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Assessment of tympanic membrane: a study of children with otitis media in general practice
Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine, Family Medicine.
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.
Series
Umeå University medical dissertations, ISSN 0346-6612 ; 1635
National Category
Otorhinolaryngology
Research subject
Family Medicine; Oto-Rhino-Laryngology
Identifiers
URN: urn:nbn:se:umu:diva-86949ISBN: 978-91-7601-027-3 (print)OAI: oai:DiVA.org:umu-86949DiVA: diva2:705007
Public defence
2014-04-04, Sal 135, byggnad 9, Norrlands universitetssjukhus, Umeå, 09:00 (Swedish)
Opponent
Supervisors
Available from: 2014-03-14 Created: 2014-03-13 Last updated: 2014-03-14Bibliographically approved
List of papers
1. Digital imaging and telemedicine as a tool for studying inflammatory conditions in the middle ear: evaluation of image quality and agreement between examiners
Open this publication in new window or tab >>Digital imaging and telemedicine as a tool for studying inflammatory conditions in the middle ear: evaluation of image quality and agreement between examiners
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.

Keyword
otitis media, tympanic membrane, digital imaging, video endoscopy, telemedicine
National Category
Medical Image Processing
Identifiers
urn:nbn:se:umu:diva-10417 (URN)10.1016/j.ijporl.2007.09.015 (DOI)000253035100012 ()17983668 (PubMedID)
Available from: 2008-09-08 Created: 2008-09-08 Last updated: 2017-12-14Bibliographically approved
2. Development and Validation of a New Grading Scale for Otitis Media
Open this publication in new window or tab >>Development and Validation of a New Grading Scale for Otitis Media
2013 (English)In: The Pediatric Infectious Disease Journal, ISSN 0891-3668, E-ISSN 1532-0987, Vol. 32, no 4, 341-345 p.Article in journal (Refereed) Published
Abstract [en]

Background: Grading of acute otitis media (AOM) is important in clinical situations as well as in research. Current grading scales for AOM have used a 6 to 9 point scoring system primarily based on variation of redness and bulging of the tympanic membrane (TM). This study aimed to develop and validate a new scale for grading AOM. Method: The scale was developed in 3 stages based on 32 patients with images taken of the TM when a child attended healthcare centre with othalgia and at follow-up visits. Content validity was used as the method for the first 2 stages. An expert panel reviewed the scale and repeated the process on a revised scale. Reliability was tested with a different expert panel that used the final scale on a sample of TM images in a test-retest and inter-rater and intra-rater agreements were calculated. Results: The scale was developed in 3 steps using expert committees. During the process the description of vascularization was judged to be of insufficient importance for our scale. Inter-rater agreement was moderate (kappa = 0.52) and intra-rater agreement was good (kappa = 0.66 to 0.89) in the test-retest of the final scale. Conclusions: The developed AOM image-based grading scale demonstrates substantial inter- and intra-rater reliability with potential use in clinical research and telemedicine applications. Furthermore, the parameter "redness of TM" is of less importance in our scale as compared with other available grading systems.

Keyword
acute otitis media, grading, tympanic membrane, digital imaging, video endoscopy
National Category
Immunology in the medical area Pediatrics
Identifiers
urn:nbn:se:umu:diva-68905 (URN)10.1097/INF.0b013e3182869397 (DOI)000316669200018 ()
Available from: 2013-04-29 Created: 2013-04-29 Last updated: 2017-12-06Bibliographically approved
3. Remote evaluation of video-otoscopy recordings in an unselected pediatric population with an otitis media scale
Open this publication in new window or tab >>Remote evaluation of video-otoscopy recordings in an unselected pediatric population with an otitis media scale
Show others...
2014 (English)In: International Journal of Pediatric Otorhinolaryngology, ISSN 0165-5876, E-ISSN 1872-8464, Vol. 78, no 9, 1489-1495 p.Article in journal (Refereed) Published
Abstract [en]

Background: A recently validated image-based grading scale for acute otitis media (OMGRADE) can be used to assess tympanic membrane (TM) status. The aim of this study was to evaluate the validity and reliability of this scale for remote assessments of TM status using video-otoscopy recordings in an unselected pediatric population.

Method: Children 2-16 years attending a South African primary health clinic were offered an ear examination by an otologist using otomicroscopy. An ear and hearing telehealth facilitator then made video-otoscopy recordings (9 – 33 seconds) of the ears and uptakes were uploaded to a secure server for remote assessments in Sweden by an otologist and general practitioner at four- and eight-weeks post onsite assessment. TM appearance was judged according to the OMGRADE scale. Concordance between onsite otomicroscopy and asynchronous assessments of video-otoscopy recordings was calculated together with intra- and inter-rater agreements.

Results: One hundred and eighty ears were included. Concordance of TM classifications using the OMGRADE scale was found to be substantial (weighted kappa range 0,66-0,79). Intra- and inter-rater agreement (test-retest) was found to be substantial to almost perfect (weighted kappa range 0,85-0,88 and 0,69-0,72, respectively).

Conclusion: The OMGRADE scale can be used to accurately assess the normal TM and secretory otitis media (SOM) remotely using video-otoscopy recordings in an unselected pediatric population.

National Category
Otorhinolaryngology
Research subject
Family Medicine; Oto-Rhino-Laryngology
Identifiers
urn:nbn:se:umu:diva-86947 (URN)10.1016/j.ijporl.2014.06.018 (DOI)000340983500016 ()
Available from: 2014-03-13 Created: 2014-03-13 Last updated: 2017-12-05Bibliographically approved
4. What does otalgia in children represent?: A study of acute otitis media in general practice related to symptoms and tympanic membrane status over time.
Open this publication in new window or tab >>What does otalgia in children represent?: A study of acute otitis media in general practice related to symptoms and tympanic membrane status over time.
(English)Manuscript (preprint) (Other academic)
Abstract [en]

Background

Otalgia is an important symptom leading children to seek health care in general practice and it can be a symptom of acute otitis media (AOM). The course of AOM can be of importance when grading severity of AOM.

The aim of this study was to assess tympanic membrane TM appearance in children aged 2–16 years with otalgia in general practice and to follow their signs and symptoms over time.

Method

The children were examined at four rural health care centers in Lapland, Sweden. Symptoms such as otalgia, fever and the general condition were recorded together with endoscopic TM images and tympanometry results and stored in a central database. The same procedures were applied at follow-up visits after 3 days, 7 days and 3 months. The symptoms were given scores 0–2, the tympanograms were labeled as type A, type C and type B (scores 0–4–8) whereas TM images were graded according to the OMGRADE scale for TM´s (score 0–8). An assessment group set a diagnosis asynchronously after a consensus discussion. Diagnoses: normal, otitis media with effusion, AOM, bullous myringitis without AOM (BM), bullous myringitis with AOM (bAOM) and AOM with perforation or a wet and chagrinated appearance of the TM (pAOM). The diagnoses were scrutinized for any difference in presentation of symptoms. The course of signs and symptoms was followed up at return visits.

Results

The children showed a normal TM and tympanogram in 19%, otitis media with effusion in 32% and AOM in 49% at first visit. The majority of children reported no symptoms after 3 days. The children with bilateral AOM reported slightly more symptoms and the BM/bAOM groups reported fewer symptoms than children with AOM. A pAOM with a chagrinated TM was found in 19% and showed a prolonged return to normal tympanograms. Forty percent of the children who presented with a chagrinated TM (pAOM) at first visit still had type-B tympanograms after 3 months.

Conclusions Half of the children with otalgia were diagnosed with AOM. Symptoms resolved faster than signs. The chagrinated TM appeared to be associated with prolonged middle ear effusion. 

Keyword
Acute otitis media, Scoring system, Tympanic membrane, Otalgia
National Category
Otorhinolaryngology
Research subject
Family Medicine; Oto-Rhino-Laryngology
Identifiers
urn:nbn:se:umu:diva-86948 (URN)
Note

Manuskript i sammanläggningsavhandling, ännu ej sänt till tidsskrift

Available from: 2014-03-13 Created: 2014-03-13 Last updated: 2014-03-14Bibliographically approved

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