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Digital imaging and telemedicine as a tool for studying inflammatory conditions in the middle ear: evaluation of image quality and agreement between examiners
Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine, Family Medicine.
Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine, Family Medicine.
Umeå University, Faculty of Medicine, Department of Clinical Sciences, Otorhinolaryngology.
Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine, Family Medicine.
2008 (English)In: International Journal of Pediatric Otorhinolaryngology, ISSN 0165-5876, E-ISSN 1872-8464, Vol. 72, no 1, 73-79 p.Article in journal (Other academic) Published
Abstract [en]

Objective: To evaluate digital imaging of the tympanic membrane by telemedicine technology and study interpersonal agreement in assessing image quality.

Methods: In an open consecutive study, 64 children aged 2-16 years who attended three rural health care centres in Northern Sweden with otalgia were examined with video endoscopic photography of their tympanic membrane in a telemedical environment. One hundred and twenty-four images were stored in a central database and Later assessed independently regarding image quality by an ENT specialist, a general practitioner and a registrar in general practice. The overall image quality was graded (0-2) regarding assessment of signs of tympanic membrane inflammation. ALL images were also assessed regarding 8 different components, four image-related components and four anatomically related components.

Results: Overall image quality was good, with 82.3% of acceptable or excellent quality. The position and thickness of the TM were found to be the most important factors of the images to be able to assess inflammatory disease. Image quality tended to be higher later in the study as a sign of improved skills of examiners. Interpersonal agreement between examiners was acceptable. Overall grade showed k 0.56, 0.49 and 0.66 respectively, and focus, light and existence of obscuring objects were the components with the highest agreement.

Conclusions: The image quality of video endoscopy of the tympanic membrane was good overall. Interpersonal agreement in evaluating image quality was acceptable but not excellent. The use of digital imaging of good quality in clinical studies can offer an objective clinical evaluation of the TM in retrospect by independent reviewers using strict criteria.

Place, publisher, year, edition, pages
2008. Vol. 72, no 1, 73-79 p.
Keyword [en]
otitis media, tympanic membrane, digital imaging, video endoscopy, telemedicine
National Category
Medical Image Processing
URN: urn:nbn:se:umu:diva-10417DOI: 10.1016/j.ijporl.2007.09.015ISI: 000253035100012PubMedID: 17983668OAI: diva2:150088
Available from: 2008-09-08 Created: 2008-09-08 Last updated: 2014-03-14Bibliographically approved
In thesis
1. Assessment of tympanic membrane: a study of children with otitis media in general practice
Open this publication in new window or tab >>Assessment of tympanic membrane: a study of children with otitis media in general practice
2014 (English)Doctoral thesis, comprehensive summary (Other academic)
Abstract [en]

Background Acute otitis media (AOM) is a common disease in children and is causing great discomfort and disability worldwide but many areas are underserved regarding skilled professional. Tele-otology offers a promising technique to provide ear health globally. Diagnostic accuracy of AOM has regardless of method been found to be low. Grading the severity of AOM my offer a guide in decision on antibiotic treatment, however grading systems need improvement.

Aim To describe and evaluate imaging of the tympanic membrane (TM), develop an image based grading scale for AOM and to study the characteristics and the course of acute otitis media (AOM) episodes in children with the use of telemedicine techniques.

Method This thesis is based on two study populations, 63 children attending with othalgia at four primary health care centers in rural Sweden (papers I, II, IV) and 140 children attending a health clinic from a township in Johannesburg, South Africa, (paper III).

Paper I: Image quality of endoscopic imaging of TM´s, from the Swedish study was assessed by an otologist and two general practitioners together with an evaluation of important characteristics of assessing TM appearance.

Paper II: In development and validation of an image-based grading scale of AOM two expert panels of otologist’s evaluated the proposed grading scale stepwise and in a test and retest validation process.

Paper III: A test of the scale in a clinical situation was set up, an otologist oto-microscopically examined children and used the grading scale, and his diagnoses were set as gold standard. A specially trained ear and hearing facilitator then recorded videos of the TM using video-otoscopy. Videos were remotely assessed by the same otologist and by a general practitioner twice; 4 and 8 weeks after the otologist’s on-site grading.

Paper IV: Children with othalgia were followed with assessments of their symptoms and signs over a period of 3 months. An assessment group of two general practitioners and one otologist evaluated TM images, tympanograms and recorded symptoms and make a diagnose.

Results The results from paper I show that image quality was good and the position and transparency of the TM was found to be the most important characteristics when assessing TM. In paper II the new grading scale (OMGRADE) was developed and validated. The image-based scale focuses on the position and transparency of the TM. The results from paper III showed that the OMGRADE scale could discriminate the normal ear as well as ears with otitis media with effusion (OME) in an unselected pediatric population. Paper IV showed that the bilateral AOM had more severe symptoms. The children with chagrinated TM’s took the longest time to resolve regarding TM appearance and tympanograms. Furthermore, symptoms resolved quicker than TM changes and tympanograms during the first week.

Conclusions TM images or video recordings taken by a trained nurse or facilitator are sufficient for remote evaluation. The new grading scale of TM appearance is valid and reliable and may function as a diagnostic guide together with evaluation of middle ear effusion. TM appearance may be of importance in grading the severity of an AOM episode. 

Place, publisher, year, edition, pages
Umeå: Umeå Universitet, 2014. 61 p.
Umeå University medical dissertations, ISSN 0346-6612 ; 1635
National Category
Research subject
Family Medicine; Oto-Rhino-Laryngology
urn:nbn:se:umu:diva-86949 (URN)978-91-7601-027-3 (ISBN)
Public defence
2014-04-04, Sal 135, byggnad 9, Norrlands universitetssjukhus, Umeå, 09:00 (Swedish)
Available from: 2014-03-14 Created: 2014-03-13 Last updated: 2014-03-14Bibliographically approved

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Lundberg, ThorbjörnWestman, GöranHellström, StenSandström, Herbert
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