Evidence assessment of the accuracy of methods of diagnosing middle ear effusion in children with otitis media with effusion

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Context Recommendations for diagnosing otitis media with effusion (OME) have largely been based on limited evidence and expert opinion.

Objective To assess the accuracy of methods of diagnosing middle ear effusion in children with OME.

Design Systematic review of diagnostic studies.

Study identification The authors searched Medline (1966-January 2000), the Cochrane Library (through January 2000), and Embase (1980-January 2000) and identified additional articles from reference lists in proceedings, published articles, reports, and guidelines.

Study selection 52 studies of varying quality were selected for analysis.

Results Among 8 diagnostic methods, pneumatic otoscopy had the best apparent performance with a sensitivity of 94% (95% CI, 92-96) and a specificity of 80% (95% CI, 75-86), with corresponding likelihood ratios of 4.7 for a positive test and 0.08 for a negative test. However, examiner qualifications were reported inconsistently, and training was not specified.

Conclusions Pneumatic otoscopy was found to do as well as or better than tympanometry and acoustic reflectometry.

Comment Takata and colleagues conducted a detailed assessment of the evidence for various diagnostic methods of identifying otitis media with effusion (OME) in children 12 years of age and younger. They established reasonable criteria to both conduct a literature search (through January 2000) and assess study quality. Fifty-two studies (1% of 4879 initial titles and abstracts) were ultimately selected for final assessment. Comparisons with three or more studies were subjected to meta-analyses. The authors did not assess combined diagnostic methods or algorithms. No study was excluded, however, on the basis of study quality. It would have been interesting to also have seen the data when studies deemed to have been of poor quality, relative to this analysis, were excluded. In the pneumatic otoscopy comparison, five of the seven studies were considered to have been of adequate to high quality. The authors concluded that pneumatic otoscopy and professional tympanometry had the highest pooled sensitivity, compared with myringotomy, the “gold standard.” Pneumatic otoscopy optimized both pooled sensitivity (94%) and specificity (80%).

Additional information on the assessment of each of the various diagnostic methods by age of the child would have been useful because otitis media occurs most frequently in infants and younger children. Moreover, the difficulty of accurately performing and interpreting these diagnostic modalities increases in very young age groups. Age distributions could not provided, however, due to limitations of the available data. In addition, specific data were not available regarding the degree of expertise of the otoscopists in each of the selected studies. One wonders how representative their skills are compared with those of pediatric practitioners. This report raises a number of other challenging questions. How much training will be required to achieve such a degree of otoscopic proficiency? How best can this training be provided? What level of otoscopic proficiency should be considered to be satisfactory at the end of a formal training process?

The authors are to be commended for undertaking this prodigious study. Their report provides support for the recommendations, based at the time on limited scientific evidence and strong panel consensus, of the 1994 AHCPR (now AHRQ) OME Guideline promoting the use of pneumatic otoscopy. In skilled hands, pneumatic otoscopy provides a powerful and relatively inexpensive diagnostic modality.