ChiroACCESS Clinical Review

Otitis Media: Diagnosis

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Lead Author(s): 

Dwain M. Daniel, D.C.


How this evidence was rated:

Strength of Recommendation Taxonomy (SORT)

Published on

April 8, 2008

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Otitis media presents in two primary forms, acute otitis media (AOM) and otitis media with effusion (OME). With the heightened concerns relating to the increasing number of antibiotic resistant microbes and inappropriate use of antibiotics, the first diagnostic concern is to distinguish between the two variants. AOM is characterized by the signs of infection (fever, otalgia, irritability, headache, rhinitis, pulling at ears) combined with a bulging, sometimes red tympanic membrane and often treated with antibiotics (1). OME does not have the signs of infection and is characterized by a neutral or retracted tympanic membrane. Recommended treatment is “watchful waiting” for 3 months (2).

Combining symptomology with examination of the tympanic membrane with an otoscope has been considered a standard diagnostic procedure by many physicians. Study after study shows this protocol is lacking in diagnostic accuracy. In a study of 383 pediatric residents only 41% gave an accurate diagnosis when examining AOM, OME and normal ears (3). A second study of 50 children compared general practitioners (GP) and otorhinolaryngology residents (OR). GP’s gave a diagnosis of OM in 64% of patients while the OR’s gave a diagnosis of OM in 44%. Further investigation found GP’s based their diagnosis on symptoms and color of the tympanic membrane while OR’s used mobility and position of the tympanic membrane as clinical evidence of OM (4). Lack of diagnostic acumen may be the result of lack of formal training. A 2001 survey found only 59% of U.S. medical schools had formalized training for the diagnosis of OM (5). Finally a study of 309 children revealed a 56% decrease in diagnosis of AOM with 80% fewer episodes when proper diagnostic criteria was used (6).

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Ramakrishnan K, Sparks RA, Berryhill WE. Diagnosis and treatment of otitis media. Am Fam Physician 2007; 76(11):1650-1658.

 [ Full-Text Link ]


Otitis media with effusion. Pediatrics 2004; 113(5):1412-1429.

 [ Full-Text Link ]


Pichichero ME. Diagnostic accuracy, tympanocentesis training performance, and antibiotic selection by pediatric residents in management of otitis media. Pediatrics 2002; 110(6):1064-1070.


Blomgren K, Pitkaranta A. Is it possible to diagnose acute otitis media accurately in primary health care? Fam Pract 2003; 20(5):524-527.

 [ Full-Text Link ]


Varrasso DA. Otitis media: the need for a new paradigm in medical education. Pediatrics 2006; 118(4):1731-1733.


Blomgren K, Pohjavuori S, Poussa T, Hatakka K, Korpela R, Pitk+ñranta A. Effect of accurate diagnostic criteria on incidence of acute otitis media in otitis-prone children. Scandinavian Journal of Infectious Diseases 2004; 36(1):6-9.


Takata GS, Chan LS, Morphew T, Mangione-Smith R, Morton SC, Shekelle P. Evidence assessment of the accuracy of methods of diagnosing middle ear effusion in children with otitis media with effusion. Pediatrics 2003; 112(6 Pt 1):1379-1387.

 [ Full-Text Link ]


Jones WS, Kaleida PH. How helpful is pneumatic otoscopy in improving diagnostic accuracy? Pediatrics 2003; 112(3 Pt 1):510-513.

 [ Full-Text Link ]


Otitis media with effusion. Pediatrics 2004; 113(5):1412-1429.

 [ Full-Text Link ]


Pichichero ME. Acute otitis media: Part I. Improving diagnostic accuracy. Am Fam Physician 2000; 61(7):2051-2056.

 [ Full-Text Link ]


Jensen PM, Lous J. Criteria, performance and diagnostic problems in diagnosing acute otitis media. Fam Pract 1999; 16(3):262-268.


Smith CG, Paradise JL, Sabo DL, Rockette HE, Kurs-Lasky M, Bernard BS et al. Tympanometric findings and the probability of middle-ear effusion in 3686 infants and young children. Pediatrics 2006; 118(1):1-13.

 [ Full-Text Link ]


McConnochie KM, Conners GP, Brayer AF, Goepp J, Herendeen NE, Wood NE et al. Differences in diagnosis and treatment using telemedicine versus in-person evaluation of acute illness. Ambul Pediatr 2006; 6(4):187-195.


Heikkinen T, Ruuskanen O. Signs and symptoms predicting acute otitis media. Arch Pediatr Adolesc Med 1995; 149(1):26-29.


Legros JM, Hitoto H, Garnier F, Dagorne C, Parot-Schinkel E, Fanello S. Clinical qualitative evaluation of the diagnosis of acute otitis media in general practice. Int J Pediatr Otorhinolaryngol 2008; 72(1):23-30.


Behn A, Westerberg BD, Zhang H, Riding KH, Ludemann JP, Kozak FK. Accuracy of the Weber and Rinne tuning fork tests in evaluation of children with otitis media with effusion. J Otolaryngol 2007; 36(4):197-202.