Produção Nacional
Revisado por pares
Tympanometry Is Not Necessary in the Diagnosis of Acute Otitis Media
2006; Lippincott Williams & Wilkins; Volume: 25; Issue: 10 Linguagem: Inglês
10.1097/01.inf.0000238672.00300.b2
ISSN1532-0987
AutoresJos Faibes Lubianca Neto, Moacyr Saffer,
Tópico(s)Sinusitis and nasal conditions
ResumoTo the Editors: Saeed et al1 discuss the unsolved dilemma of the diagnosis of acute otitis media (AOM). The premise of the authors that “studies that directly compare the usefulness of tympanometric and otoscopic findings in AOM, using tympanocentesis as the standard are lacking” is partially true. There are no papers comparing tympanometry to tympanocentesis in AOM, but at least 3 papers have analyzed the value of different symptoms and otoscopic signs in the diagnosis of AOM. As early as 1968, Halsted et al2 aspirated fluid from the middle ears of 81 children who had moderate or marked bulging of the tympanic membrane, with or without erythema, stating that this sign is probably the most useful indicator of AOM. Karma et al3 have found that although a combination of otoscopic signs and symptoms is better than an isolated finding, bulging of the tympanic membrane is the best isolated sign, with a specificity of 96.8% and a positive predictive value of 96%. We found a similar result (97 and 94%, respectively).4 If it is true that the role of tympanometry in the diagnosis of otitis media with effusion is well-established, in the AOM it does not appear to be so useful. It should be considered that it has practically the same limitations of otoscopy but carries a certain degree of morbidity. In the study by Saeed et al, both tests failed together when 18 ears were diagnosed with AOM with effusion by these 2 methods, but they yielded a dry tap. The authors also stated that tympanometry may be less sensitive than otoscopy in some cases, as is shown when a normal tympanogram was associated with the presence of middle ear effusion in 3 of 10 cases, and in all 3 cases otoscopic findings were abnormal. However, the main reason for this letter is to question the appropriateness of performing tympanometry in cases of AOM in practice. It is an uncomfortable, painful procedure in acute cases and is not necessary in the great majority of children, even in uncertain cases. Otoscopy is enough to diagnose at least the severe ones, where bulging is almost always present. In cases in which there is uncertainty about the diagnosis, even the American Academy of Pediatrics now advocates expectant treatment of children with mild symptoms, at least for those older than 2 years old.5 Therefore the need for an extremely accurate diagnosis in these cases is questionable, and even more so if the method to improve this diagnosis is not perfectly accurate and causes morbidity (pain). Continuing medical education, with hands-on otoscopy courses for pediatricians, as we have been performing in our city for 10 years, is the best way to further improve the diagnosis of AOM. We fear that papers advocating tympanometry in an AOM scenario may give the wrong impression, especially to recently trained physicians, that otoscopy can be replaced by other objective methods in the diagnosis of AOM. José Faibes Lubianca Neto, MD, PhD Moacyr Saffer, MD, MSc Department of Ophthalmology and Otorhinolaryngology Faculdade Federal de Ciências Médicas de Porto Alegre Division of Pediatric Otorhinolaryngology at Hospital da Criança Santo Antônio Porto Alegre, Brazil
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