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  • 1. Biagio, L.
    et al.
    Swanepoel, D. W.
    Laurent, Claude
    Umeå universitet, Medicinska fakulteten, Institutionen för klinisk vetenskap, Öron- näs- och halssjukdomar. Department of Speech-Language Pathology and Audiology, University of Pretoria, South Africa.
    Lundberg, Thorbjörn
    Umeå universitet, Medicinska fakulteten, Institutionen för folkhälsa och klinisk medicin, Allmänmedicin.
    Paediatric otitis media at a primary healthcare clinic in South Africa2014Ingår i: SAMJ South African Medical Journal, ISSN 0256-9574, E-ISSN 2078-5135, Vol. 104, nr 6, s. 431-435Artikel i tidskrift (Refereegranskat)
    Abstract [en]

    BACKGROUND: No published studies on the prevalence of paediatric otitis media at primary healthcare clinics (PHCs) in South Africa (SA) are available. OBJECTIVE: To examine the point prevalence of otitis media in a paediatric population in a PHC in Johannesburg, SA, using otomicroscopy. METHODS: A sample of 140 children aged 2 - 16 years (mean 6.4; 44.1% females) were recruited from patients attending the PHC. Otomicroscopy was completed for each of the participants' ears by a specialist otologist using a surgical microscope. RESULTS: Cerumen removal was necessary in 36.0% of participants (23.5% of ears). Otitis media with effusion was the most frequent diagnosis (16.5%). Chronic suppurative otitis media (CSOM) was diagnosed in 6.6% of children and was the most common type of otitis media in participants aged 6 - 15 years. Acute otitis media was only diagnosed in the younger 2 - 5-year age group (1.7%). Otitis media was significantly more prevalent among younger (31.4%) than older children (16.7%). CONCLUSION: CSOM prevalence, as classified by the World Health Organization, was high. Consequently diagnosis, treatment and subsequent referral protocols may need to be reviewed to prevent CSOM complications.

  • 2. Biagio, Leigh
    et al.
    Swanepoel, De Wet
    Laurent, Claude
    Umeå universitet, Medicinska fakulteten, Institutionen för klinisk vetenskap, Öron- näs- och halssjukdomar.
    Lundberg, Thorbjörn
    Umeå universitet, Medicinska fakulteten, Institutionen för folkhälsa och klinisk medicin, Allmänmedicin.
    Video-otoscopy recordings for diagnosis of childhood ear disease using telehealth at primary health care level2014Ingår i: Journal of Telemedicine and Telecare, ISSN 1357-633X, E-ISSN 1758-1109, Journal of telemedicine and telecare, ISSN 1758-1109, Vol. 20, nr 6, s. 300-306Artikel i tidskrift (Refereegranskat)
    Abstract [en]

    We studied the diagnoses made by an otologist and general practitioner (GP) from video-otoscopy recordings on children made by a telehealth facilitator. The gold standard was otomicroscopy by an experienced otologist. A total of 140 children (mean age 6.4 years; 44% female) were recruited from a primary health care clinic. Otomicroscopic examination was performed by an otologist. Video-otoscopy recordings were assigned random numbers and stored on a server. Four and eight weeks later, an otologist and a GP independently graded and made a diagnosis from each video recording. The otologist rated the quality of the video-otoscopy recordings as acceptable or better in 87% of cases. A diagnosis could not be made from the video-otoscopy recordings in 18% of ears in which successful onsite otomicroscopy was conducted. There was substantial agreement between diagnoses made from video-otoscopy recordings and those from onsite otomicroscopy (first review: otologist κ = 0.70 and GP κ = 0.68; second review: otologist κ = 0.74 and GP κ = 0.75). There was also substantial inter-rater agreement (κ = 0.74 and 0.74 at the two reviews) and intra-rater agreement (κ = 0.77 and 0.74 for otologist and GP, respectively). A telehealth facilitator, with limited training, can acquire video-otoscopy recordings in children for asynchronous diagnosis. Remote diagnosis was similar to face-to-face diagnosis in inter- and intra-rater variability.

  • 3.
    Lundberg, Thorbjörn
    Umeå universitet, Medicinska fakulteten, Institutionen för folkhälsa och klinisk medicin, Allmänmedicin.
    Assessment of tympanic membrane: a study of children with otitis media in general practice2014Doktorsavhandling, sammanläggning (Övrigt vetenskapligt)
    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. 

  • 4.
    Lundberg, Thorbjörn
    et al.
    Umeå universitet, Medicinska fakulteten, Institutionen för folkhälsa och klinisk medicin, Allmänmedicin.
    Biagio, Leigh
    Univ Pretoria, Dept Speech Language Pathol & Audiol, ZA-0002 Pretoria, South Africa.
    Laurent, Claude
    Umeå universitet, Medicinska fakulteten, Institutionen för klinisk vetenskap, Öron- näs- och halssjukdomar. Univ Pretoria, Dept Speech Language Pathol & Audiol, ZA-0002 Pretoria, South Africa.
    Sandström, Herbert
    Umeå universitet, Medicinska fakulteten, Institutionen för folkhälsa och klinisk medicin, Allmänmedicin.
    Swanepoel, De Wet
    Univ Pretoria, Dept Speech Language Pathol & Audiol, ZA-0002 Pretoria, South Africa.
    Remote evaluation of video-otoscopy recordings in an unselected pediatric population with an otitis media scale2014Ingår i: International Journal of Pediatric Otorhinolaryngology, ISSN 0165-5876, E-ISSN 1872-8464, Vol. 78, nr 9, s. 1489-1495Artikel i tidskrift (Refereegranskat)
    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.

  • 5.
    Lundberg, Thorbjörn
    et al.
    Umeå universitet, Medicinska fakulteten, Institutionen för folkhälsa och klinisk medicin, Allmänmedicin.
    de Jager, Leigh Biagio
    Swanepoel, De Wet
    Laurent, Claude
    Umeå universitet, Medicinska fakulteten, Institutionen för klinisk vetenskap, Öron- näs- och halssjukdomar. Department of Speech-Language Pathology and Audiology, University of Pretoria, Pretoria, South Africa.
    Diagnostic accuracy of a general practitioner with video-otoscopy collected by a health care facilitator compared to traditional otoscopy2017Ingår i: International Journal of Pediatric Otorhinolaryngology, ISSN 0165-5876, E-ISSN 1872-8464, Vol. 99, s. 49-53Artikel i tidskrift (Refereegranskat)
    Abstract [en]

    Objective: Video-otoscopy is rapidly developing as a new method to diagnose common ear disease and can be performed by trained health care facilitators as well as by clinicians. This study aimed to compare remote asynchronous assessments of video-otoscopy with otoscopy performed by a general practitioner. Method: Children, aged 2-16 years, attending a health center in Johannesburg, South Africa, were examined. An otologist performed otomicroscopy and a general practitioner performed otoscopy. Video-otoscopy was performed by a health care facilitator and video sequences were stored on a server for assessment by the same general practitioner 4 and 8 weeks later. At all examinations, a diagnosis was set and the tympanic membrane appearance was graded using the OMgrade-scale. The otologist's otomicroscopic diagnosis was set as reference standard to compare the accuracy of the two otoscopic methods. Results: Diagnostic agreement between otologist's otomicroscopic examination and the general practitioner's otoscopic examination was substantial (kappa 0.66). Agreement between onsite otomicroscopy and the general practitioners asynchronous video assessments were also substantial (kappa 0.70 and 0.80). Conclusion: Video-otoscopy performed by a health care facilitator and assessed asynchronously by a general practitioner had similar or better accuracy compared to face-to-face otoscopy performed by a general practitioner.

  • 6.
    Lundberg, Thorbjörn
    et al.
    Umeå universitet, Medicinska fakulteten, Institutionen för folkhälsa och klinisk medicin, Allmänmedicin.
    Hellström, Sten
    Sandström, Herbert
    Umeå universitet, Medicinska fakulteten, Institutionen för folkhälsa och klinisk medicin, Allmänmedicin.
    Development and Validation of a New Grading Scale for Otitis Media2013Ingår i: The Pediatric Infectious Disease Journal, ISSN 0891-3668, E-ISSN 1532-0987, Vol. 32, nr 4, s. 341-345Artikel i tidskrift (Refereegranskat)
    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.

  • 7.
    Lundberg, Thorbjörn
    et al.
    Umeå universitet, Medicinska fakulteten, Institutionen för folkhälsa och klinisk medicin, Allmänmedicin.
    Laurent, Claude
    Umeå universitet, Medicinska fakulteten, Institutionen för klinisk vetenskap, Öron- näs- och halssjukdomar.
    Sandström, Herbert
    Umeå universitet, Medicinska fakulteten, Institutionen för folkhälsa och klinisk medicin, Allmänmedicin.
    Hellström, Sten
    Department of Audiology and Neurotology Karolinska University Hospital, Stockholm, Sweden.
    What does otalgia in children represent?: A study of acute otitis media in general practice related to symptoms and tympanic membrane status over time.Manuskript (preprint) (Övrigt vetenskapligt)
    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. 

  • 8.
    Lundberg, Thorbjörn
    et al.
    Umeå universitet, Medicinska fakulteten, Institutionen för folkhälsa och klinisk medicin, Allmänmedicin.
    Westman, Göran
    Umeå universitet, Medicinska fakulteten, Institutionen för folkhälsa och klinisk medicin, Allmänmedicin.
    Hellström, Sten
    Umeå universitet, Medicinska fakulteten, Institutionen för klinisk vetenskap, Öron- näs- och halssjukdomar.
    Sandström, Herbert
    Umeå universitet, Medicinska fakulteten, Institutionen för folkhälsa och klinisk medicin, Allmänmedicin.
    Digital imaging and telemedicine as a tool for studying inflammatory conditions in the middle ear: evaluation of image quality and agreement between examiners2008Ingår i: International Journal of Pediatric Otorhinolaryngology, ISSN 0165-5876, E-ISSN 1872-8464, Vol. 72, nr 1, s. 73-79Artikel i tidskrift (Övrigt vetenskapligt)
    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.

  • 9.
    Sandström, Josefin
    et al.
    Umeå universitet, Medicinska fakulteten, Institutionen för folkhälsa och klinisk medicin, Allmänmedicin.
    Swanepoel, DeWet
    Laurent, Claude
    Umeå universitet, Medicinska fakulteten, Institutionen för klinisk vetenskap, Öron- näs- och halssjukdomar. Department of Speech-Language Pathology and Audiology, University of Pretoria, Pretoria, South Africa.
    Umefjord, Göran
    Umeå universitet, Medicinska fakulteten, Institutionen för folkhälsa och klinisk medicin, Allmänmedicin.
    Lundberg, Thorbjörn
    Umeå universitet, Medicinska fakulteten, Institutionen för folkhälsa och klinisk medicin, Allmänmedicin.
    Accuracy and Reliability of Smartphone Self-Test Audiometry in Community Clinics in Low Income Settings: A Comparative Study2020Ingår i: Annals of Otology, Rhinology and Laryngology, ISSN 0003-4894, E-ISSN 1943-572X, artikel-id UNSP 0003489420902162Artikel i tidskrift (Refereegranskat)
    Abstract [en]

    Background: There is a lack of hearing health care globally, and tele-audiology and mobile technologies have been proposed as important strategies to reduce the shortfall. Objectives: To investigate the accuracy and reliability of smartphone self-test audiometry in adults, in community clinics in low-income settings.

    Methods: A prospective, intra-individual, repeated measurements design was used. Sixty-three adult participants (mean age 52 years, range 20-88 years) were recruited from ENT and primary health care clinics in a low-income community in Tshwane, South Africa. Air conduction hearing thresholds for octave frequencies 0.5 to 8 kHz collected with the smartphone self-test in non-sound treated environments were compared to those obtained by reference audiometry.

    Results: The overall mean difference between threshold seeking methods (ie, smartphone thresholds subtracted from reference) was -2.2 dB HL (n = 467 thresholds, P = 0.00). Agreement was within 10 dB HL for 80.1% (n = 467 thresholds) of all threshold comparisons. Sensitivity for detection hearing loss >40 dB HL in one ear was 90.6% (n = 84 ears), and specificity 94.2% (n = 84 ears).

    Conclusion: Smartphone self-test audiometry can provide accurate and reliable air conduction hearing thresholds for adults in community clinics in low-income settings.

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