Author Affiliations: Departments of Medicine and Pediatrics, Vanderbilt University Medical Center, Nashville, Tenn (Dr Rothman); and Departments of Medicine and Pediatrics, Duke University Medical Center (Dr Owens), and Durham Veterans Affairs Medical Center and Duke University Medical Center (Dr Simel), Durham, NC.
The Rational Clinical Examination Section Editors: David L. Simel, MD, MHS, Durham Veterans Affairs Medical Center and
Duke University Medical Center, Durham, NC; Drummond Rennie, MD, Deputy Editor, JAMA.
Context Acute otitis media (AOM) is one of the most common problems in pediatrics.
An accurate diagnosis of AOM can guide proper treatment and follow-up.
Objective To systematically review the literature regarding precision and accuracy
of history taking and physical examination in diagnosing AOM in children.
Data Sources We searched MEDLINE for English-language articles published from 1966
through May 2002. Bibliographies of retrieved articles and textbooks were
Study Selection We located studies with original data on the precision or accuracy of
history or physical examination for AOM in children. Of 397 references initially
identified, 6 met inclusion criteria for analysis.
Data Extraction Two authors independently reviewed and abstracted data to calculate
likelihood ratios (LRs) for symptoms and signs.
Data Synthesis Four studies of symptoms used clinical diagnosis as the criterion standard
and were limited by incorporation bias. Ear pain is the most useful symptom
(positive LRs, 3.0-7.3); fever, upper respiratory tract symptoms, and irritability
are less useful. One study of clinical signs used tympanocentesis as the criterion
standard, and we adjusted the results to correct for verification bias. A
cloudy (adjusted LR, 34; 95% confidence interval [CI], 28-42), bulging (adjusted
LR, 51; 95% CI, 36-73), or distinctly immobile (adjusted LR, 31; 95% CI, 26-37)
tympanic membrane on pneumatic otoscopy are the most useful signs for detecting
AOM. A distinctly red tympanic membrane is also helpful (adjusted LR, 8.4;
95% CI, 6.7-11) whereas a normal color makes AOM much less likely (adjusted
LR, 0.2; 95% CI, 0.19-0.21).
Conclusions Although many of the studies included in this analysis are limited by
bias, a cloudy, bulging, or clearly immobile tympanic membrane is most helpful
for detecting AOM. The degree of erythema may also be useful since a normal
color makes otitis media unlikely whereas a distinctly red tympanic membrane
increases the likelihood significantly.
Rothman R, Owens T, Simel DL. Does This Child Have Acute Otitis Media?. JAMA. 2003;290(12):1633-1640. doi:10.1001/jama.290.12.1633