Smartphone Otoscopy Performed by Parents.

Introduction:Implementation of pediatric telemedicine has been emphasized. We examined whether parents could perform smartphone otoscopy for the diagnosis of otitis media.Materials and Methods:We included children (6-35 months) attending day care with at least one episode of acute otitis media (AOM) within 90 days of the study entry. The timing for a teaching intervention was randomized. In the immediate teaching group, parents were taught smartphone otoscopy and cerumen was removed at the first visit. The delayed teaching group received the teaching intervention after 1 week's independent use. During the 60 study days, parents performed home examinations. The main outcome, the diagnostic quality of the tympanic membrane videos to determine healthy ear, otitis media with effusion (OME) and AOM diagnoses was measured with a structured video analysis independently by three physicians. Parents' experience was measured with a questionnaire.Results:AOM could be detected or excluded in 87% (609/699) of the videos during acute symptoms. After the teaching intervention, healthy ear, OME, or AOM could be diagnosed in 40% (521/1,293) of the videos. During the first week's intervention, one of the three diagnoses was attained in 33% (50/153) and in 12% (22/179) of the videos in the immediate and delayed teaching group, respectively (p < 0.001). The performance of the smartphone otoscopy examination was easy in 85% (35/41) of families.Discussion:After been taught, parents are able to perform smartphone otoscopy for the remote detection or exclusion of AOM.Conclusions:Future studies should assess the clinical usefulness of parent-performed smartphone otoscopy.

Impact of Antimicrobial Treatment for Acute Otitis Media on Carriage Dynamics of Penicillin-Susceptible and Penicillin-Nonsusceptible Streptococcus pneumoniae.

Background: Despite concerns that antimicrobial treatment of prevalent infections may select for drug-resistant bacteria, the effects of antimicrobial treatment on colonization dynamics have not been well quantified. Methods: We measured impacts of antimicrobial treatment on nasopharyngeal carriage of penicillin-susceptible Streptococcus pneumoniae (PSSP) and penicillin-nonsusceptible (PNSP) lineages at the end of treatment and 15, 30, and 60 days after treatment in a previously conducted randomized, double-blinded, placebo-controlled trial of amoxicillin-clavulanate for stringently defined acute otitis media. Results: In intention-to-treat analyses, immediate treatment with amoxicillin-clavulanate reduced PSSP carriage prevalence by 88% (95% confidence interval [CI], 76%-96%) at the end of treatment and by 27% (-3%-49%) after 60 days but did not alter PNSP carriage prevalence. By the end of treatment, 7% of children who carried PSSP at enrollment remained colonized in the amoxicillin-clavulanate arm, compared with 61% of PSSP carriers who received placebo; impacts of amoxicillin-clavulanate persisted at least 60 days after treatment among children who carried PSSP at enrollment. Amoxicillin-clavulanate therapy reduced PSSP acquisition by >80% over 15 days. Among children who carried PNSP at enrollment, no impacts on carriage prevalence of S. pneumoniae, PSSP, or PNSP were evident at follow-up visits. Conclusions: Although the absolute risk of carrying PNSP was unaffected by treatment, antimicrobial therapy conferred a selective impact on colonizing pneumococci by accelerating clearance and delaying acquisition of PSSP.

Adaptation of pain scales for parent observation: are pain scales and symptoms useful in detecting pain of young children with the suspicion of acute otitis media?

BACKGROUND: The assessment of ear pain is challenging in young, mostly preverbal children. Our aim was to investigate whether pain scales are useful tools for parents to detect pain in their young children with the suspicion of acute otitis media (AOM), and to assess associations between 16 symptoms and the severity of pain. METHODS: This cross-sectional study included 426 children (6-35 months) with symptoms suggestive of AOM. We surveyed symptoms and pain via parental interview. As part of the interview, parents assessed their child's pain by using two pain scales: The Faces Pain Scale-Revised (FPS-R) and the Face, Legs, Activity, Cry, Consolability (FLACC) Scale. The outcome of interest was moderate/severe pain. We used the χ2 test or Fisher's test as applicable to compare the severity of pain between three parental pain assessment methods (the parental interview, the FPS-R and the FLACC Scale). We also used multivariable logistic regression models to study the association between the severity of pain and AOM and to study the association between symptoms and the severity of pain. RESULTS: In children with AOM (n = 201), pain was assessed by parents as moderate/severe in 65% via interview; 90% with the FPS-R; and 91% with the FLACC Scale (P < 0.001). In children without AOM (n = 225), the percentages were 56, 83 and 88%, respectively (P < 0.001). Between children with and without AOM, the occurrence of moderate/severe pain did not differ with any of the pain evaluation methods. Of symptoms, ear pain reported by child and restless sleep were significantly associated with moderate/severe pain, regardless of the pain evaluation method. CONCLUSIONS: It seems that nearly all the children with respiratory tract infection, either with or without AOM, might suffer from moderate/severe pain. Without pain scales, parents may underestimate their child's pain. Of symptoms, ear pain reported by child and restless sleep might indicate pain in children with respiratory tract infection. We suggest that the adaptation of pain scales for parent observation is a possibility in children with respiratory tract infection which, however, requires further studies. TRIAL REGISTRATION: www.clinicaltrials.gov , identifier NCT00299455 . Date of registration: March 3, 2006.

Can nurses exclude middle-ear effusion without otoscopy in young asymptomatic children in primary care?

OBJECTIVE: Scandinavian guidelines recommend controlling middle-ear effusion (MEE) after acute otitis media. The study aim was to determine whether nurses without otoscopic experience can reliably exclude MEE with tympanometry or spectral gradient acoustic reflectometry (SG-AR) at asymptomatic visits. DESIGN: Three nurses were taught to perform examinations with tympanometry and SG-AR. Pneumatic otoscopy by the study physician served as the diagnostic standard. SETTING: Study clinic at primary health care level. PATIENTS: A total of 156 children aged 6-35 months. MAIN OUTCOME MEASURES: Predictive values (with 95% confidence interval) for tympanometry and SG-AR, and the clinical usefulness, i.e. the proportion of visits where nurses obtained the exclusive test result from both ears of the child. RESULTS: At 196 visits, the negative predictive value of type A and C1 tympanograms (tympanometric peak pressure > -200 daPa) was 95% (91-97%). Based on type A and C1 tympanograms, the nurse could exclude MEE at 81/196 (41%) of visits. The negative predictive value of SG-AR level 1 result was 86% (79-91%). Based on SG-AR level 1 results, the nurse could exclude MEE at 29/196 (15%) of visits. CONCLUSION: Tympanograms with tympanometric peak pressure > -200 daPa (types A and C1) obtained by nurses are reliable test results in excluding MEE. However, these test results were obtained at less than half of the asymptomatic visits and, thus, the usefulness of excluding MEE by nurses depends on the clinical setting.

Can trained nurses exclude acute otitis media with tympanometry or acoustic reflectometry in symptomatic children?

OBJECTIVE: Since acute otitis media (AOM) is the most prevalent bacterial infection in young children, the reliable exclusion of AOM by nurses might save physicians' time for other duties. The study aim was to determine whether nurses without otoscopic experience can reliably use tympanometry or spectral gradient acoustic reflectometry (SG-AR) to exclude AOM. DESIGN: Three nurses were trained, who performed examinations with tympanometry and SG-AR. Pneumatic otoscopy by the study physician served as the diagnostic standard. SETTING: Study clinic at primary health care level. PATIENTS: 281 children 6-35 months of age. MAIN OUTCOME MEASURES: Predictive values (with 95% confidence interval) for tympanometry and SG-AR, and the clinical usefulness, i.e. the proportion of visits where nurses obtained the exclusive test result from both ears of the child. RESULTS: At 459 visits, the negative predictive value of type A and C1 tympanograms (tympanometric peak pressure >-200 daPa) was 94% (91-97%). Based on type A and C1 tympanograms, the nurse could exclude AOM at 94/459 (20%) of visits. The negative predictive value of SG-AR level 1 result (>95°) was 94% (89-97%). Based on the SG-AR level 1 result, the nurse could exclude AOM at 36/459 (8%) of visits. CONCLUSION: Type A and C1 tympanograms and SG-AR level 1 results obtained by nurses are reliable test results in excluding AOM. However, the clinical usefulness of these test results is limited by their rarity. Type A and C1 tympanograms were obtained by nurses from both ears of the child only at one-fifth of the symptomatic visits. Key Points Acute otitis media (AOM) is the most prevalent bacterial infection in young children. Nurses' role in excluding AOM is unknown. Type A and C1 tympanograms (tympanometric peak pressure >-200 daPa) obtained by nurses are reliable test results in excluding AOM. With type A and C1 tympanograms, nurses could exclude AOM only at one-fifth of the symptomatic visits. The clinical usefulness of the exclusion of AOM performed by nurses seems to be limited.

A placebo-controlled trial of antimicrobial treatment for acute otitis media.

BACKGROUND: The efficacy of antimicrobial treatment in children with acute otitis media remains controversial. METHODS: In this randomized, double-blind trial, children 6 to 35 months of age with acute otitis media, diagnosed with the use of strict criteria, received amoxicillin-clavulanate (161 children) or placebo (158 children) for 7 days. The primary outcome was the time to treatment failure from the first dose until the end-of-treatment visit on day 8. The definition of treatment failure was based on the overall condition of the child (including adverse events) and otoscopic signs of acute otitis media. RESULTS: Treatment failure occurred in 18.6% of the children who received amoxicillin-clavulanate, as compared with 44.9% of the children who received placebo (P<0.001). The difference between the groups was already apparent at the first scheduled visit (day 3), at which time 13.7% of the children who received amoxicillin-clavulanate, as compared with 25.3% of those who received placebo, had treatment failure. Overall, amoxicillin-clavulanate reduced the progression to treatment failure by 62% (hazard ratio, 0.38; 95% confidence interval [CI], 0.25 to 0.59; P<0.001) and the need for rescue treatment by 81% (6.8% vs. 33.5%; hazard ratio, 0.19; 95% CI, 0.10 to 0.36; P<0.001). Analgesic or antipyretic agents were given to 84.2% and 85.9% of the children in the amoxicillin-clavulanate and placebo groups, respectively. Adverse events were significantly more common in the amoxicillin-clavulanate group than in the placebo group. A total of 47.8% of the children in the amoxicillin-clavulanate group had diarrhea, as compared with 26.6% in the placebo group (P<0.001); 8.7% and 3.2% of the children in the respective groups had eczema (P=0.04). CONCLUSIONS: Children with acute otitis media benefit from antimicrobial treatment as compared with placebo, although they have more side effects. Future studies should identify patients who may derive the greatest benefit, in order to minimize unnecessary antimicrobial treatment and the development of bacterial resistance. (Funded by the Foundation for Paediatric Research and others; ClinicalTrials.gov number, NCT00299455.).

Effect of Antimicrobial Treatment on the Resolution of Middle-Ear Effusion After Acute Otitis Media.

BACKGROUND: Acute otitis media (AOM) induces middle-ear effusion (MEE), which affects hearing. The effect of antimicrobial treatment on the resolution of MEE is controversial, and the factors that affect resolution are unknown. METHODS: We studied the effect of antimicrobial treatment on the time to the resolution of MEE as a secondary objective in our randomized double-blind placebo-controlled trial. Children aged 6 to 35 months with stringently diagnosed AOM were allocated to receive amoxicillin-clavulanate (161 patients) or placebo (158 patients) for 7 days and closely followed for 3 months. This study was registered at ClinicalTrials.gov (identifier NCT00299455). RESULTS: The median times to resolution of MEE were 20 days (95% confidence interval [CI], 16-24 days) and 29 days (95% CI, 26-32 days) in the amoxicillin-clavulanate and placebo groups, respectively (P = .10). The resolution of MEE was confirmed in 138 (86%) of 161 and 132 (84%) of 158 patients in the amoxicillin-clavulanate and placebo groups, respectively (P = .59). In multivariable analysis, the resolution of MEE was prolonged most significantly by at least 1 recurrence of AOM during follow-up. MEE resolved in 65 (65%) of 100 patients with a recurrence of AOM during follow-up and in 205 (94%) of 219 of those without a recurrence (P < .001) (median times to resolution, 67 vs 15 days, respectively; P < .001). CONCLUSIONS: Immediate antimicrobial treatment of AOM does not significantly affect the resolution of MEE in young children. Subsequent recurrences of AOM are a major reason for the persistence of MEE.

Prognostic Factors for Treatment Failure in Acute Otitis Media.

BACKGROUND AND OBJECTIVES: Antimicrobial treatment is effective in the management of acute otitis media (AOM), but approximately half of the children may recover without antimicrobial agents. By identifying patients who may not require antimicrobial treatment for the management of AOM, the use of antimicrobial agents could be substantially reduced. Our aim was to identify subgroups of children with AOM who would benefit most from antimicrobial treatment and children who could be suitable for initial observation. METHODS: This is a secondary analysis of randomized, double-blind, placebo-controlled trial. Children 6 to 35 months of age with AOM (N = 319) were randomly allocated to receive amoxicillin-clavulanate (40/5.7 mg/kg per day) or placebo for 7 days. Our primary outcome was time until treatment failure. RESULTS: Treatment failure occurred in 31.7% of all children. Older age (24-35 months) and peaked tympanogram at entry decreased the hazard for treatment failure (hazard ratio, 0.53; 95% confidence interval [CI], 0.29 to 0.96; P = .04; and hazard ratio, 0.43; 95% CI, 0.21 to 0.88; P = .02, respectively). The rate difference for treatment failure between antimicrobial treatment and placebo groups was highest among children with severe bulging of the tympanic membrane (11.1% vs 64.1%; rate difference -53.0%; 95% CI, -73.5% to -32.4%), resulting in a number needed to treat of 1.9. CONCLUSIONS: Children with severe bulging of the tympanic membrane seem to benefit most from antimicrobial treatment of AOM. On the other hand, children with peaked tympanogram (A and C curves) may be optimal candidates for initial observation.

Can changes in parentally measured acoustic reflectometry levels predict the middle ear status?

OBJECTIVE: Spectral gradient acoustic reflectometry (SG-AR) may be used to detect middle ear effusion. Our aim was to investigate whether increasing SG-AR levels between two SG-AR examinations indicate deterioration from a healthy middle ear to acute otitis media (AOM). METHODS: We enrolled 185 children (age 6-35 months) whose parents were willing to use the SG-AR at home daily. Measurement pairs of parental home SG-AR examination results were generated and analyzed. There was one SG-AR examination result obtained within ±1 day of the reference visit and another result within ±1 day of the subsequent visit. We defined the SG-AR level as increasing when the difference between two measurements was ≥2 levels from a lower to a higher level, suggesting development of AOM. When the SG-AR level difference was ≤1, we defined this no change of the SG-AR level. The middle ear diagnosis was determined by pneumatic otoscopy at the study clinic. RESULTS: 361 paired SG-AR home measurements were obtained. The reference measurement was related to a healthy middle ear as determined by pneumatic otoscopy. Increasing SG-AR levels (59/361), were 63% (95% CI 50%-74%) sensitive and 94% (91%-97%) specific for deterioration of a healthy middle ear to AOM. The positive predictive value was 71% (58%-82%) and the negative predictive value was 92% (88%-95%). When there was no SG-AR level difference between the SG-AR examinations, the corresponding figures were 88% (95% CI 84%-92%), 69% (56%-79%), 93% (89%-95%) and 57% (45%-68%), respectively. CONCLUSIONS: This study shows that increasing SG-AR levels might not be sufficiently sensitive to detect deterioration of the middle ear status from healthy middle ear to AOM in symptomatic children. Importantly, however, the development of AOM seems to be unlikely in an initially healthy middle ear when there is no difference between the SG-AR levels in two separate measurements.

Parental role in the diagnostics of otitis media: can layman parents use spectral gradient acoustic reflectometry reliably?

OBJECTIVE: Spectral gradient acoustic reflectometry (SG-AR) can be used to detect middle ear effusion (MEE). Since both families and primary health care systems carry the burden of otitis media, our aim was to determine whether layman parents could be taught to use the SG-AR reliably. METHODS: We enrolled 359 children (age 6-35 months) whose parents were willing to use SG-AR at home. The parents were asked to perform bilateral SG-AR daily on their child. In this study, we included children who had undergone successful parental home SG-AR examination performed on the same day that a physician had also performed successful SG-AR examination and pneumatic otoscopy at the study clinic. We compared the parental and study physician SG-AR examination results to the study physicians' pneumatic otoscopy, which served as the diagnostic standard. RESULTS: We analyzed 571 successful parental home SG-AR examinations performed on the same day that a study physician had performed a successful SG-AR examination and pneumatic otoscopy at the study clinic. None of the evaluated SG-AR level combinations resulted in both high sensitivity and specificity. For symptomatic visits, the negative predictive value of a parental SG-AR level 1 to detect MEE was 64%. For parental SG-AR levels 4-5, the positive predictive value to detect MEE was 88%. However, for asymptomatic visits, the negative predictive value of a parental SG-AR level 1 to detect MEE was 83%. CONCLUSION: This study showed that layman parents are able to use the SG-AR technically successfully. In symptomatic children, parentally obtained SG-AR level 1 examination is not adequate to exclude MEE. However, parentally obtained SG-AR levels 4-5 do indicate the presence of MEE. At the same time, in asymptomatic children, parentally obtained SG-AR level 1 examination seems to indicate a healthy middle ear. From the perspective of primary care, the implementation of parental SG-AR examinations in the diagnostic chain of otitis media would be intriguing. This study showed that the possibilities lie in the follow up of the resolution of MEE after an episode of OM in asymptomatic children. However, it seems that currently, the SG-AR technique is an obstacle for wider clinical implementation.

Role of Nasopharyngeal Bacteria and Respiratory Viruses in Acute Symptoms of Young Children.

BACKGROUND: The spectrum of acute symptoms in young outpatient children with respiratory tract infection (RTI) is variable, and it cannot be explained by the diagnosis of acute otitis media (AOM) versus uncomplicated RTI. We studied that the variation of symptoms is explained by the nasopharyngeal bacteria and/or respiratory viruses. METHODS: Children aged 6-35 months with acute symptoms with AOM (n = 201) or without AOM (n = 225) were eligible in this cross-sectional study. We analyzed their nasopharyngeal samples for pathogenic bacteria by culture and for respiratory viruses by polymerase chain reaction. We surveyed 17 symptoms (fever, respiratory, ear related, nonspecific, gastrointestinal) with a structured questionnaire. RESULTS: Fever had a positive association with influenza viruses [odds ratio (OR): 6.61; 95% confidence interval (CI): 1.66-26.27], human metapneumovirus (OR: 3.84; 95% CI: 1.25-11.77), coronaviruses (OR: 3.45; 95% CI: 1.53-7.75) and parainfluenza viruses (OR: 2.18; 95% CI: 1.07-4.47). Rhinitis (OR: 5.07; 95% CI: 1.93-13.36), nasal congestion (OR: 2.03; 95% CI: 1.25-3.31) and cough (OR: 1.91; 95% CI: 1.15-3.17) had positive associations with Moraxella catarrhalis. Furthermore, cough had a positive association with respiratory syncytial virus (OR: 7.20; 95% CI: 1.59-32.71) and parainfluenza viruses (OR: 2.79; 95% CI: 1.02-7.69). CONCLUSIONS: The variation of acute symptoms in young children may be influenced by both nasopharyngeal bacteria and respiratory viruses. Our results showed a strong association between fever and respiratory viruses; rhinitis, nasal congestion and cough were associated with M. catarrhalis in the presence of viruses. Further studies are required to determine the possible synergistic role of M. catarrhalis in symptoms of RTI.

Parental role in the diagnostics of otitis media: can parents be taught to use tympanometry reliably?

OBJECTIVE: Tympanometry can be used to detect middle ear effusion (MEE). As the need for rearrangement of clinical resources at the primary care level increases, it is important to determine whether layman parents could be taught to use the tympanometer reliably, aiming to reduce unnecessary physician visits during respiratory tract infections. METHODS: From our AOM treatment trial we enrolled 78 children (age 6-35 months) who had persistent MEE, parents were voluntary and willing to use a tympanometer at home, the child was sufficiently co-operative, and parents learned technically the use of the tympanometer. At home, parents were asked to perform daily bilateral tympanometry on their child. We included those parental tympanometric examinations, to which the corresponding tympanometric examination, within one day by a study physician was available. Parental tympanometric examinations were compared to the pneumatic otoscopy by a study physician which served as the diagnostic standard. RESULTS: This study involved 78 children and a total of 432 parental tympanometric examinations. From these 432 examinations, parents obtained an interpretable tympanogram in 83% (359/432) and physicians in 91% (393/432) (absolute rate difference 8%, 95% CI 3-12%). Both obtained an interpretable tympanogram from the same ear in 75% (326/432) of the tympanometric examinations. Of these 326 interpretable examinations, parents and physicians were in accordance with either a peaked or a flat tympanogram in 88% of examinations (288/326) (kappa-value 0.77). When the tympanogram was peaked, pneumatic otoscopy indicated healthy middle ear in 72% (122/169) of parental and in 69% (149/217) of study physicians' tympanometric examinations (absolute rate difference 4%, 95% CI -6% to 13%). When the tympanogram was flat, pneumatic otoscopy indicated any MEE in 92% of parental (174/190) and in 96% (169/176) of study physicians' tympanometric examinations (absolute rate difference 4%, 95% CI -9% to 1%). CONCLUSION: This study showed that layman parents are able to use tympanometry technically successfully, and that the parental tympanometric examinations are as reliable as those obtained by study physicians.

Symptoms and otoscopic signs in bilateral and unilateral acute otitis media.

OBJECTIVE: Bilateral acute otitis media (AOM) is considered more severe than unilateral AOM, and several guidelines recommend more active treatment and/or follow-up of bilateral AOM. We studied whether bilateral AOM is a clinically more severe illness than unilateral AOM by comparing symptoms and otoscopic signs between bilateral and unilateral AOM. METHODS: Two hundred thirty-two children aged 6 to 35 months diagnosed with AOM were eligible. We surveyed the symptoms with a structured questionnaire and recorded the otoscopic signs systematically. RESULTS: Ninety-eight children had bilateral and 134 children unilateral AOM. Children with bilateral AOM were more often <24 months than children with unilateral AOM (87% vs 75%; P = .032). Fever (≥38°C) occurred in 54% and 36% (P = .006) and severe conjunctivitis in 16% and 44% (P = .047) of children with bilateral and unilateral AOM, respectively. In 15 other symptoms, we found no overall differences even when adjusted with age. We observed the following severe otoscopic signs in the bilateral and unilateral AOM group, respectively: moderate/marked bulging of tympanic membrane (63% and 40%; P = .001), purulent effusion (89% and 71%; P = .001), bulla formation (11% and 10%; P = .707), and hemorrhagic redness of tympanic membrane (7% and 10%; P = .386). CONCLUSIONS: Bilateral AOM seems to be a clinically only slightly more severe illness than unilateral AOM. Therefore, when assessing AOM severity, bilaterality should not be used as a determining criterion; instead, the child's symptomatic condition together with otoscopic signs should also be taken into consideration.

Bacterial and viral interactions within the nasopharynx contribute to the risk of acute otitis media.

OBJECTIVES: To understand relationships between microbes in pathogenesis of acute otitis media during respiratory tract infections, we compared nasopharyngeal bacteria and respiratory viruses in symptomatic children with and without AOM. METHODS: We enrolled children (6-35 months) with acute symptoms suggestive of AOM and analyzed their nasopharyngeal samples for bacteria by culture and for 15 respiratory viruses by PCR. Non-AOM group had no abnormal otoscopic signs or only middle ear effusion, while AOM group showed middle ear effusion and acute inflammatory signs in pneumatic otoscopy along with acute symptoms. RESULTS: Of 505 children, the non-AOM group included 187 and the AOM group 318. One or more bacterial AOM pathogen (Streptococcus pneumoniae, Haemophilus influenzae, or Moraxella catarrhalis) was detected in 78% and 96% of the non-AOM and AOM group, respectively (P < .001). Colonization with S. pneumoniae and H. influenzae, each alone, increased risk of AOM (odds ratio (OR) 2.92; 95% confidence interval (CI), .91-9.38, and 5.13; 1.36-19.50, respectively) and co-colonization with M. catarrhalis further increased risk (OR 4.36; 1.46-12.97, and 9.00; 2.05-39.49, respectively). Respiratory viruses were detected in 90% and 87% of the non-AOM and AOM group, respectively. RSV was significantly associated with risk of AOM without colonization by bacterial AOM pathogens (OR 6.50; 1.21-34.85). CONCLUSIONS: Co-colonization by M. catarrhalis seems to increase risk of AOM and RSV may contribute to AOM pathogenesis even without nasopharyngeal bacterial colonization.

Delayed versus immediate antimicrobial treatment for acute otitis media.

BACKGROUND: Watchful waiting with the option of delayed antimicrobial treatment for acute otitis media is recommended in several guidelines. Our aim was to study whether delayed, as compared with immediate, initiation of antimicrobial treatment worsens the recovery from acute otitis media in young children. METHODS: Children (6-35 months) with acute otitis media received either delayed or immediate antimicrobial treatment with amoxicillin-clavulanate for 7 days. The delayed antimicrobial treatment group (n = 53) consisted of placebo recipients from a randomized-controlled trial to whom antimicrobial treatment was initiated after a watchful waiting period. The immediate antimicrobial treatment group (n = 161) consisted of children allocated to receive antimicrobial treatment immediately. RESULTS: Improvement during antimicrobial treatment (which includes both symptoms and otoscopic signs) was observed in 91% and 96% of children in the delayed and immediate antimicrobial treatment groups, respectively (P = 0.15). Median watchful waiting period was 48 hours. Delayed initiation of antimicrobial treatment was associated with prolonged resolution of fever, ear pain, poor appetite and decreased activity, but not ear rubbing, irritability, restless sleep or excessive crying. Parents of children in the delayed antimicrobial treatment group missed more work days (mean 2.1 versus 1.2 days, P = 0.03). Diarrhea, vomiting and rash were equally common in both groups. CONCLUSIONS: Our results indicate that delayed initiation of antimicrobial treatment does not worsen the recovery from acute otitis media, as measured by improvement during treatment. However, watchful waiting before the initiation of delayed antimicrobial treatment might be associated with transient worsening of a child's condition, prolongation of symptoms and economic losses.

Acoustic reflectometry in discrimination of otoscopic diagnoses in young ambulatory children.

BACKGROUND: Studies concerning spectral gradient acoustic reflectometry (SG-AR) have analyzed middle ear effusion only as 1 entity. The usefulness of SG-AR to detect specific otoscopic diagnoses of otitis media in young children is unknown. METHODS: Among 515 children aged 6-35 months, we compared SG-AR with pneumatic otoscopy and evaluated the proportions of 5 manufacturer-recommended SG-AR levels in relation to specific otoscopic diagnoses in 2802 and 1240 examinations at symptomatic and asymptomatic visits, respectively. RESULTS: At symptomatic visits, when the angle value was >95° (level 1), healthy middle ear was diagnosed in 76% of otoscopic examinations and acute otitis media in 5%. Levels 2 (70-95°) and 3 (60-69°) did not relate to any otoscopic diagnosis. Levels 4 and 5 associated with acute otitis media in 50% and 64%, and otitis media with effusion in 33% and 32% of examinations, respectively. At asymptomatic visits, levels 1, 2 and 3 were associated with healthy middle ear in 87%, 71% and 54% of examinations, respectively. With levels 4 and 5, otitis media with effusion was diagnosed in 62% and 79% of examinations, respectively. CONCLUSIONS: SG-AR is not useful in making specific otoscopic diagnoses. Although the extremities of 5 SG-AR levels are able to differentiate ears with and without effusion, SG-AR is not able to differentiate acute otitis media from otitis media with effusion. Therefore, SG-AR can aid in diagnostics, but careful pneumatic otoscopy is needed to determine accurate diagnoses.

Tympanometry in discrimination of otoscopic diagnoses in young ambulatory children.

BACKGROUND: Tympanometry can indicate middle ear effusion in children referred for tympanostomy tube placement. In outpatient setting, objective adjunctive tools are needed to diagnose the otitis media spectrum. METHODS: We enrolled and followed 515 children aged 6-35 months at primary care level. We compared tympanometry with pneumatic otoscopy and evaluated the proportions of type A, C1, C2, Cs and B tympanograms in relation to specific otoscopic diagnoses in 2206 and 1006 examinations at symptomatic and asymptomatic visits, respectively. RESULTS: At symptomatic visits, different peaked tympanograms were associated with a healthy middle ear as follows: type A in 78%, type C1 in 62%, type C2 in 54% and type Cs in 18% of examinations. In contrast, any peaked tympanogram was related to healthy middle ear in 67% of examinations. Flat (type B) tympanogram was related to otitis media with effusion in 44% and to acute otitis media in 56% of examinations, respectively. At asymptomatic visits, the peaked tympanograms together were associated with a healthy middle ear in 87% of otoscopic examinations. Flat tympanogram indicated otitis media with effusion as well in 87% of examinations. CONCLUSIONS: Tympanometry is not a useful tool in detecting specific otoscopic diagnoses because it cannot distinguish between otitis media with effusion and acute otitis media. However, among outpatients all peaked tympanograms suggest a healthy middle ear and a flat tympanogram is useful in detecting any middle ear effusion. Thus, tympanometry can be used as an adjunctive tool, but accurate diagnosis requires careful pneumatic otoscopy.

Symptoms or symptom-based scores cannot predict acute otitis media at otitis-prone age.

OBJECTIVE: Acute symptoms are used to diagnose and manage acute otitis media (AOM). We studied whether AOM could be predicted by the reason for parental suspicion of AOM or by the occurrence, duration, and/or severity of symptoms. We also compared scores including or excluding tympanic-membrane examination of children with and without AOM. PATIENTS AND METHODS: Children aged 6 to 35 months with parental suspicion of AOM were eligible. Before tympanic-membrane examination, we registered on a structured questionnaire the reason for parental suspicion of AOM, symptoms, and score components. RESULTS: Of 469 children studied, 237 had AOM and 232 had respiratory tract infection without AOM. The most common reason for parental suspicion of AOM, restless sleep, was not predictive for AOM (RR: 1.0 [95% CI: 0.8-1.2]), nor was ear-rubbing (relative risk [RR]: 0.7 [95% confidence interval (CI): 0.5-1.0]). Neither the occurrence of fever (RR: 1.2 [95% CI: 1.0-1.4]) nor the highest mean temperature within 24 hours predicted AOM, nor did the occurrences of ear-related, nonspecific, respiratory, or gastrointestinal symptoms. The duration and severity of symptoms were not predictive for AOM, although rhinitis lasted longer and conjunctivitis was more severe in children with AOM. The clinical/otologic score (median: 4.0 vs 2.0; P = .000) and the AOM total-severity index (11.0 vs 6.0; P = .000), both including symptoms and tympanic-membrane examination, were higher in those with AOM. The AOM severity-of-symptom scale, based solely on symptoms, was equal in children with and without AOM (6.0 vs 6.0; P = .917). CONCLUSIONS: AOM cannot be predicted by the occurrence, duration, or severity of symptoms at otitis-prone age. Likewise, solely symptom-based scores do not differentiate between respiratory tract infections with or without AOM. Thus, tympanic-membrane examination is crucial in the diagnosis and severity classification of AOM in clinical practice and research settings.