Pediatric Annals

resident's viewpoint 

Technique Crucial When Evaluating Children's Ears

David J Skey, MD

Abstract

Bartolomeo Eustachi, a 16th Century Italian anatomist and physician, provided the first written description of the eponymous tube that plays a central role in the majority of pediatric ear disease. His description of what had previously been known as the tube auditiva appeared in Espistola de auditus organis, published in 1562. Alhough Eustachi was the first to publish, the earliest description of the tube is credited to Almaceon of Sparta who, in 400 BC, mistakenly relied on his primitive understanding of anatomy and physiology by positing the theory that the tube auditiva allowed goats to breathe through their ears.

For most practicing pediatricians, contemplation of otic pathology is somewhat more mundane than ancient Greek theories of goat ventilation. However, diseases of the middle ear deserve special attention from pediatric residents and their training programs. The skillful evaluation of children's ear-related complaints will continue to be a cornerstone of practice for the next generation of pediatricians and thus constitutes an important learning topic for today's residents.

Knowledge of the various disease processes involving the middle ear is of essential importance to the practicing pediatrician and is provided in the articles in this edition of Pediatric Annals. A correct diagnosis often rests, however, on an accurate assessment of the ear canal and tympanic membrane. It is therefore vital that pediatricians be skilled at pneumatic otoscopy and that pediatric residents learn these skills during their training.

The practical issues of examining a fussy or uncooperative child and the variability in tympanic membrane appearance present challenges to pediatric residents. The salient features found on otoscopy - eardrum position, mobility, color and translucency - all are objective findings that an adequate otoscopie exam will reveal. Even so, every resident knows the feeling of trepidation encountered when an attending physician pulls the otoscope down from the wall to confirm or deny the resident's diagnosis of acute otitis media. Thoughts of, "Did I see what I think I saw?" and "I must not know what I'm looking at" invariably pass through the mind of every resident at one time or another. Interestingly, it is a common experience for residents to discover through the course of their training that their judgment of tympanic membrane pathology seems to align more with that of certain attending physicians and stray from that of others. This anecdotal variation in diagnostic correlation speaks to the challenge of skillful otoscope use and experience with eardrum evaluation.

Most residents have observed wide variations in otoscopie technique among their attending physicians. American Academy of Pediatrics guidelines regarding ear diseases now all strongly recommend use of an insufflator with otoscopy to assess tympanic membrane mobility.1,2 Despite these recommendations and substantial evidence that pneumatic otoscopy is a comparable diagnostic tool to tympanometry and acoustic reflectometry, many pediatricians still fail to use air insufflation regularly as an adjunct to otoscopy.3'5 Even when it is used, however, several technical problems can hinder an accurate evaluation by pneumatic otoscopy. The seal created with disposable otoscopie specula often is inadequate for sufficient ear canal insufflation.6 Illumination of the tympanic membrane is often suboptimal as well, due to outdated and unchanged light bulbs.7 Additionally, there is wide intra-examiner variation in pressures generated with the pneumatic otoscope; insufflation pressure for a reliable and reproducible exam remains unclear.8

These limitations can be minimized by several simple steps. First, cuffed ear specula, available from all otoscope manufacturers, assist in creating a seal with the ear canal, thereby allowing for reliable insufflation. Second, timely replacement of otoscope bulbs (generally every 2 years or less) improves the chances of adequate lighting for examinations. The proper degree of insufflation…

Bartolomeo Eustachi, a 16th Century Italian anatomist and physician, provided the first written description of the eponymous tube that plays a central role in the majority of pediatric ear disease. His description of what had previously been known as the tube auditiva appeared in Espistola de auditus organis, published in 1562. Alhough Eustachi was the first to publish, the earliest description of the tube is credited to Almaceon of Sparta who, in 400 BC, mistakenly relied on his primitive understanding of anatomy and physiology by positing the theory that the tube auditiva allowed goats to breathe through their ears.

For most practicing pediatricians, contemplation of otic pathology is somewhat more mundane than ancient Greek theories of goat ventilation. However, diseases of the middle ear deserve special attention from pediatric residents and their training programs. The skillful evaluation of children's ear-related complaints will continue to be a cornerstone of practice for the next generation of pediatricians and thus constitutes an important learning topic for today's residents.

Knowledge of the various disease processes involving the middle ear is of essential importance to the practicing pediatrician and is provided in the articles in this edition of Pediatric Annals. A correct diagnosis often rests, however, on an accurate assessment of the ear canal and tympanic membrane. It is therefore vital that pediatricians be skilled at pneumatic otoscopy and that pediatric residents learn these skills during their training.

The practical issues of examining a fussy or uncooperative child and the variability in tympanic membrane appearance present challenges to pediatric residents. The salient features found on otoscopy - eardrum position, mobility, color and translucency - all are objective findings that an adequate otoscopie exam will reveal. Even so, every resident knows the feeling of trepidation encountered when an attending physician pulls the otoscope down from the wall to confirm or deny the resident's diagnosis of acute otitis media. Thoughts of, "Did I see what I think I saw?" and "I must not know what I'm looking at" invariably pass through the mind of every resident at one time or another. Interestingly, it is a common experience for residents to discover through the course of their training that their judgment of tympanic membrane pathology seems to align more with that of certain attending physicians and stray from that of others. This anecdotal variation in diagnostic correlation speaks to the challenge of skillful otoscope use and experience with eardrum evaluation.

Most residents have observed wide variations in otoscopie technique among their attending physicians. American Academy of Pediatrics guidelines regarding ear diseases now all strongly recommend use of an insufflator with otoscopy to assess tympanic membrane mobility.1,2 Despite these recommendations and substantial evidence that pneumatic otoscopy is a comparable diagnostic tool to tympanometry and acoustic reflectometry, many pediatricians still fail to use air insufflation regularly as an adjunct to otoscopy.3'5 Even when it is used, however, several technical problems can hinder an accurate evaluation by pneumatic otoscopy. The seal created with disposable otoscopie specula often is inadequate for sufficient ear canal insufflation.6 Illumination of the tympanic membrane is often suboptimal as well, due to outdated and unchanged light bulbs.7 Additionally, there is wide intra-examiner variation in pressures generated with the pneumatic otoscope; insufflation pressure for a reliable and reproducible exam remains unclear.8

These limitations can be minimized by several simple steps. First, cuffed ear specula, available from all otoscope manufacturers, assist in creating a seal with the ear canal, thereby allowing for reliable insufflation. Second, timely replacement of otoscope bulbs (generally every 2 years or less) improves the chances of adequate lighting for examinations. The proper degree of insufflation continues to pose a problem, though generally a tympanic membrane with impaired mobility will be evident even with forceful insufflation.

Even with adequate pneumatic examination, however, a substantial percentage of pediatricians are unable to distinguish acute otitis media (AOM) from otitis media with effusion (OME) reliably.9 Structured training in evaluating images of tympanic membranes has been shown to improve resident accuracy in diagnosing middle ear effusion and characterizing the nature of the effusion.10 Historical and clinical findings play a central role in helping to clarify the nature of effusions as well. For example, fever and acute onset of pain or fussiness are more indicative of AOM, whereas recent minor hearing loss and ear tugging without systemic symptoms are suggestive of OME.

Armed with insight into the importance of recognizing and describing effusions and the effectiveness of formal training, several pediatric residency programs have instituted formalized teaching in otoscopie evaluation and interpretation. Given the conjectured role of liberal antibiotic use, because of abnormalappearing tympanic membranes, promoting the development of antibiotic resistance, accurate tympanic membrane evaluation is of particular importance to today's pediatrician. Because the prevalence of OME is greater than that of AOM in the general pediatric population and OME often is misdiagnosed as AOM, one would hypothesize that adequate resident training in pneumatic otoscopy technique and interpretation would result in decreased antibiotic prescribing. Such a study has yet to be done.

Although few, if any, pediatric residents and pediatricians choose the specialty for its abundant opportunity to diagnose and treat otic pathology, the frequency of ear-related complaints should induce each of us to gain a thorough understanding of the pathophysiology, evaluation, and management of ear disease. Training and experience in evaluating the tympanic membrane remain important goals of pediatric residency. In addition, familiarity with evaluating less common ear-related complaints, such as otorrhea and suspected hearing loss, are vital skills for pediatric residents to master.

REFERENCES

1. American Academy of Pediatrics Subcommittee on Management of Acute Otitis Media. Diagnosis and management of acute otitis media. Pediatrics. 2004; 113(5):1451-1465.

2. American Academy of Family Physicians; American Academy of Otolaryngology-Head and Neck Surgery; American Academy of Pediatrics Subcommittee on Otitis Media With Effusion. Otitis media with effusion. Pediatrics. 2004; 113(5):1412-1429.

3. Barnett ED, Klein JO, Hawkins KA, et al. Comparison of spectral grathent acoustic reflectometry and other diagnostic techniques for detection of middle ear effusion in children with middle ear disease. Pediatr Infect Dis J. 1 998; 1 7(6):556-559.

4. Takata GS, Chan LS, Morphew T, et al. Evidence assessment of the accuracy of methods of diagnosing middle ear effusion in children with otitis media with effusion. Pediatrics. 2003; 112(6 Pt 1):1379-1387.

5. Jones WS, Kaleida PH. How helpful is pneumatic otoscopy in improving diagnostic accuracy? Pediatrics. 2003; 112(3 Pt 1):510-513.

6. Cavanaugh RM Jr. Obtaining a seal with otic specula: must we rely on an air of uncertainty? Pediatrics. 1991:87(1): 114-116.

7. Barriga F, Schwartz RH, Hayden GF. Adequate illumination for otoscopy. Variations due to power source, bulb, and head and speculum design. Am J Dis Child. 1986; 140(1 2): 1 237- 1240.

8. Cavanaugh RM Jr. Pediatricians and the pneumatic otoscope: are we playing it by ear? Pediatrics. 1989;84(2):362-364.

9. Pichichero ME. Diagnostic accuracy of otitis media and tympanocentesis skills assessment among pediatricians. Eur J Clin Microbiol Infect Dis. 2003 22(9):5 19-524.

10. Wormald PJ, Browning GG. Robinson K Is otoscopy reliable? A structured teach ing method to improve otoscopie accura cy in trainees. Clin Otolaryngol. 1995 20(l):63-67.

10.3928/0090-4481-20041201-12

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