CRD summary

This review assessed history taking and physical examination in the diagnosis of acute otitis media in children. The authors concluded that although many studies had methodological limitations, a cloudy, bulging or clearly immobile tympanic membrane is highly suggestive of acute otitis media. The conclusions were based on poor-quality studies and may not be reliable.

Authors' objectives

To assess the precision and accuracy of history taking and physical examination in the diagnosis of acute otitis media (AOM) in children.

Searching

MEDLINE was searched from inception to May 2002 for studies published in English. The bibliographies of selected studies and general and specialist textbooks were also checked.

Study selection

Assessment of study quality

The studies were graded using a hierarchy of study design that ranged from level 1 (best quality) to level 5. The studies in the review were level 3 (independent, blind comparison of symptoms to standard with nonconsecutive patients suspected of having AOM) or level 4 (nonindependent comparison of symptoms with standard and convenience sample of patients with AOM plus some healthy children). Two reviewers independently assessed validity.

Data extraction

Two reviewers independently extracted the data. The extracted data included sample size, age of children, reference standard and methodological limitations. Where possible, raw data were extracted and used to calculate the sensitivity, specificity, positive and negative LRs, and 95% confidence intervals (CIs) for each study. Data from patients for all groups combined were extracted. In one study in which selective tympanocentesis was performed, data from children with perforations who did not undergo tympanocentesis were excluded. For this study, the LRs were adjusted for verification bias assuming children not undergoing tympanocentesis had ears that appeared normal. The diagnostic accuracy of tympanic membrane colour (classified on an ordinal scale as cloudy, distinctly red, slightly red, or normal) was assessed using the area under the receiver operating characteristic curve.

Methods of synthesis

Results of the review

Six studies (3,919 children) were included.

Precision of signs and symptoms (1 study, 43 children with complete examination).

Agreement on the diagnosis of AOM between paediatric residents and otolaryngologists was fair (kappa 0.30). Agreement on specific tympanic membrane features was fair to slight (kappa ranged from 0.4 for erythema to 0.16 for position).

Accuracy of symptoms (4 studies).

Methodological problems included spectrum bias (2 studies) and use of clinical diagnosis as the reference standard (4 studies). The highest positive LR was for ear pain (positive LR ranged from 3.0 to 7.3), but ear pain was only present in 50 to 60% of children with AOM. The results for fever were mixed: one study showed a slight increase in the likelihood of AOM, while two studies found no effect. Other symptoms were listed in the paper

Accuracy of signs (1 study, 2,911 children).

Methodological problems included spectrum bias. The results showed that a cloudy, bulging or clearly immobile tympanic membrane was highly suggestive of AOM. Positive LRs, adjusted for verification bias, were 34 (95% CI: 28, 42) for cloudy, 51 (95% CI: 36, 73) for bulging, and 31 (95% CI: 26, 37) for immobile. A distinctly red tympanic membrane suggested AOM (positive LR 8.4, 95% CI: 6.7, 11), while a normal colour made AOM unlikely (positive LR 0.2, 95% CI: 0.19, 0.21).

Authors' conclusions

Although many studies had methodological limitations, a cloudy, bulging or clearly immobile tympanic membrane is highly suggestive of AOM. A distinctly red membrane is also suggestive of AOM, while a normal coloured membrane makes AOM unlikely. Ear pain may be an important symptom.

CRD commentary

The review question was broadly defined in terms of the study design, intervention and participants. The inclusion criteria were not defined in terms of outcomes, and were widened for the reference standard after surveying the literature. Only one database was searched and this might have resulted in the omission of relevant studies. In addition, no attempts to minimise language or publication bias were made. Two reviewers independently selected the studies, assessed validity and extracted the data, thus reducing the potential for bias and errors. The validity assessment was limited to a hierarchy of study design and was not adequate.

The narrative synthesis was appropriate given the small number of diverse studies. Evidence for the diagnostic accuracy of tympanic membrane features came from only one study in which only one observer examined each patient. The conclusions were based on studies limited by bias.

Implications of the review for practice and research

Practice: The authors stated that pneumatic otoscopy should be used to examine drum colour, appearance and mobility in cases of suspected AOM. They recommended that standard guidelines, such as those of the Agency for Health Care Research should be considered and that methods should be used to improve performance of physical examination techniques (see Other Publications of Related Interest). The authors also noted that the American Academy of Pediatrics provides a website to help clinicians improve their skills in the diagnosis and treatment of AOM (http://www.aap.org/en-us/about-the-aap/Committees-Councils-Sections/Section-on-infectious-diseases/Pages/VideoHighlights.aspx accessed 24/07/2014).

Research: The authors stated that future studies should be conducted in general populations of at-risk children using standardised diagnostic criteria, and with outcomes assessed using independent examinations by blinded examiners. They also stated that physical findings should be classified on ordinal scales, and that the relative importance of colour, position and mobility should be assessed.

Bibliographic details

Rothman R, Owens T, Simel D L. Does this child have acute otitis media? JAMA 2003; 290(12): 1633-1640. [PubMed: 14506123]

Original Paper URL

http://jama.ama-assn.org/

Other publications of related interest

Marcy M. Management of acute otitis media. Rockville (MD): Agency for Healthcare Research and Quality; 2001.

This additional published commentary may also be of interest. Uhari M. Review: ear pain and a cloudy, bulging, or distinctly immobile tympanic membrane appear to help diagnose acute otitis media in children. Evid Based Med 2004;9:58.

Indexing Status

Subject indexing assigned by NLM

MeSH

Acute Disease; Child, Preschool; Humans; Infant; Medical History Taking; Otitis Media /diagnosis; Physical Examination; Sensitivity and Specificity

AccessionNumber

12003008593

Database entry date

31/07/2005

Record Status

This is a critical abstract of a systematic review that meets the criteria for inclusion on DARE. Each critical abstract contains a brief summary of the review methods, results and conclusions followed by a detailed critical assessment on the reliability of the review and the conclusions drawn.