polysomnography results was 77.8 per cent. CONCLUSION: The diagnostic scale can be used to diagnose paediatric obstructive sleep apnoea hypopnea syndrome for clinical application when polysomnography cannot be performed. However, it is not suitable for assessing the severity of paediatric obstructive sleep apnoea hypopnea syndrome.

Wideband Tympanometry Normative Data for Different Age Groups in Turkish Population.

OBJECTIVE: Studies on the use of wideband tympanometry (WBT) for the evaluation of middle ear pathologies have been increasing gradually in recent years. However, studies regarding normative data of WBT are not sufficient. The aim of this study was to determine normative values of WBT for different age groups in Turkish population. MATERIALS AND METHODS: One hundred fifty volunteers from five age-related groups were included in this study. Values of resonance frequency (RF), absorbance percentage according to frequency, maximum absorbance ratio, and maximum absorbance frequency were obtained using WBT. Measurements were recorded at a pressure of 0 decapascal (daPa) using a sound stimulus given at 90±3 decibel sound pressure level (dB SPL). RESULTS: The RF was detected to be significantly lower only in the group of subjects in the age range of 0-1 month. The absorbance value at 250 Hz was detected to be significantly higher in the age groups of 0-1 month and 1 month-2 years than in the other groups. CONCLUSION: We believe that the findings obtained in this study would be helpful in determining normative data regarding WBT; by the determination of this normative data, the clinical use of WBT would become widespread.

Accuracy of tympanometric middle ear pressure determination in secretory otitis media: dose-dependent overestimation related to the viscosity and amount of middle ear fluid.

HYPOTHESIS: Tympanometric measurements of middle ear pressure in children with secretory otitis media are overestimated in a dose-response manner because of increased hysteresis explained by the viscosity and amount of middle ear fluid. BACKGROUND: Tympanometric middle ear pressure is important in evaluating children with secretory otitis media. These measurements are influenced by hysteresis appearing as a peak pressure difference in bidirectional tympanometry. This represents an inaccuracy of 0.5 x peak pressure difference, which is only 5 to 25 daPa in normal ears. However, previous experiments found increased hysteresis, suggesting an inaccuracy of 225 daPa in secretory otitis media ears. MATERIALS AND METHODS: In 56 patients with secretory otitis media, bidirectional tympanometry was performed; Type B curves were excluded. The middle ear fluid was semiquantified subsequently at surgery according to viscosity (serous, seromucoid, or mucoid) and amount (small, medium, or large). A control group included 28 normal children. Peak pressure difference was calculated by the difference between middle ear pressure determined by a positive and negative pressure sweep. RESULTS: Mean peak pressure difference was 10 and 69 daPa in the normal and secretory otitis media groups, respectively (p <0.001). However, peak pressure difference ranged to 205 daPa in the secretory otitis media group and showed a significant positive correlation to viscosity and amount of the fluid (both p <0.0001). CONCLUSION: Peak pressure difference is significantly increased in secretory otitis media because of additional damping explained by the viscosity and amount of the fluid. The mean error was 5 daPa in normal ears and 35 daPa in secretory otitis media ears, but ranged to greater than 100 daPa. These results were only a low estimate of the inaccuracy, because patients with Type B tympanograms could not be included, and errors of more than 100 daPa can be anticipated.

Otitis media in children: use of diagnostic tools by family practice residents.

BACKGROUND AND OBJECTIVES: Although otitis media is a common problem in primary care, little is known about the use of diagnostic tools such as pneumatic otoscopy, tympanometry, acoustic reflectometry, or tympanocentesis by family physicians in training. METHODS: This was a self-reported observational study of family practice residents' use of otitis media diagnostic tools. Twenty-three family practice programs in Texas and Oklahoma were surveyed during November and December 2000. Residents were asked about their use of diagnostic tools, and, if tools were not used, they were asked the reason for not using them. Residents were also asked about the criteria they used to diagnose otitis media, and their responses were compared to criteria recommended by national guideline panels. RESULTS: The response rate was 61% (n = 316). The percentage of residents using pneumatic otoscopy was 66%, tympanometry 29%, acoustic reflectometry 2%, and tympanocentesis 0%. The most common reasons cited for not using tools were lack of training or unavailability of equipment. Fifty-five percent of family practice residents do not report pneumatic otoscopy for diagnosing otitis media and thus did not use recommended criteria. Faculty training of residents in the use of diagnostic tools was associated with a higher rate of using these tools. DISCUSSION: Few residents believed that diagnostic tools had no value in the diagnosis of otitis media, but lack of training or equipment problems were reported as contributing to their not using these tools. Half of family practice residents may be inadequately diagnosing middle ear problems since they did not report that pneumatic otoscopy was necessary for diagnosing otitis media. Because training was associated with higher rates of using appropriate diagnostic tools, family medicine faculty can play a significant role in improving the residents' diagnostic skills.

[Diagnosis and treatment of ear diseases in general practice. A controlled trial of the effect of the introduction of middle ear measurement (tympanometry)]. / Diagnostik og behandling af øresygdomme i almen praksis. En kontrolleret undersøgelse af virkningen af indførelse af mellemøretrykmåling (tympanometri).

The diagnosis and treatment of diseases of the ear in general practice could be rendered optimal by employing tympanometry (measurement of the pressure in the middle ear) which is already known from specialist practice. This was investigated by means of a controlled investigation with cooperation between general practice, otologists and the health services in the County of Vejle. Following randomizing among 20 general practitioners, ten were trained in tympanometry (the test group) while ten did not change their principles for diagnosis and treatment (control group). The criteria for inclusion in the investigation were the findings of indications for otoscopy in children under the age of 16 years. During a period of 12 months, parallel registrations of the data were made in the two groups and 3,166 children with an average age of 3.4 years were included. The clinical course showed statistically significant differences (p less than 0.05) between the groups as regards diagnosis and treatment: acute otitis media was found in 8.4% in the control group and 2.6% in the test group. Secretory otitis media (glue ear) was found in 14.2% in the control group and in 25% in the test group. Correspondingly, penicillin was prescribed for 7.6% in the control group and 4.1% in the test group. The otologists performed tubulation of the tympanic membrane in 0.9% in the control group and 3.2% in the test group. Continued investigations are necessary to elucidate whether tympanometry should be part of the daily routine in general practice.