Can trained nurses exclude acute otitis media with tympanometry or acoustic reflectometry in symptomatic children?

OBJECTIVE: Since acute otitis media (AOM) is the most prevalent bacterial infection in young children, the reliable exclusion of AOM by nurses might save physicians' time for other duties. The study aim was to determine whether nurses without otoscopic experience can reliably use tympanometry or spectral gradient acoustic reflectometry (SG-AR) to exclude AOM. DESIGN: Three nurses were trained, who performed 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: 281 children 6-35 months of age. 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 459 visits, the negative predictive value of type A and C1 tympanograms (tympanometric peak pressure >-200 daPa) was 94% (91-97%). Based on type A and C1 tympanograms, the nurse could exclude AOM at 94/459 (20%) of visits. The negative predictive value of SG-AR level 1 result (>95°) was 94% (89-97%). Based on the SG-AR level 1 result, the nurse could exclude AOM at 36/459 (8%) of visits. CONCLUSION: Type A and C1 tympanograms and SG-AR level 1 results obtained by nurses are reliable test results in excluding AOM. However, the clinical usefulness of these test results is limited by their rarity. Type A and C1 tympanograms were obtained by nurses from both ears of the child only at one-fifth of the symptomatic visits. Key Points Acute otitis media (AOM) is the most prevalent bacterial infection in young children. Nurses' role in excluding AOM is unknown. Type A and C1 tympanograms (tympanometric peak pressure >-200 daPa) obtained by nurses are reliable test results in excluding AOM. With type A and C1 tympanograms, nurses could exclude AOM only at one-fifth of the symptomatic visits. The clinical usefulness of the exclusion of AOM performed by nurses seems to be limited.

Routine hearing screening in primary care for adult populations using distortion product Otoacoustic Emissions testing.

PURPOSE: The purpose of this study was to determine the prevalence of undiagnosed hearing loss in adults in two busy primary care rural health centers. DATA SOURCES: Using Otoacoustic Emissions (OAE) testing, participants were screened for hearing loss by trained personnel. Participants were those who presented to the primary care provider with complaints other than hearing loss or ear problems. CONCLUSION: Of the 86 participants, 48.8% were found to have failed OAE testing, indicating some type of undiagnosed hearing loss. The average age of the participants was 49.27 years, yet nearly half had hearing loss. This finding makes hearing screening in the adult population, other than the elderly, an important issue. IMPLICATIONS FOR PRACTICE: Hearing loss affects over 40% of the adult population. Undiagnosed and untreated hearing loss can be associated with depression, decreased social activities, and low self-esteem. The project identified the need for routine hearing screening and thus may become the foundation for the development and implementation of a hearing-screening program for primary care. The primary care nurse practitioner needs to incorporate hearing screening into the exam for early identification and for proper referral.

Detection of middle-ear fluid in children with spectral gradient acoustic reflectometry: a screening tool for nurses?

OBJECTIVE: To evaluate the validity of spectral gradient acoustic reflectometry (SG-AR) in the hands of nurses in screening children for middle-ear fluid (MEF). DESIGN: Prospective, blinded study. SETTING: A satellite study within the Finnish Otitis Media Vaccine Trial in primary care in 1995-99. PATIENTS: Some 739 ear examinations among a cohort of 271 children under the age of 2 years during different healthcare contacts (acute sick visits, check-up visits after otitis media, and scheduled healthy control visits at 24 months of age). MAIN OUTCOME MEASURES: Specificity, sensitivity and positive and negative predictive values of SG-AR performed by nurses in detecting MEF using pneumatic otoscopy by trained physicians as a reference. RESULTS: SG-AR was successful in 585 (79%) ears. None of the cut-off points assessed resulted in both excellent sensitivity and specificity. Nevertheless, at the sick visits, positive predictive values at 50 and 60 degrees were as high as 94% and 89%, respectively. However, negative predictive value for the cut-off point of 100 degrees was considerably lower, at 75%. At the non-acute visits, negative predictive values were excellent. CONCLUSION: SG-AR is a useful device for nurses in screening MEF among children. It detects ears with both very high and very low probability of MEF and is especially effective in detecting MEF during sick visits and in ruling out MEF among non-acute patients. We recommend the use of the SG-AR cut-off point of 60 degrees as a sign of MEF when screening sick children, and the cut-off point of 100 degrees as a sign of a healthy ear among non-symptomatic patients.