9/18/03 Clinical considerations in the diagnosis of otitis media (Part I - the history)SummaryOtitis media (OM) is the most frequently diagnosed infectious condition in pediatric practice (other than viral URI) estimated to result in $5 billion in annual health care costs in the USA. This subject of diagnosing OM was reviewed recently by Klaudt et al of Stanford Univ. in Palo Alto, CA. They pointed out that several studies that concluded that level of accuracy in diagnosing OM in usual clinical practice is less than satisfactory. Therefore, they discussed what they felt were key items in the diagnosis of OM. It is important to distinguish acute OM (AOM) from OM with effusion (OME). The latter is a collection of fluid (serous, mucoid, or purulent) within the middle ear, with a resultant dullness and decreased mobility of the tympanic membrane (TM). Fluid may also be present in the middle ear in AOM; however, in AOM there are also signs of acute inflammation such as fever and local pain (otalgia). Although the presence of otalgia makes AOM more likely, especially in older children (who can better verbalize pain), a history of otalgia does not itself make a diagnosis of AOM. Pulling on the ear is an unreliable sign of AOM (present in only 60% of AOM and often present in the absence of AOM). Fever is also a poor predictor (PPV of 38%). Associated rhinitis is present in almost all AOM but has low specificity in diagnosis. Thus, treating a child for AOM or not based simply on the history is inappropriate. The history alone is also inaccurate in diagnosing OME. Reference Current Allergy and Asthma Reports 2003;3:313-20 Editor’s Comments This discussion dispels some common myths about the values of certain elements in the clinical history in diagnosing OM. I have seen a number of cases where a diagnosis of AOM was "made" on the basis of a telephone conversation with the parent and no physical examination of the child. Such actions may be responsible for the over-use of antibiotics in such situations, contributing to the increase in bacterial resistance to antibiotics which has become such a problem. The aspects of physical examination in diagnosing OM discussed in this article will be reviewed subsequently by me.
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