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, pediatric discipline, 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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