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Ear Infections can easily be misdiagnosed

By Rod Moser, PA, PhDMarch 30, 2006
From the WebMD Archives

It is amazing how often middle ear infections (otitis media) are misdiagnosed by medical professionals.

I recently attended the Advances in Pediatrics conference that had hundreds of clinicians from all over the country. During a workshop on otitis media, participants were asked to provide a diagnosis of various eardrum slides using an Audience Response System (ARS) — a wireless device so that people can anonymously answer questions. The slides were shown on a screen, thousands of times bigger than life, accompanied by a brief clinical description.

The medical providers in the groups had 15 seconds to provide a diagnosis — more than the average time we actually look at the ears. A computer analyzes the responses and the results are projected on the screen. In the vast majority of cases, as few as 50% of the clinicians got the correct answer. Transferring this data to the doctor’s office or emergency room would indicate that you may be misdiagnosed half of the time. Why is that?

First, there is a wide range of clinical interpretation by medical providers as to what constitutes a middle ear infection. Some clinicians felt that any red eardrum in a feverish child is otitis media and required antibiotics. Not true. Pink or red eardrums do not necessarily mean there is an infection. Feverish children can have red eardrums. Crying children can have red eardrums. Basically, any child with a flushed, red face may have a corresponding flushed, red eardrum.

Second, many clinicians are cutting corners doing quick, cursory examinations. An accurate diagnosis of otitis media is not rocket science, and the diagnostic criteria are well-known and published:

  1. The eardrum needs to be OPAQUE. In other words, you should not be able to see through it during an exam. The normal eardrum is translucent, like a frosted shower door.
  2. The COLOR of the eardrum may be red, yellow, or cloudy. Many times, a true otitis media is more likely to be yellow, than red.
  3. The eardrum should be BULGING. If the eardrum is not bulging out from pressure behind it, there is only a 7-10% chance that it is a bacterial infection.
  4. Most importantly, the eardrum must have REDUCED MOBILITY, as observed using a pneumatic otoscope. An otoscope is the device that a medical provider uses to observe the ear; the pneumatic attachment is a little bulb syringe that is used to puff air against the eardrum so that movement can be seen. A middle ear infection would have an eardrum that did not move very well, if at all. This most important diagnostic step is the one most frequently skipped by medical providers, even though it only takes a few extra seconds.

Third, many clinicians are diagnosing ear infections by the seat of their pants. They are not even seeing the eardrum! A mother told me that she watched an urgent care physician look in her child’s ear without even inserting the otoscope tip in the ear opening; he only looked at the skin of the outer ear! Additionally, people can have significant wax in their ears completely obscuring the eardrum.

There is absolutely no way to accurately diagnose an ear infection without seeing the eardrum — simple as that. Not all clinicians are skilled at removing excess wax from ears, but they should be.

Patients should hold their medical providers accountable for Standard of Care practices. You and your children deserve to have a complete medical assessment, resulting in an accurate diagnosis.

  1. Did the clinician take a thorough medical history?
  2. Did the clinician do a thorough examination? Did they examine more than just the ear that was hurting? Did they take the time to clean out any obstructing earwax? And, more importantly, did they take the time to use a pneumatic otoscope?
  3. When asked, did the clinician allow YOU to look in your child’s ear through the otoscope? The doctor may be put off by this request, but ask anyway. You may not be skilled enough to validate the clinical findings, but with a little practice and a home otoscope, you can develop those skills. I have been a long-time advocate of people having and using home otoscopes. If the doctor refuses to let you see the eardrum, just tell him/her that you will check it when you get home, with your OWN otoscope. I bet that will get their attention.
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