Diagnostic methods for acute otitis media in 1 to 12-year-old children in primary health care

Problem

Acute otitis media (AOM) is one of the most common childhood infections. Otoscopy alone has low sensitivity and specificity for otitis media (61%). Otomicroscopy provides an enlarged view and binocular viewing, which facilitates depth perception and detailed assessment of the tympanic membrane (TM). Therefore, otomicroscopy is superior to otoscopy (sensitivity 87-91% and specificity 89-93%). Compared to otoscopy, pneumatic otoscopy increases the sensitivity to 94% and specificity to 80%, as pneumatic methods evaluate the degree of mobility of the TM, a reliable sign of the presence or absence of middle-ear effusion. However, otomicroscopy and pneumatic 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.

Approach

This study aimed to describe the extent of which diagnostic methods were used for the diagnosis of AOM, and investigate the frequency with which written advice was provided to parents of children aged 1 to 12 with AOM in primary health care. Furthermore, the aim was to investigate the association between the physician’s educational level and gender and the use of diagnostic methods and written advice.All general practitioners (GPs) and resident physicians (RPs) at 27 Primary health care centres in southern Sweden were asked to complete a self-administrated questionnaire including diagnostic approach and the management of AOM. Main outcome measures: Physician educational level and gender, the use of otoscopy, pneumatic otoscopy, otomicroscopy and tympanometry to diagnose AOM, and how often written advice was provided to parents.

Findings

75% (111/148) responded to the questionnaire at 27 primary health care centres in Sweden. To diagnose AOM, 98% of the physicians (109/111) 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 physicians.The GPs used otomicroscopy more often than RPs, adjusted OR 4.9 (95% CI 1.5-17; p=0.011). For the other diagnostic methods, no differences were found. Female physicians provided written advice more often than male physicians, adjusted OR 5.2 (95% CI, 1.6-17; p=0.0061).

Consequences

Otoscopy was by far the most commonly used method for the diagnosis of AOM in 1 to 12-year-old children consulting primary care. Female physicians provided written advice to parents more frequently than did their male colleagues. GPs used the significantly better method otomicroscopy more often than RPs, 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.