Otoscopy-based diagnosis of paediatric acute otitis media: An evaluation of guideline adherence.

OBJECTIVES

Over diagnosis of acute otitis media (AOM) may lead to unnecessary antibiotic prescriptions and overuse of health care resources. To date, no study has determined which otoscopy findings frontline physicians use to diagnose AOM, and whether lack of adherence to otoscopy guidelines contributes to over diagnosis.

METHODS

In this single-centre multisite retrospective chart review, we determined adherence to Canadian Paediatric Society (CPS) AOM diagnosis guidelines based on documented otoscopy findings in patient charts.

RESULTS

Of 192 cases of nonperforated AOM with a documented physical examination, only 124 (64.6%) had otoscopy findings of both middle ear effusion and inflammation, consistent with CPS criteria. Fifty-eight cases (30.2%) had documented middle ear inflammation without effusion. The most reported otoscopy findings were a red and bulging tympanic membrane (TM) in 81 (42.2%) cases. The presence (n = 104) or absence (n = 4) of bulging was only documented in 108 (56.2%) cases. The odds ratio for cases meeting diagnostic criteria was significantly higher for those seen by paediatricians compared with general providers (OR 2.82, 95% CI: [1.44-5.53], P < 0.01), for those assessed by residents or medical students compared with staff physicians (OR 2.04, 95% CI [1.05-3.98], P = 0.03), and those of older age (OR 1.14, 95% CI [1.00-1.29], P = 0.044).

CONCLUSIONS

This study highlights that AOM over diagnosis may be related to lack of adherence to diagnosis guidelines. Simplification of guidelines, such as more explicitly requiring a bulging TM, may improve diagnostic accuracy and reduce health care resource overuse for this common paediatric condition.