Can nurses exclude middle-ear effusion without otoscopy in young asymptomatic children in primary care?

Abstract

Objective: Scandinavian guidelines recommend controlling middle-ear effusion (MEE) after acute otitis media. The study aim was to determine whether nurses without otoscopic experience can reliably exclude MEE with tympanometry or spectral gradient acoustic reflectometry (SG-AR) at asymptomatic visits.

Design: Three nurses were taught to perform examinations with tympanometry and SG-AR. Pneumatic otoscopy by the study physician served as the diagnostic standard.

Setting: Study clinic at primary health care level.

Patients: A total of 156 children aged 6-35 months.

Main outcome measures: Predictive values (with 95% confidence interval) for tympanometry and SG-AR, and the clinical usefulness, i.e. the proportion of visits where nurses obtained the exclusive test result from both ears of the child.

Results: At 196 visits, the negative predictive value of type A and C1 tympanograms (tympanometric peak pressure > -200 daPa) was 95% (91-97%). Based on type A and C1 tympanograms, the nurse could exclude MEE at 81/196 (41%) of visits. The negative predictive value of SG-AR level 1 result was 86% (79-91%). Based on SG-AR level 1 results, the nurse could exclude MEE at 29/196 (15%) of visits.

Conclusion: Tympanograms with tympanometric peak pressure > -200 daPa (types A and C1) obtained by nurses are reliable test results in excluding MEE. However, these test results were obtained at less than half of the asymptomatic visits and, thus, the usefulness of excluding MEE by nurses depends on the clinical setting.

Keywords: Children; Finland; exclusion; general practice; middle ear effusion; routine control; spectral gradient acoustic reflectometry; tympanometry.

Figure 1.

Flow chart of the included children, visits, and tympanometric and spectral gradient acoustic reflectometry (SG-AR) examinations.

Figure 2.

Flow chart of the clinical usefulness of excluding middle-ear effusion (MEE) based on tympanometry performed by the nurses at asymptomatic visits (n = 196). Type A and C1 tympanograms from both ears of the child were regarded as the exclusive test result for MEE. Notes: ^aTympanogram types: Type A (tympanometric peak pressure greater than −100 daPa); type C1 (the pressure between −100 and −199 daPa); type C2 (the pressure −200 daPa or less); type Cs (width > 300 daPa or static acoustic admittance < 0.2 mmho); and type B (flat).