Evidence Based Practice Presentation

Transcription

1 Evidence Based Practice Presentation Does the assessment of tympanic membrane mobility using pneumatic otoscopy reduce the diagnosis of Acute otitis media & otitis media with effusion in children? Ashley Phillips Ambulatory Care 2 May 2010

2 Rationale For Question To establish if pneumatic otoscopy is more effective than otoscopy and as effective as tympanometry when diagnosing AOM and OME. At Tayside Children s s Hospital SSAA in Ninewell s pneumatic otoscopy is not routinely carried out by medical staff or trainee e nurse practitioners. Ear examinations are predominantly carried out by plain otoscopy and diagnosis is generally made through visualisation of the tympanic membrane. The insufflator is not routinely used. Medical staff have little or no experience of pneumatic otoscopy and its uses. If tympanic membrane mobility is to be assessed in the Short stay assessment area in Ninewells Hospital a referral is made to ENT clinic for tympanometry However, this referral is extremely rare and diagnosis of AOM and OME is done solely on how the tympanic membrane looks. AOM and OME are common conditions which are referred to Tayside Children s s Hospital.

3 Facts relating to Acute Otitis Media (A0M) Incidence: Acute otitis media is a common condition with a high morbidity and low mortality rate. In the United Kingdom about 30% of children aged under 3 years visit their GP with acute otitis media each year, and 97% receive antimicrobial treatment. (Froom( 1997) About 1 in 10 children will have an episode of acute otitis media by 3 months of age. It is the most common reason for outpatient antimicrobial treatment in the United States. (Froom1997) Aetiology: The most common bacterial causes for acute otitis media are Streptococcus pneumoniae, Haemophilus influenzae,, and Moraxella catarrhalis.. (Froom( 1997) Prognosis: In about 80% of children the condition resolves without antibiotic treatment in about three days. Complications are rare but include hearing loss, mastoiditis,, meningitis, and recurrent attacks. (Froom 1997)

4 .. Facts relating to Otitis Media with effusion Incidence : Otitis media with effusion (OME) is a common condition of early childhood (Nice 2008). OME has a prevalence of about 20% of children at 2 years of age. OME remains common up to the age of 7 at which the the prevalence reduces to between 3% and 8%.(Butler 2003) Aetiology: OME may be overlooked because of the insidious nature of the condition (Nice 2008). It is not clear why or how OME develops. Low grade infection, poor eustachian tube function, local inflammatory reaction and adenoidal infection or hypertrophy have all been indicated. (Butler 2003) Prognosis: In most cases of OME symptoms resolve spontaneously and no treatment is required as the fluid disperses. Hearing can be affected The hearing loss is usually transient and self-limiting over several weeks, but may be more persistent if the fluid in the middle ear does not disperse thus may lead to educational, language and behavioural problems. So needs careful observation. (Nice 2008)

5 Spot the difference! Acute Otitis Media (AOM): The rapid onset of signs and symptoms such as otalgia and fever. (Bluestone 2007). Clinical features include middle-ear ear effusion, evidence of ear pain and /or marked redness, fullness and bulging of the tympanic membrane. (Pelton( 1998). Image at meddean.luc.edu Image at ganfyd.org Otitis media with effusion (OME): Inflammation of the middle ear with a collection of fluid in the middle ear space. The signs and symptoms differ from AOM as evidence of acute infection is absent and there is no TM perforation. (Bluestone 2007). OME may result from the aftermath of AOM or as a consequence of eustachian tube obstruction or due to another cause, such as an upper respiratory tract infection. Children who are subjected to smoking have a high risk of developing OME. (Agius 1995)

6 Pneumatic Otoscopy and Otoscopy An otoscope is a hand-held held instrument with a tiny light and a funnel-shaped attachment called an ear speculum, which is used to examine the ear canal and eardrum. The pneumatic otoscope differs slightly from the plain otoscope as it has an extra attachment, a small bulb also known as an insufflator. (Davidson 2006) By pressing the insufflator gently the otoscope produces a small puff of air which vibrates the eardrum (pneumatic otoscopy). Pneumatic otoscopy is an examination that allows determination of the mobility of a patient s s tympanic membrane (TM) in response to pressure changes. The normal tympanic membrane moves in response to pressure. Immobility may be a result of fluid in the middle ear.

7 Tympanometry / Myringotomy Image at lsm- 300./html Tympanometry is a test which measures the function of the middle ear. It works by varying the pressure within the ear canal and measuring the movement of the tympanic membrane. The test also measures the ears response to sound. The tympanometer then records the results. Image at crc.comfaqs.htm Myringotomy is a procedure which involves an incision being made into the tympanic membrane which allows fluid to be drained from the ear sometimes a small plastic tube (grommet or Pressure equilization tube) can be inserted into the incision to allow further drainage.

8 Research Question PICO Format Does the assessment of tympanic membrane mobility using pneumatic otoscopy, reduce the diagnosis of acute otitis media & otitis media with effusion in children? Patient Group Intervention Comparison Outcome Children under 15 years Pneumatic otoscopy / tympanic membrane mobility Visualisation of tympanic membrane by otoscopy / tympanometry / myringotomy Accurate diagnosis of AOM or OME

9 Search Strategy Search terms Children <15 years Pneumatic otoscopy Tympanometry / myringotomy Tympanic membrane mobility Otoscopy Visualisation of tympanic membrane Accurate diagnosis of AOM Accurate diagnosis of OME Inclusion Criteria All articles written in the English Language. Articles available electronically via Scottish e-library e / Athens. Articles available at University of Dundee Medical and Nursing library. l Exclusion Criteria Articles written prior to Articles which include adults in study. Tympanocentesis Accoustic reflectometry Video otoendoscopic examination

10 Databases Searched and Results Database searched Ovid Medline Joanna Briggs Institute Ebsco Cinahl Cochrane library Embase Google Scholar Articles Dated From Week Week Week All articles 2000 Week Feb 2010 Results 7 articles 0 articles 20 articles 0 articles 18 articles 217 articles 2 articles were selected. Other articles were disregarded due to: Inclusion of other diagnostic tests. Inclusion of adults in study. Articles published prior to Articles not published in the English language Articles not available through Scottish e-library/athens, e LJMU or Dundee University Medical / Nursing library.

11 Research Article Selected Article 1 HEE-DONG L, and SANG-WON Y. (2004) Clinical diagnostic accuracy of Otitis Media with Effusion in Children and significance of Myringotomy: : Diagnostic or Therapeutic. Journal of Korean Medical Science pp A Diagnostic study carried out from November 2002 February children were included in the study aged < 10 years with suspected OME. The study s s aim was to determine the accuracy of pneumatic otoscopy, tympanometry and otomicroscopy when diagnosing OME. The 3 diagnostic tests were carried out prior to myringotomy.. The myringotomy results were used to confirm the accuracy of the other 3 tests.

12 Research Article Selected Article 2 HARRIS, P.K et al., The use of Tympanometry and Pneumatic Otoscopy for Predicting Middle Ear Disease. American Journal of Audiology June 2005; 14 pp A diagnostic test study carried out on 21 children aged between 1 to 10 years who had suspected middle ear disease. The study was carried d out prior to myringotomy and insertion of PE tubes. The physician examined the mobility of the TM with a pneumatic otoscope and classified the mobility and appearance of the TM,S. MFT and conventional tympanography was then carried out. Following this the myringotomy was carried out and the presence or absence of fluid in the TM was reported. The study then discussed the findings and compared the pneumatic and tympanometry results with the surgical findings.

13 Critical Appraisal Tool Critical appraisal skills programme (CASP) tool (2004). ( tm) The articles were critically appraised using the diagnostic test critical appraisal tool. 12 questions to help make sense of a diagnostic study.

14 Diagnostic Test Critical Appraisal Tool Article 1 Article 2 1. Was there a clear question for the study to address? Yes. To determine the accuracy of 3 diagnostic tools in diagnosis of OME pneumatic otoscopy, tympanometry and otomicroscopy. Yes. To measure the effectiveness of pneumatic otoscopy and tympanometry for dagnosis of AOM. 2. Was there a comparison with an appropriate reference standard? 3. Did all patients get the diagnostic test and the reference standard? Yes. Myringotomy was carried out without anaesthesia (emla( cream was applied to TM) to confirm the results of the 3 diagnostic tests. Yes. 118 patients were selected for study but only 51 patients were included due to exclusion data such as non compliance for myringotomy,, perforated TM, failed tympanograms and discharging ears. Yes. The gold standard myringotomy under anaesthesia was used to assess the accuracy of the results. Yes. 21 children participated in the study. However only 35 of the 42 ears had completed Pneumatic otoscopy myringotomy and tympanograms due to patent PE tubes and occluding cerumen.. 2 false negative examinations were excluded. So 7 ear exams were excluded from study

15 Diagnostic Test Critical Appraisal Tool 4. Could the results of the test of interest have been influenced by the results of the reference standard? Article 1 No. Blinding of staff was not possible due to the nature of the diagnostic tests. Pneumatic otoscopy, tympanometry and otomicroscopy were carried out and results noted prior to the myringotomy. Article 2 No. Blinding of staff was not possible due to the nature of the diagnostic tests. Pneumatic otoscopy and tympanometry was carried out prior to myringotomy. 5. Is the disease status of the tested population clearly described? 6. Were the methods of performing the test described in sufficient detail? No. Article states all children aged <10years old with suspected OME included in study. No reference is made to stages of disease, presenting symptoms or date of onset. Yes. Article clearly states how each diagnostic test was carried out. The same method is used for each patient. Yes. 21 new patients seen by the otolaryngologist aged between 1 to 10 years who were seeking treatment for middle ear disease. Yes.. Article explains in depth when and how each diagnostic test was carried out. The same method is used for each patient

16 Diagnostic Test Critical Appraisal Tool 7. What are the results? Article 1 Sensitivity and specificity of each test are clearly presented. Sensitivity of pneumatic otoscopy was 97.2% specificity was 38.5%. Sensitivity of tympanography was 87.5% specificity 0%. Otomicroscopy was most accurate with sensitivity of 100% and specificity of 61.5%. Mcnemers test showed that there was no significant difference in the ability of each of the diagnostic tests. Pneumatic otoscopy and myringotomy p= Article 2 Sensitivity and specificity of each test clearly presented in table form and explanation given in article. Each diagnostic test was compared with myringotomy result. Pneumatic otoscopy had a sensitivity of 95% and specificity of 54%. The results showed that pneumatic otoscopy was significant in diagnosis of MEE. (p.000) Tympanometry was carried out using three diffferent typanometers with different frequencys. 226 hz had a sensitivity of 80 and specificity of 54%. This low frequency tympanometer was poor at accurately predicting middle ear fluid. The 678hz & 1000hz tympanometers had a sensitivity of 95% & 100% with a specificity of 54%.

17 Diagnostic Test Critical Appraisal Tool 8. How sure are we about the results? 9. Can the results be applied to your patients/ the population of interest? Article 1 Results are accurate confidence levels are documented for each diagnostic test. Study has 95% confidence limits. International peer reviewed journal. However study size is small only 51 patients included in the study. Yes. Results can be applied to the SSAA at Tayside children s Hospital at Ninewells.. Similar patients were used in the study which would present to the SSAA. Article 2 Results are accurate confidence levels are documented for each diagnostic test. Study has 95% confidence limits. Peer reviewed journal. However study size small only 21 patients included in the study. Yes.Results can be applied to the SSAA at Tayside children s s Hospital at Ninewells.. Similar patients were used in the study which would present to the SSAA.

18 Diagnostic Test Critical Appraisal Tool 10. Can the test be applied to your patient or population of interest? Article 1 Yes. Pneumatic otoscopy can be carried out in Tayside children s s hospital SSAA as we have access otoscopes with insufflators. These are currently not used due to lack of understanding by staff of there benefits in diagnosing AOM and OME. Article 2 Yes. Pneumatic otoscopy can be carried out in Tayside children s s hospital SSAA as we have access otoscopes with insufflators. These are currently not used due to lack of understanding by staff of there benefits in diagnosing AOM and OME. 11. Were all outcomes important to the individual or population considered? Yes. The test prooves that pneumatic otoscopy is a valuable tool in reducing the diagnosis of AOM and OME. By introducing pneumatic otoscopy into practice the over prescribing of antibiotics should be reduced. Yes. The test proves that pneumatic otoscopy is a valuable tool in reducing the diagnosis of AOM and OME. By introducing pneumatic otoscopy into practice the over prescribing of antibiotics should be reduced.

19 Diagnostic Test Critical Appraisal Tool 12, Impact of using this test on patients in Ninewells Hospital. Reduction in the diagnosis of AOM and OME. Number of antibiotics prescribed would reduce. A saving for the trust in cost of antibiotics. Reduced referrals for tympanometry. Overall a more precise accurate diagnosis of AOM and OME.

20 Answer Does the assessment of tympanic membrane mobility using pneumatic reduce the diagnosis of Acute otitis media & otitis media with effusion in children? YES

21 Implication of Study Results on Practice These studies have highlighted that pneumatic otoscopy is an accurate diagnostic test when it comes to diagnosing AOM and OME. Confidence is lacking with health professional in the SSAA as they have never been taught the value of pneumatic otoscopy.. Education of professionals is required to increase the accuracy of AOM and OME diagnosis in Tayside children s s hospital. Clinical practice should change to avoid children becoming resisitant to antibiotics due to over prescribing. As an APNP It is my duty to implement change in my area and educate staff of new practice and its benefits.

22 Any Questions?

23 References AGIUS, A.M. et al., Smoking and middle ear ciliary beat frequency in otitis media with effusion. Acta-Oto-Laryngologica, 115 (1), pp BLUESTONE, C.D. and O. Klein J., Otitis media in infants and children. 4 th ed. Italy: BC Decker inc, 2007, pp. 2. BUTLER, C.C. and WILLIAMS, R.G., The etiology, pathophysiology, and management of otitis media with effusion. Current Infectious Disease Reports, 5 (3), pp CASP, Questions to help you make sense of a diagnostic test study. Oxford:Public Health Resource Unit. (Accessed on25/02/10.) DAVIDSON, T. and EDGREN, A., Gale Encyclopedia of Children s Health : Infancy through Adolescence. (Accessed on 22/02/2010). FROOM, J. et al., Antimicrobials for acute otitis media? A review from the International Primary Care Network. BMJ, 315, pp

24 References HARRIS, P.K. et al., The use of tympanometry and pneumatic otoscopy for predicting middle ear disease. American Journal of Audiology, 14, pp HEE DONG, and SANG-WON W., 2004 Clinical diagnostic accuracy of otitis media with effusion in children and significance of myringotomy: diagnostic or therapeutic. Journal of Korean Medical Science, 19, pp NICE CLINICAL GUIDELINES 60, Surgical management of otitis media with effusion in children. NICE Online. (Accessed on 22/2/2010). O NEILL, P Acute otis media. BMJ, 319 (7213), pp PELTON, S.I Otoscopy for the diagnosis of otitis media. Paediatric Infectious Diseases Journal, 17, pp