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The Rational Clinical Examination
Clinician's Corner
September 24, 2003

Does This Child Have Acute Otitis Media?

Author Affiliations

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.

JAMA. 2003;290(12):1633-1640. doi:10.1001/jama.290.12.1633

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 also searched.

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.

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