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The Rational Clinical Examination
David L. Simel, Drummond Rennie
Otitis Media, Child
Russell Rothman, Thomas Owens, David L. Simel
A final symptom that deserves mention is ear pulling. Ear pulling has long been debated as a...


Topics Discussed: diagnostic process, diagnostic studies, otitis, otitis media, otitis media, acute, pediatrics, sensitivity, specificity, summarizing the evidence

Excerpt: "From the 397 references initially identified, we found 6 articles that satisfied inclusion criteria. This included 1 article concerning precision, 4 articles on accuracy of symptoms, and 1 article on accuracy of signs (Table 37-1).4,16,23,35,36,41To our knowledge, no studies concerning precision of symptoms have been published, and there are only a few studies on precision of signs. A comparison of diagnoses among practitioners would be important, especially during training, when medical students and house staff learn to interpret otoscopic findings from their instructors. Recently, Steinbach et al4 compared diagnoses of AOM among pediatric residents with diagnoses made by otolaryngologists. Complete examinations were available for 43 children, but the study found only fair agreement between the residents and the otolaryngologists. Overall agreement on diagnosis of AOM between the 2 types of practitioners had a statistic of 0.30 (fair). Statistics on tympanic membrane features such as erythema, color, effusion, mobility, and position were fair to slight ( = 0.40, 0.40, 0.31, 0.21, and 0.16, respectively). Correlations between pediatric residents and otolaryngologists comparing tympanometry in the detection of an effusion were also fair ( = 0.25 and 0.30, respectively). Sensitivity, specificity, and positive and negative LRs derived from articles that examined the role of symptoms in the diagnosis of AOM are included in Table 37-2.16,35,36,41 The presence of ear pain appears to be the symptom most useful in making the diagnosis of AOM. Ear pain has a positive LR (LR+) of 3.0 to 7.3 but is present in only 50% to 60% of children with AOM. With a baseline prevalence for AOM of 20% among children aged 5 years or younger who make an acute pediatric office visit (estimated from the National Ambulatory Medical Care Survey), the presence of ear pain increases the probability of AOM to approximately 43% to 65%...."
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