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.

Diagnostic methods for acute otitis media in 1 to 12 year old children: a cross sectional study in primary health care.

BACKGROUND: Otoscopy alone has low sensitivity and specificity for acute otitis media (AOM). Otomicroscopy and pneumatic methods are superior to otoscopy. However, these methods require clinical skills. The use of different diagnostic methods for AOM differs between countries and has not been evaluated in Sweden since new guidelines were introduced in 2010. This study aimed to describe the extent of which diagnostic methods and written advice were used for AOM in children 1 to 12 years old. METHODS: In this cross-sectional study all general practitioners (GPs) and specialist trainees in primary care (STs) at 27 primary health care centres in Sweden were asked to complete a self-administrated questionnaire including diagnostic approach and the management of AOM; 75% (111/148) responded to the questionnaire. OUTCOME MEASURES: GPs versus STs and their gender, the use of otoscopy, pneumatic otoscopy, otomicroscopy, tympanometry and written advice. Logistic regressions were used to evaluate the association between GPs versus STs and their gender and the use of diagnostic methods and written advice. RESULTS: To diagnose AOM, 98% of the GPs and STs often or always used otoscopy, in addition to this 17% often or always used otomicroscopy, 18% pneumatic otoscopy and 11% tympanometry. Written advice to parents was provided often or always by 19% of the GPs and STs. The GPs used otomicroscopy more often than STs, adjusted OR 4.9 (95% CI 1.5-17; p = 0.011). For the other diagnostic methods, no differences were found. Female GPs and STs provided written advice more often than male GPs and STs, OR 5.2 (95% CI, 1.6-17; p = 0.0061), adjusted for GP versus ST. CONCLUSIONS: Otoscopy was by far the most commonly used method for the diagnosis of AOM. Female GPs and STs provided written advice more frequently than did their male colleagues. GPs used the significantly better method otomicroscopy more often than STs, therefore, it is important to emphasise teaching of practical skills in otomicroscopy in the specialist training programme for general practice. A correct diagnosis is important for avoiding potentially harmful antibiotic treatments, antimicrobial resistance and possible delay of other diagnoses.

Assessment of a Statistical Algorithm for the Prediction of Benign Paroxysmal Positional Vertigo.

Importance: Benign paroxysmal positional vertigo (BPPV) is an otologic pathologic condition defined as a sensation of spinning triggered by changes in head position relative to gravity and caused by an entrapment of fragmented endolymph debris most commonly in the posterior semicircular canal. Confirmation of diagnosis requires experience with procedures that are poorly known by those other than practitioners with advanced otologic training. The complexity in the diagnosis of BPPV inspired the design of a questionnaire-based algorithm that would be useful for determining a vestibular diagnosis and treatment options. Objective: To assess a statistical algorithm for the diagnosis of BPPV in a busy tertiary care setting, with the long-term goal of implementing a clinical pathway to efficiently diagnose and treat patients with dizziness. Design, Setting, and Participants: In this retrospective case series, 200 patients who visited the Department of Otolaryngology-Head and Neck Surgery at Johns Hopkins University School of Medicine for their initial vertigo symptoms from September 1, 2016, to December 31, 2016, were assessed. Interventions: Use of a validated patient questionnaire as a tool to differentiate patients with dizziness in an electronic medical record review. Main Outcomes and Measures: Linear predictor (LP) value based on the questionnaire for the diagnosis of BPPV. Results: Of the 200 patient visits reviewed (132 [66%] female), 106 (53.0%; 68 [64%] female) had the information necessary to calculate the LP value and had a confirmed final diagnosis. On the basis of an LP value of 0.2 or greater, the sensitivity for a diagnosis of BPPV was 0.75 and the specificity was 1.0. The positive predictive value was 1.0, whereas the negative predictive value was 0.96. Patients with BPPV had a statistically significantly different LP value (odds ratio, 5.92; 95% CI, 2.73-12.83) than did patients without BPPV. Conclusions and Relevance: The findings of this study suggest that the algorithm is efficient for the diagnosis of BPPV in a clinical care setting.

Agreement between diagnoses of otitis media by audiologists and otolaryngologists in Aboriginal Australian children.

OBJECTIVES: To determine the degree of agreement of diagnoses by audiologists and otolaryngologists of otitis media (OM) in Aboriginal children. DESIGN: Cross-sectional study of agreement between diagnoses. SETTING: Study of Environment on Aboriginal Resilience and Child Health (SEARCH), a prospective cohort study of Aboriginal children attending four Aboriginal Community Controlled Health Services in New South Wales (three metropolitan, one regional) during 2008-2012. PARTICIPANTS: 1310 of 1669 SEARCH participants (78.5%; mean age, 7.0 years; SD, 4.4 years) were assessed and received a diagnosis from one of five experienced audiologists. Test results (but not case histories) were forwarded to one of three otolaryngologists for blinded independent assessment. MAIN OUTCOME MEASURES: Agreement of OM diagnoses by audiologists and otolaryngologists at ear and child levels; correctness of audiologist diagnoses (otolaryngologist diagnosis as reference). RESULTS: Paired diagnoses by audiologists and otolaryngologists were available for 863 children at the child level and 1775 ears (989 children) at the ear level. Otolaryngologists diagnosed OM in 251 children (29.1%), including 11 (1.3%) with tympanic membrane perforation, and in 396 ears (22.3%), including 12 (0.7%) with perforation. Agreement between audiologists and otolaryngologists for OM at the ear level was 92.2% (κ = 0.78; 95% CI, 0.74-0.82), and at the child level 91.7% (κ = 0.81; 95% CI, 0.77-0.85). No otolaryngologist-diagnosed perforation was missed by audiologists. Among 1000 children triaged by an audiologist, there would be 45 false positives and 30 false negatives when compared with assessments by an otolaryngologist, with no missed perforations. CONCLUSIONS: There was substantial agreement between audiologists' and otolaryngologists' diagnoses of OM in a high prevalence population of Aboriginal children. In settings with limited access to otolaryngologists, audiologists may appropriately triage children and select those requiring specialist review.

Assessment of DPOAE test-retest difference curves via hierarchical Gaussian processes.

Distortion product otoacoustic emissions (DPOAE) testing is a promising alternative to behavioral hearing tests and auditory brainstem response testing of pediatric cancer patients. The central goal of this study is to assess whether significant changes in the DPOAE frequency/emissions curve (DP-gram) occur in pediatric patients in a test-retest scenario. This is accomplished through the construction of normal reference charts, or credible regions, that DP-gram differences lie in, as well as contour probabilities that measure how abnormal (or in a certain sense rare) a test-retest difference is. A challenge is that the data were collected over varying frequencies, at different time points from baseline, and on possibly one or both ears. A hierarchical structural equation Gaussian process model is proposed to handle the different sources of correlation in the emissions measurements, wherein both subject-specific random effects and variance components governing the smoothness and variability of each child's Gaussian process are coupled together.

Evaluation of a hearing screening questionnaire for use with Ecuadorian school-aged children.

OBJECTIVE: The purpose of this study was to evaluate the accuracy of a teacher-administered hearing screening questionnaire to detect hearing loss among first-grade Ecuadorian children in public schools. DESIGN: A cross-sectional design was used to compare screening results from the teacher-administered questionnaire and pure-tone audiometry. STUDY SAMPLE: Children were randomly selected from 117 schools. The study was conducted in two phases to accommodate different school calendars in the country. Data for both screening methods were available for 4616 children. RESULTS: For Phase 1, almost 90% who failed the questionnaire passed audiometry; and, 85% who failed audiometry passed the questionnaire. A revised questionnaire was used for Phase 2 and 70% who failed the questionnaire passed audiometry; and 85% who failed audiometry, passed the questionnaire. Of the 27 children identified in Phase 2 as having hearing loss at the time screening was done, 88.9% failed audiometry, but only 22.2% failed the questionnaire. CONCLUSIONS: Because there was little agreement between the questionnaire and the audiometry, it was recommended that the questionnaire not be used to screen Ecuadorian children for hearing loss. The results of this evaluation of the school hearing screening program provided the Ecuadorian government with important information to guide policy decisions.

Survey on the state of otoneurology in Spain.

Otoneurology is a subspecialty of otolaryngology-neurology, which has experienced extraordinary progress in the last 50 years and is currently fully consolidated in our environment. Through this study, prepared by the Otoneurology Commission of the Spanish Society of Otorhinolaryngology (SEORL), we have attempted to design an approach to provide information on what the current situation regarding the exercise in Spain is, trying to determine who practice it and where, what resources are available and what the teaching and scientific productions are. The results obtained are generally satisfactory and reflect the strength of the exercise of otoneurology. The number of centres with otoneurology units is significant and the majority of centres that lack such a unity consider it necessary. However, there are aspects to establish related to minimum requirements for its performance in satisfactory conditions, as well as determining future guidelines to ensure improved teaching and increased scientific production.

Understanding protocol performance: impact of criterion and test correlation.

BACKGROUND: A test protocol is created when individual tests are combined. Protocol performance can be calculated prior to clinical use; however, the necessary information is seldom available. Thus, protocols are frequently used with limited information as to performance. The next best strategy is to base protocol design on available information combined with a thorough understanding of the factors that determine protocol performance. Unfortunately, there is limited information as to these factors and how they interact. PURPOSE: The objective of this article and the next article in this issue is to examine in detail the three factors that determine protocol performance: (1) protocol criterion, (2) test correlation, (3) test performance. This article examines protocol criterion and test correlation. The next article examines the impact of individual test performance and summarizes the results of this series. The ultimate goal is to provide guidance on the formulation of a protocol using available information and an understanding of the impact of these three factors on performance. RESEARCH DESIGN: A mathematical model is used to calculate protocol performance for different protocol criteria and test correlations while assuming that all individual tests in the protocol have the same performance. The advantages and disadvantages of the different criteria are evaluated for different test correlations. RESULTS: A loose criterion will produce the highest protocol hit and false alarm rates; however, the false alarm rate may be unacceptably high. A strict criterion will produce the smallest protocol hit and false alarm rates; however, the hit rate may be unacceptably low. Adding tests to a protocol increases the probability that the protocol false alarm rate will be too high with a loose criterion and that the protocol hit rate will be too low with a strict criterion. The intermediate criterion, about which little has been known, provides advantages not available with the other two criteria. This criterion is much more likely to produce acceptable protocol hit and false alarm rates. It also has the potential to simultaneously produce a protocol hit rate higher, and a false alarm rate lower, than the individual tests. The intermediate criteria produce better protocol performance than the loose and strict criteria for protocols with the same number of tests. For all criteria, best protocol performance is obtained when the tests are uncorrelated and decreases as test correlation increases. When there is some test correlation, adding tests to the protocol can decrease protocol performance for a loose or strict criterion. The ability of a protocol to manipulate hit and false alarm rates, or improve performance relative to that of the individual tests, is reduced with increasing test correlation. CONCLUSIONS: The three criteria, loose, strict, and intermediate, have definite advantages and disadvantages over a large range of test correlations. Some of the advantages and disadvantages of the loose and strict criteria are impacted by test correlation. The advantages of the intermediate criteria are relatively independent of test correlation. When three or more tests are used in a protocol, consideration should be given to using an intermediate criterion, particularly if there is some test correlation. Greater test correlation diminishes the advantages of adding tests to a protocol, particularly with a loose or strict criterion. At higher test correlations, fewer tests in the protocol may be appropriate.

Understanding protocol performance: impact of test performance.

BACKGROUND: This is the second of two articles that examine the factors that determine protocol performance. The objective of these articles is to provide a general understanding of protocol performance that can be used to estimate performance, establish limits on performance, decide if a protocol is justified, and ultimately select a protocol. The first article was concerned with protocol criterion and test correlation. It demonstrated the advantages and disadvantages of different criterion when all tests had the same performance. It also examined the impact of increasing test correlation on protocol performance and the characteristics of the different criteria. PURPOSE: To examine the impact on protocol performance when individual tests in a protocol have different performance. This is evaluated for different criteria and test correlations. The results of the two articles are combined and summarized. RESEARCH DESIGN: A mathematical model is used to calculate protocol performance for different protocol criteria and test correlations when there are small to large variations in the performance of individual tests in the protocol. RESULTS: The performance of the individual tests that make up a protocol has a significant impact on the performance of the protocol. As expected, the better the performance of the individual tests, the better the performance of the protocol. Many of the characteristics of the different criteria are relatively independent of the variation in the performance of the individual tests. However, increasing test variation degrades some criteria advantages and causes a new disadvantage to appear. This negative impact increases as test variation increases and as more tests are added to the protocol. CONCLUSIONS: Best protocol performance is obtained when individual tests are uncorrelated and have the same performance. In general, the greater the variation in the performance of tests in the protocol, the more detrimental this variation is to protocol performance. Since this negative impact is increased as more tests are added to the protocol, greater test variation indicates using fewer tests in the protocol.

Evaluación de la fase de screening auditivo en menores con factores de riesgo / Evaluation of the auditive screening stage in minors with risk factors

Se analizan los resultados obtenidos en la primera fase del programa de Detección Precoz de la Sordera en el Hospital Sótero del Río durante el año 2004. Se estudia un total 244 casos, evaluados en el Servicio de Otorrinolaringología (ORL), en cuanto a los resultados obtenidos de la primera evaluación con emisiones otoacústicas transientes (EOAT) automáticas, en el Servicio de Neonatología, examen impedanciométrico y emisiones otoacústicas por producto de distorsión (EOAPD) clínica. Además, se evalúa el tiempo promedio que transcurre entre el screening tomado en la maternidad y el primer examen de emisiones otoacústicas (EOA) clínico, en 144 casos. Como resultados se obtiene que el 22,8 por ciento de los menores evaluados en neonatología son derivados a re-screening y 6 por ciento va a estudio audiológico diagnóstico. En cuanto a la eficiencia del sistema se desprende un promedio de 14 días entre el screening de la maternidad y la primera EOA clínica.

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.

What is the value of ENT specialist outreach clinics?

Ear, nose and throat (ENT) specialist outreach clinics, in which hospital-based consultants hold clinics in general practice surgeries, have been popular with general practitioners (GPs) and patients. This prospective study recorded data on 1155 consecutive patients seen by one ENT surgeon in two GP surgeries. At each consultation, a record was kept of the requirement for further investigations that would normally be done at the same time as the consultation in a hospital department. The results showed that 76 per cent of patients needed an investigation, which would be readily available in a hospital but not in a GP surgery (audiometry, endoscopy, microscopy of the ear, a minor procedure or X-ray). This study indicates that despite the apparent convenience of outreach ENT clinics to patients and GPs, patients may need to spend more time being assessed than they would if they were investigated in one visit to a hospital department. Unless an outreach clinic is used frequently, it is difficult to justify the cost of equipping it to the same level as a hospital department. Limited resources would be better spent providing good access to well-equipped regularly-used hospital ENT outpatient departments.

Infant hearing screening: a comparison of two techniques.

Hearing screening programs for Australian children are known to have poor coverage in many areas. In addition, only a minority of children are screened for hearing loss before 2 years of age. However, early detection of hearing loss and early treatment are generally considered very important to successful rehabilitation outcomes. Traditional methods of screening infants have limitations with their accuracy in detecting children with hearing loss. This study compared the results obtained with a traditional questionnaire approach to screening and a newer objective technique involving otoacoustic emission measures. Poor correlation was found between pass rates for the two techniques, suggesting that the questionnaire approach is not an accurate screening method for detecting infant hearing loss. With further development, otoacoustic emission testing holds promise as an objective alternative hearing screening procedure.