- Manifestations of AOM include: otalgia, pyrexia, thickened or bulging tympanic membrane, hearing loss, and otorrhea.
- Manifestations of OME include: persistent hearing loss, dull or immobile tympanic membrane, and flat tympanogram.
Accurate diagnosis of AOM versus OME is becoming increasingly important, especially in the present day challenge of antibiotic-resistant organisms. Diagnosis of AOM and OME can be made by direct visualization of the TM using an otoscope or pneumatic otoscope. The symptoms most often associated with AOM are otalgia, fevers, decreased appetite, upper respiratory infection, and fatigue. In children less than 2 years old, otalgia is evidenced by fussiness, insomnia, and generalized irritability. Since these symptoms are vague and may be attributable to a variety of conditions, symptomatology alone should not be used as sole criteria to render a diagnosis of AOM or OME.
Examination of the TM can be challenging and heavily clinician dependent. Description of otoscopic findings is variable and subjective. It is helpful to consider physical examination of the TM systematically—the use of a mnemonic, “COMPLETES” has been published as a teaching and clinical tool to ensure thorough and methodical examination (Table 49–2).
Table 49–2. Completes: Mnemonic for Otoscopic Examinations. ||Download (.pdf)
Table 49–2. Completes: Mnemonic for Otoscopic Examinations.
|Color||Gray, white, yellow, amber, pink, red, blue|
|Other conditions||Fluid level, bubbles, perforation, retraction pocket, atrophic area, otorrhea, bullae, tympanosclerosis, cholesteatoma|
|Mobility||4+, 3+, 2+, 1+|
|Position||Neutral, bulging, retracted|
|Lighting||Battery charged, halogen or xenon bulb|
|Entire surface||Visualize all quadrants|
|Translucency||Translucent or opaque|
|External auditory canal and auricle||Inflammation, foreign body, displacement, deformed|
|Seal||Appropriate sized speculum|
|Airtight pneumatic system|
Otoscopy in AOM classically demonstrates a thickened, hyperemic, immobile TM. As diagnosis can often be made on history and physical exam alone, further studies are not indicated for AOM. OME, in contrast, is often asymptomatic. The most common complaint associated with OME is decreased hearing. Otoscopy classically demonstrates a dull gray- or yellow-tinged, immobile TM. If the TM is clear, bubbles or air fluid levels can be elucidated. Tympanometry and audiometry are complimentary diagnostic tools used in evaluating patients with OME.
Tympanometry is an objective and quantitative way to evaluate TM mobility and middle ear function. It is defined as “the measurement of the acoustic immittance of the ear as a function of ear canal air pressure”. The procedure involves placing a probe into the external auditory canal and measuring the amount of sound energy returned. Patients with OME demonstrate flattened tracings on tympanometry indicating fluid in the middle ear space. Table 49–3 depicts examples of different tympanometry tracings.
Table 49–3. Types of Tympanograms. (Current Diagnosis and Treatment in Otolaryngology—Head & Neck Surgery, 2004; P. 700) ||Download (.pdf)
Table 49–3. Types of Tympanograms. (Current Diagnosis and Treatment in Otolaryngology—Head & Neck Surgery, 2004; P. 700)
|Tympanogram Type||Middle Ear Presure||Typical Appearance of Trace|
|A||−99 daPa to +200 daPa|
|B||No compliance peak|
|C||−400 daPa to −100 daPa|
As mentioned, OME often presents with varying degrees of hearing loss. Therefore, serial audiometry is helpful in establishing a diagnosis of OME. Audiologic testing may include pure tone threshold, speech reception threshold, speech awareness testing, behavioral observation, and auditory brain-stem response (ABR). Conductive hearing loss is most often documented in children with OME.
Kaleida PH. The COMPLETES exam for otitis. Contemp Pediatr. 1997;4:93–101. (Describes a detailed and systematic method of observing and documenting otoscopic findings.)
Margolis RH, Henter LL, Giebink GS. Tympanometric evaluation of middle-ear function in children with otitis media. Ann Otol Rhinol Laryngol 1994;103:34–38. (Review describing the different types of tympanometry used to evaluate middle ear function. Established that multifrequency tympanograms are more sensitive in identifying sequelae of otitis media than conventional audiometry.)
Lalwani AK, Yates PD. Otitis Media. Current Diagnosis and Treatment in Otolaryngology—Head and Neck Surgery. McGraw-Hill, 2004, p. 700. (Comprehensive and accessible review of the sciences and clinical practice of otolaryngology-head & neck surgery.)