PEDIATRIC ANNALS 42:12 | DECEMBER 2013 Healio.com/Pediatrics | 485

Healthy BabyPractical advice for treating newborns and toddlers.

Acute otitis media (AOM) should remain an entirely visual di-agnosis for all of us. A much-improved guideline on the diagnosis and management of AOM was recently pub-lished in Pediatrics.1 The new diagnostic emphasis in AOM is now the presence of infected middle ear effusion (MEE), as it appears with different levels of a bulging or convex tympanic membrane (TM). In the guidelines, the child with moderate to severe bulging TM or otorrhea is definitely considered to have AOM, whereas the child with mild bulging TM (once termed “fullness”) should also have concomitant recent ear pain or intense TM erythema. Remember that straight-forward otitis me-dia with effusion, or serous otitis, should not be treated with antibiotics, but rather followed up over several months.

As every pediatrician is keenly aware, AOM is the most common reason for pre-scribing antibiotics in every general clinical practice. In fact, before routine PCV7/13 vaccination, an AOM episode developed

in 94% of all children in a non-inner city population by the age of 24 months.2 So, one would assume that probably the most important aspect in the entire discussion of AOM and its treatment would be how to correctly diagnose AOM and the optimal methods needed to obtain its diagnosis; however, one would be mistaken. Shaikh and Hoberman3 briefly addressed this problem in 2010.

We are all painfully aware of how poor-ly diagnosed or misdiagnosed AOM can often be. Just ask any otolaryngologist or general pediatrician who sees patients in follow-up from many of their own less-experienced health providers, community emergency rooms, urgent care centers, and even from other too-busy pediatric offices.

Unfortunately, for such an everyday problem, the amount of time spent on teaching the correct diagnoses and man-agement of AOM in medical school is negligible. Even in most pediatric and fam-ily practice training programs, training is minimal. So, why do we give such short shrift to such an important, ubiquitous pe-diatric assessment that must be ascertained in nearly every young pediatric patient’s well or sick visit?

Do not kid yourself; this is one of the most technically difficult tasks to perform on young children within a general pedi-atric practice. It requires a confident, firm parent to restrain the child, as well as your own extreme diligence, patience, a lot of upper arm strength, and a stable eye to

Improving the Diagnosis of Acute Otitis Media: “Seeing Is Believing”Stan L. Block, MD, FAAP

Stan L. Block, MD, FAAP, is Professor of Clinical

Pediatrics, University of Louisville, and University of

Kentucky, Lexington, KY; President, Kentucky Pedi-

atric and Adult Research Inc.; and general pediatri-

cian, Bardstown, KY.

Address correspondence to Stan L. Block, MD,

FAAP, via email: slblockmd@hotmail.com.

Disclosure: Dr. Block has no relevant financial

relationships to disclose.

doi: 10.3928/00904481-20131122-05

Figure 1. Welch-Allyn otoscopic heads and a handle. (A) This is the “Macroview” (preferred). (B) This is the less expensive “standard” oto-scopic head. (C) This is the Welch-Allyn “sur-gical” head with green round speculum. (D) Otoscopic handle (top): the lithium ion battery (preferred); otoscopic handle (bottom): the nickel cadmium battery — just not as bright or long lasting, and as the battery wears, the light becomes subtly and almost imperceptibly duller for quite awhile.

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perform this task in most children younger than 24 months and in many children up to 4 years old. To compound the technical difficulties, the TMs in nearly 80% of chil-dren under age 12 months are partially or totally obscured by wax.4 You may never adequately see the TMs in most of these children without some manner of cleaning the debris from the ear canals. Thus, it can often take a great deal of extra time and ef-

fort to obtain the correct diagnosis — hard to do in busy office practice!

For example, each of the following ob-stacles may become glaringly manifest as you examine the TMs of young children:

• Inadequate instrumentation.• Tiny ear canals.• Too much ear cerumen.• Too much feistiness and pushback

from the child toward either the parent or the pediatrician.

• Poor practitioner training in assess-ment of TM markers of bona fide AOM.

The remainder of this article addresses each of these issues from my point of view as a U.S. Food and Drug Administration preferred clinical investigator of AOM. I have previously written many treatises on the management of AOM, most recently touching on the diagnosis of AOM in the neonate in the June 2012 issue of Pedi-atric Annals5 and in the third edition of our book, Diagnosis and Management of Acute Otitis Media.4 For the last 31 years, I have examined bilateral TMs in more than 3,000 patients annually, performed tympa-nocentesis in more than 400 patients with severe AOM, and been a principal investi-gator in nearly 50 clinical trials involving AOM and approximately 10 clinical trials involving TM instrumentation.

THE STUMBLING BLOCKS TO ACCURATE TM ASSESSMENT Inadequate Instrumentation

One of the most important and most overlooked areas of assessing the TM is the use of optimal instruments. Fig-ures 1A and 1B display the primary op-tions for otoscopes: the Welch-Allyn MacroView and the standard head. I much prefer the new version MacroView be-cause of its crisper optics and longer-last-ing, brighter lithium battery. It is worth the price differential. Just be sure to line up or adjust the green line according to your own visual needs.

I cannot emphasize enough the criti-cal importance of using the original non-disposable specula as shown in Figure 2

for all children younger than age 4 years.6 These specula are longer in order to get past the bend of the ear canal, more ta-pered, have a critically wider aperture, and reflect light better from the plastic onto the TM. You will need to wipe them down with an alcohol pad after each visit, and they sometimes require cleaning of the aperture with a cotton swab. The little bit of extra ef-fort is well worth it, as the shorter, stubbier disposable specula are simply inadequate for younger children.

Occasionally, you may encounter a child with such tiny ear canals that they may preclude the entrance of even the 2.5-mm speculum. Some may even have atretic canals, and you will need to con-sider otolaryngology referral and probably a CT scan of the middle ear space to see if any functional TM remains. For the rest of these rarely encountered patients, the Welch-Allyn surgical otoscopic head and its 2-mm green speculum (Figure 1C) will frequently allow you to visualize the TM until it enlarges enough for the routine oto-scope as the child matures over time.

Ear CerumenYou will often encounter children with

significant amounts of cerumen obstructing the ear canal, challenging your adequate visualization of the TM. It is important to make sure that the debris is not pus and/or blood from otorrhea.

Cleaning the cerumen ear canals is the bane of pediatrics, without a doubt. You will need one or several of the curettes shown in Figure 3. Personally, I prefer the stiffer metal curettes like the dark-handled one shown in Figure 3B, but it can pose the potential hazard of scratching the canal and causing subsequent secondary brief bleed-ing; however, this can be tamponaded with a portion of cotton ball.

The key is the gentle but firm restraint of the child by the parent or, rarely, by your nurse. When cleaning ear canals in infants or obstreperous young children, I now always use the technique of laterally positioning the child upon the exam table

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Figure 2. Original manufacturer non-disposable specula: 4-mm, 3-mm, and 2.5-mm sizes. Better for children younger than 4 years old, these longer more tapered specula are highly preferred over the shorter stubbier disposable 2.5-mm speculum.

Figure 3. (A) Assortment of tympanic membrane curettes: colored curettes (Bionix Medical Tech-nologies)are plastic and more bendable, and pre-ferred by the less experienced otoscopists due to its lower likelihood of scratching the canal. (B) The larger, black-handled curette is metal, and is preferred by many experienced otoscopists; the bottom “Farrell” curette should only be used along with a wrap-around corner of a piece of alcohol swab to “wet mop” the remaining softer debris in the ear canal.

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with the parent firmly restraining the arms while lying on the lower trunk and legs; I can then restrain the head with one hand. The cleaning often takes up to a few minutes, as well as patience and gentle strength on the part of the physician, as most of us know. This positioning technique especially pays off in children aged younger than 6 months. The less we aggravate the child, the easier the exam will usually be the next time.

For those children who are too difficult or too compacted with cerumen, ancillary personnel are needed when resorting to the instruments shown in Figure 4; however, make sure the child does not have a history of recent PE tubes or TM perforation. Our techs pre-soften the cerumen by instill-ing several drops of peroxide for about 5 minutes. Often, young children can merely sit on a parent’s lap during the process of gentle irrigation until the tech perceives that the wax has been flushed into the ir-rigation basin. The tech has to be keenly aware, however, and stop if the child seems to really be in pain — not just fussing — during the flushing process, as very rarely, a hidden perforation or patent tube may be present.

Feistiness and Pushback by the ChildThis is truly the art of pediatrics. You

must decide how much restraint, pressure, and calm reassurance to administer to each child. My preference for most “non-ballis-tic” children aged older than 6 months is to allow them to sit comfortably sideways on the parent’s lap while I firmly press the child’s head against the parent’s chest. You should tell the parent to sit firmly back against the chair, to keep the child’s feet hanging off the chair or his or her leg, and to not be alarmed by the child’s likely re-sistance. You should not “box” the ear, but rather use the gentle force of your thumb against the pinna and the child’s skull to apply mild upward traction. Novices also tend to force the speculum too far into the canal, when it often only requires inserting a few millimeters or so. Being gentle but firm must be finessed. A minimally trau-

matic experience will often pay off, with quicker and more compliant future exami-nations of all body parts.

For those “ballistic” children, accept your losses for the TM examination and routinely place them on the exam table as described above. I suggest keeping your stethoscope in your ears when examining a “screamer” as, over time, this will prevent damage to your hearing, and this may also make you less likely rush your TM exam at hand due to your own “ear pain.”

TM CHARACTERISTICS OF AOMFortunately, the 2013 AAP guidelines

on AOM now emphasize the diagnostic importance of purulent or cloudy middle ear effusion (MEE), along with severe redness or new-onset otorrhea. Symptoms plus a non-purulent MEE are no longer considered evidence for the diagnosis of AOM. AOM symptoms in young children “are mostly non-specific, variable, and not

infrequently absent.”7 The current AOM definition is now mostly synchronous with my previous delineations of AOM diagno-sis over the last decade (Table 1). However, according to the AAP guidelines, presence of significant fever (102.2° F) or signifi-cant ear complaints will place the child into different categories of AOM severity, which will have implications as to how to approach antibiotic therapy.

Most pediatricians in practice can read-ily ascertain fullness or bulging of the TM within a clear ear canal. It is this positive pressure upon the TM that foremost as-sures the diagnosis of AOM, even as es-poused by the new AOM guidelines.

Interestingly, the “true” mobility of the TM (a very difficult process for most of us to determine) or ascertaining the severity of otalgia rarely ever changes the diagnosis of AOM, as shown by the data from Shaikh

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Figure 4. Two instruments for flushing the ceru-men filled canal. (A) Waterpik [Water Pik, Inc.] electric device. Bottom: 20-cc, hand-held manu-al-pump 20 cc syringe with a cut-off, large-bore plastic IV catheter.

TABLE 1.

Three Criteria for TM Physical Diagnosis of AOM

(without Otorrhea)

Position

Bulging or “full”

always means acute

otitis media (AOM)

vs. neutral (normal)

or retracted (serous

otitis media, or OME)

Opacification

Absence of

bony landmarks,

completely opaque,

opaque air-fluid

level (AOM or OME)

vs. translucent

(normal)

Discoloration

Mostly or entirely

cloudy / purulent

(green, pale yellow

or non-scarring

white fluid) or

marked hyperemia

indicates AOM vs.

gray (normal) or

amber / orange

(OME).

AOM = acute otitis media; OME = otitis media with effusion; TM = tympanic membrane.

Data from Block7

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et al.9 Seven U.S. experts in AOM assessed 945 middle ear images; out of all AOM cases, bulging TM and marked redness alone was present in 93% and 2%, respec-tively. Otherwise, knowing the presence or absence of TM mobility altered their di-agnosis of AOM in only three of 945 TM evaluations. Of these three cases, one each was changed from AOM to OME (otitis media with effusion), one from AOM to normal, and one from normal to AOM. Furthermore, knowing the presence or ab-sence of “otalgia” changed the diagnosis of OME to AOM in seven (10%) of otalgia cases, and from AOM to OME in seven (0.8%) of non-otalgia cases.

For those who wish to pursue TM mobility, one primary and two ancillary instruments are available, as shown in Figure 5. Note that each of these instru-ments requires a fairly clean ear canal. The latter two are also not likely to be very

reliable in children aged younger than 6 months due to the elasticity and tininess of the ear canal in this age group.

The simplest and cheapest method is to use the handheld insufflator shown in Figure 5A. However, this inexpensive auxiliary otoscope part also requires much bimanual dexterity, as well as the sufficient restraint of the child for a period of several “eternal” arduous seconds. This time may be better spent in pursuing the accurate position and color of the TM in the often unruly child. Also, if you are not careful, this blowing process and “jamming” the speculum into the canal to create a seal can be quite uncomfortable for the child, thus jeopardizing future cooperation with this and other simple examinations.

Two other options for the indirect as-sessment of MEE are the use of the tym-panometry (Figure 5B) and spectral-gradient acoustic reflectometry (SGAR)

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Figure 5. (A) Hand-held otoscopic insufflator to help determine tympanic membrane (TM) mo-bility when using the otoscope. (B) Tympanom-etry machine for detecting middle ear fluid and mobility by the curve’s appearance, as well as patency of pressure equalization tubes or pres-ence of a TM perforation by the volume reading of the entire ear canal space versus the entire middle ear. (C) Close-up of the schematic of po-tential readings and their interpretation. A print-out of the TM findings is available. (D). EarCheck device (Innnovia Medical), or spectral gradient acoustic reflectometry, for consumer use. Among other things, the professional, more advanced EarCheck Pro device (not shown) provides an ad-ditional feature of a printout of the TM findings.

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Figure 6. Obvious diagnostic tympanic membrane (TM) findings regardless of TM mobility and patient symptoms. (A) and (B) Examples of bulging, infected TM. (C) An example of a normal TM.

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Figure 7. The subtler and more difficult diagnostic tympanic membrane (TM) findings, regardless of TM mobil-ity or patient symptoms. Each one has an element of middle ear effusion: infected/treatment-worthy or not?

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(Figure 5C) machines. However, neither instrument will differentiate AOM from OME, and the sensitivity for either machine in predicting merely MEE ranges from 80% to 90%.9,10 SGAR is cheaper, portable, does not require a seal, and is simpler to use. By contrast, tympanometry is a stand-alone machine in a separate room and requires a canal-to-instrument tip seal. However, it is also considered the only adequate supple-mental measure to determine MEE within the 2013 AAP AOM guidelines.1

TM Characteristics for AOMThe best way to learn about the defin-

ing characteristics of AOM versus OME versus normal is to examine a plethora of variations on TM findings with oversight from a qualified mentor. An excellent ini-tiation and training CME program for dif-ferentiation of the TM findings has been developed by the otolaryngology experts at the University of Pittsburgh. The website is located at www.pedsed.pitt.edu under sub-heading: Enhancing proficiency in otitis media (eprom).

The diagnosis of normal TM and bulg-ing TM is relatively straight-forward, as seen in the first three middle ear samples (Figure 6). However, it is those TMs with more subtle findings, as shown in the re-mainder of TM photos, that create the di-agnostic dilemma for all of us in pediatrics. My evaluations for each of these TMs were corroborated by and totally harmonious with each of my three astute, highly experi-enced otoscopist general pediatric partners, James Hedrick, MD, Ron Tyler, MD, and Dan Finn, MD.

In the group of TMs in Figure 7, the TM photographs in A to E were each consid-ered by us to be definitive cases of OME, and therefore not treated with antibiotics. Photographs F and G were considered as cases of OME with early superimposed in-fection due to the “fullness” in F, and the notable hyperemia and fullness of the pars flaccida in G. Thus, we would prescribe antibiotics for them.

Each of the TMs in Figure 8 was con-sidered to have a purulent air-fluid level and, therefore, we would treat them, if they

initially presented with significant symp-toms of URI, fever, or fussiness. Over the decades, having performed tympanocente-sis in numerous similar-appearing, mildly infected TMs (simultaneous with a contra-lateral bulging TM) as those in Figure 8, we nearly always observed the recovery of an identical bacterial pathogen from both ears. However, we would also not treat any asymptomatic children in Figures 8C, 8D, and 8F if they had recently finished antibi-otics within the last few weeks. We readily acknowledge both the common persistence of some MEE after an episode of AOM and the “post-antibiotic effect” or persistent low-level antibiotic concentrations after a recent course of antibiotics. Because of the fullness or mild bulging that we perceived in Figures 8A, 8B, and 8E, we would pro-ceed with further antibiotic therapy. Only one of us thought that the findings on insuf-flation of these particular TMs would pos-sibly change our mind.

With all due respect to the AAP 2013 guidelines, the concept of “otalgia” and “ear tugging” or direct ear pain is much

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Figure 8. The subtler and more difficult diagnostic tympanic membrane (TM) findings, regardless of TM mobility or patient symptoms. Each one has an ele-ment of purulent middle ear effusion: infected/treatment-worthy or not?

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too infrequently observed, too vague, too non-specific, and too unreliable to be of much use in the infant or child aged younger than 36 months.12 And far too many young children with normal TMs constantly tug at their ears during any illness.

CONCLUSIONThe diagnosis of AOM continues to

remain almost exclusively “what you see, not what you hear.” New, improved 2013 AAP guidelines for management of AOM have refined the physical diagnostic cri-teria for AOM without providing many specifics about diagnostic techniques. Practitioners need to use the optimal in-struments and approaches, particularly in infants and younger children, when at-tempting to differentiate AOM from OME and normal. With all the physical and time obstacles, as well as the major difficulties encountered while examining TMs of young children, I recommend a simpli-fied and quick approach using my three

criteria for the diagnosis of AOM: posi-tion, opacification, and discoloration. The plethora of subtle variations in TM find-ings when MEE is present will continue to challenge the diagnostic skills of every otoscopist, as well.

ACKNOWLEDGMENTSpecial thanks to Alejandro Hober-

man, MD, of the University of Pittsburgh, for allowing me to use his magnificent diverse photographs of actual tympanic membranes.

REFERENCES 1. Lieberthal AS, Carroll AE, Chonmaitree T, et

al. The diagnosis and management of acute oti-tis media. Pediatrics. 2013;131(3):e964-999.

2. Block SL, Harrison C, Hendrick J, et al. Re-stricted use of antibiotic prophylaxis for recur-rent acute otitis media in the era of pencillin non-susceptible Streptococcus pneumonia. Int J Pedicatr Otorhinolarynol. 2001;61(1):47-60.

3. Shaikh N, Hoberman A. Update: acute otitis media. Pediatr Ann. 2010;39(1):28-33.

4. Block S, Harrison CJ. Diagnosis and Manage-ment of Acute Otitis Media. Third edition. Cad-do, OK: Professional Publications, Inc. 2005.

5. Block SL. Management of acute otitis media in afebrile neonates. Pediatr Ann. 2012;41:(6) 225-228.

6. Block SL. Accurately diagnosing acute otitis media: “dispose of the disposables.” Pediatr Infect Dis J. 1998;17(12):1179-1180.

7. Paradise JL, Hoberman A, Rockette HE, Shai-kh N. Treating acute otitis media in young chil-dren: what constitutes success? Pediatr Infect Dis J. 2013;32(7):745-747

8. Block, SL Diagnosing acute otitis media: it’s what you see, not what you hear. Post-grad Med. 2005;118(6 Supplement Emerg-ing);32-33, 5-12.

9. Shaikh N, Hoberman A, Kaleida PH, et al. Oto-scopic signs of otitis media. Pediatr Infect Dis J. 2011;30(10):822-826.

10. Laine MK, Tähtinen PA, Helenius KK, Luoto R, Ruohola A. Acoustic reflectometry in dis-crimination of otoscopic diagnoses in young ambulatory children. Pediatr Infect Dis J. 2012;31(10):1007-1011.

11. Block SL, Pichichero M, McKlinn S, Arono-vitz G, Kimball S. Spectral-gradient acoustic reflectometry: detection of middle ear effusion in suppurative acute otitis media. Pediatr Infect Dis J. 1999;18(8):741-744.

12. Laine MK, Tähtinen PA, Ruuskanen O, Huovinen P, Ruohola A.. Symptoms or symptom-based scores cannot predict acute otitis media at otitis-prone age. Pediatrics. 2010;125(5):e1154-1161.

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