How helpful is pneumatic otoscopy in improving diagnostic accuracy?

BACKGROUND: Pneumatic otoscopy is believed to be helpful in optimally assessing the presence or absence of middle ear effusion (MEE). Although expert clinicians teach the importance of this diagnostic skill to trainees, evidence exists that many pediatric providers do not typically perform pneumatic otoscopy.

OBJECTIVE: To determine if the otoscopic accuracy within a group of clinicians improves with the pneumatic assessment when compared with the static assessment using videotaped otoendoscopic examinations (VOEs).

METHODS: Residents and faculty from 2 pediatric training programs served as subjects. All viewed a set of 50 video otoscopic examinations of tympanic membranes (TMs) from a validated VOE developed previously for training purposes. The video displays each TM in a static presentation and then in a pneumatic (mobile) presentation, followed by a final static presentation. Each subject first viewed the initial static presentation of each TM and responded "yes/no" to the presence of MEE, and then viewed the pneumatic presentation of the same TM and again responded "yes/no" to the presence of MEE. We compared the accuracy of assessment for both the static and the pneumatic tests.

RESULTS: Thirty-four pediatric residents and 6 clinical faculty participated. Accuracy (percent of total test items correct) on the pneumatic test was uniformly greater than accuracy on the static test. The mean absolute improvement in the accuracy from the static test (61%) to the pneumatic test (76%) was 15% (95% confidence interval [CI] = 12%-18%). The mean relative improvement in accuracy from the static test to the pneumatic test was 26% (95% CI = 19%-32%). Higher accuracy on the VOE was associated with greater absolute (r = 0.57) and greater relative (r = 0.47) improvement. The mean relative improvement in sensitivity and specificity from static viewing to pneumatic viewing was 24% (95% CI = 15%-33%) and 42% (95% CI = 27%-58%), respectively.

CONCLUSIONS: Using a video otoendoscopic test, we found that accurate identification of both the presence and the absence of MEE improved after pneumatic assessment of TM mobility. Providers who were more accurate at otoscopy, defined by higher video total test scores, benefited more from the pneumatic component than providers with lower scores.