Keywords
otoscopy - pediatrics - otologic
Introduction
The otologic evaluation is highly significant in those branches of medicine in which
the general evaluation of the patient is conducted by general practitioners and pediatricians.
The otoscopic examination should become a part of the routine examination. An early
diagnosis of primary infections and of any pathology during a simple examination using
only an otoscope can prevent possible complications and sequelae. Besides, misdiagnoses
determined by pediatricians are a clinical problem that may result in unnecessary
treatment.[1]
[2] Therefore, pediatricians must be in close interaction with otorhinolaryngologists
regarding the methodology of the detected pathologies. Hence, it will be more convenient
to manage diseases through a correct diagnosis and treatment. In addition, the branches
of medicine in which the general evaluation of the patient is performed will gain
experience, the percentages of correct diagnoses will rise, and unnecessary treatments
will be avoided.
Objective
The aim of the present study is to assess otologic findings in pediatric patients
without any ENT complaints who presented to a polyclinic for any reason.
Methods
After receiving the approval from Ethics Committee (protocol number 215), the authors
signed the informed consent form and indicated that there were no conflicts of interest
in the present study.
A total of 973 patients were included in the study. The ages of the patients ranged
from 2 to 16 years. The patients presented to a pediatric polyclinic between June
2016 and June 2017 for any reason; however, they did not have any otorhinolaryngological
complaints, and no history of otorhinolaryngological surgery. All patients were evaluated
by the same pediatrician. Findings regarding the external auditory canal (EAC) and
the tympanic membrane obtained during the otoscopic examination were registered from
the file of each patient. Patients with any detected pathology were referred to an
otorhinolaryngologist. The otoscopic findings, medical, and surgical treatments and
the examinations for the diagnosis of those patients were recorded.
Patients with otitis media with effusion (OME) were submitted to a tympanogram. The
measurements of the tympanometry were evaluated as type A, B and C, according to the
Jerger classification system.[3]
Results
Of a total of 973 patients included in the present study, 556 (58.2%) were male, and
407 (41.8%) were female. The age of the patients ranged from 2 to 16 years, and the
mean age was 8.9 years. The results of the otoscopic examination of 844 (86.8%) of
the patients were normal. A total of 129 (13.2%) of them were referred to the otorhinolaryngology
department due to an ear pathology ([Fig. 1]). Out of the total of 844 referred patients, 12 were observed with myringosclerosis
and atrophic membrane indistinguishable from perforation, which represents a false
positivity rate of 1.2% in the pediatrician's examination. Pathologic findings were
detected in the otoscopic examinations of 117 (12%) patients in the post otorhinolaryngological
examination ([Fig. 2]).
Fig. 1 Pediatrician's otoscopic examination findings.
Fig. 2 Patient's otoscopic findings, with true or false positivity numbers of patients who
were referred from a pediatrician to an otorhinolaryngologist.
A total of 117 patients diagnosed with pathologies were evaluated. A total of 68 (6.9%)
patients were diagnosed with OME, which was unilateral in 14 (20.5%) patients and
bilateral in 54 (79.5%) patients. Regarding the evaluation of the tympanograms, type
B was detected in 51 (75%) patients, while type C was detected in 17 (25%) patients.
Cerumen impaction (25 bilateral, 12 unilateral) was detected in 37 (3.8%) patients.
Acute otitis media (AOM) was diagnosed in 8 (0.8%) patients (5 unilateral, 3 bilateral).
One of the patients diagnosed with AOM presented the following complaints: nausea,
vomiting and discomfort while seven of them had fever. A foreign body (tick) was detected
in the EACs of 2 (0.2%) patients. Unilateral central dry perforation in the tympanic
membrane was observed in 1 (0.1%) patient, while retraction pockets were observed
in 2 (0.2%) patients. A type C tympanogram was obtained as a result of the tympanometry
test performed on the patients with retraction pockets. Congenital cholesteatoma was
prediagnosed in 1 (0.1/%) patient whose computed tomography of the temporal bone (CTTB)
and diffusion magnetic resonance imaging (MRI) tests were conducted by the otorhinolaryngologist;
the patient was referred to surgery, and the final diagnosis of cholesteatoma was
determined as a result of the histopathological evaluation of the specimen ([Table 1]).
Table 1
All patients' pathological findings in the routine examination and rates compared
to all examined patients
|
Pathological findings in the routine examination
|
Rates
|
|
OME
|
68 (6.9%)
|
|
Cerumen impaction
|
37 (3.8%)
|
|
AOM
|
8 (0.8%)
|
|
Foreign body (tick) in the EAC
|
2 (0.2%)
|
|
Retraction pocket in tympanic membrane
|
2 (0.2%)
|
|
Perforation of the tympanic membrane
|
1 (0.1%)
|
|
Congenital cholesteatoma
|
1 (0.1%)
|
Abbreviations: AOM, acute otitis media; EAC, external auditory canal; OME, otitis
media with effusion.
Discussion
Additional otologic findings have been obtained, which may be significant to be diagnosed
or noticed in a rate of 12% in the pediatric patient group that presented to the pediatrics
department without any otorhinolaryngological complaints, but with various other complaints.
The findings detected during the examination were OME, cerumen impaction, AOM, and
live foreign body (tick) in the EAC. Pathologies such as congenital cholesteatoma
and tympanic membrane perforation or retraction are vital issues both for a child's
healthcare and for his/her speech and language development.
Otitis media with effusion is an accumulation of fluid in the middle ear without acute
infection symptoms and findings. Ninety percent of the children experience at least
once OME attack before school age, which is the most common reason for hearing loss
in children.[4] The prevalence of OME has been found to be between 10% to 40% in several studies.[5]
[6]
[7] However, in the present study, it was found in 6.9% of the cases. However, none
of these patients had any complaints about their ears, which we think is the reason
why we found a lower result. It is significant to diagnose OME and perform a follow-up
of the patients in order to prevent possible complications. Chronic otitis media,
adhesive otitis media, formation of a retraction pocket and tympanosclerosis are common
complications. If not treated regularly, they may cause permanent hearing loss.[8]
[9] In addition, OME not treated for a long period has such risks as language and speech
disorders and learning difficulties due to hearing loss in children.[7]
[9] It is significant that pediatric patients should be evaluated by pediatricians for
these reasons. Furthermore, it is essential to receive a reliable medical history
from the caretaker, and to inform him/her about the disease and the possible sequelae.
Cerumen is secreted by the EAC for protection, lubrication and cleaning. Cerumen is
removed from the EAC through a self-cleaning function. However, the accumulation of
cerumen in the EAC causes cerumen impaction.[10] Cerumen impaction may result in hearing difficulty, pain and loss of balance. Sneaky
hearing loss caused by cerumen impaction may bring about serious problems in children
during a critical period for speech and language development.[11] As it has been observed in the present study, neither a caretaker nor a child may
recognize cerumen impaction and its symptoms. We think the percentage of asymptomatic
cerumen impaction is high in the present study. This may result from the fact that
we have carried out the study in a region where the sociocultural level is low. However,
although it seems insignificant, the detection of cerumen impaction during routine
examination has serious impacts on a child's speech and language development and success
at school.
Acute otitis media is an inflammation of the middle ear accompanied by systemic infection
findings. Earache and fever are the most encountered symptoms. However, in the hyperemia
phase, which is the beginning phase of AOM, the earache has not started yet, and the
fever is at a low grade. In this phase, AOM is usually diagnosed circumstantially.[12] Sometimes the hyperemia formed in the tympanic membrane, especially while a baby
is crying, may result in misdiagnosis. An accurate diagnosis of AOM is significant
to remove symptoms of the infection and prevent possible complications, while the
detection of a misdiagnosis is important to avoid the unnecessary use of antibiotics.[13]
[14] All of the patients referred to us with suspicion of AOM were evaluated and diagnosed
on the same day. Only one of the patients had middle ear exudate and others had only
hyperemia. The patients were at the beginning phase of AOM, and only had symptoms
of systemic infection. Their medical treatments were arranged and the disease was
controlled without progression. It is easy to manage the disease and avoid complications
thanks to an early diagnosis.
Ticks mediate as a vectors that transfer infections from various microorganisms to
humans.[15] They infect humans through animal or environmental contact in rural regions. Ticks
attaching inside the EAC may cause serious systematic effects, which may result in
death, unlike other foreign bodies. They may bring about various symptoms, such as
earache, abrasion in the skin of the EAC, sensation of ear fullness and local infection.[16] Sometimes, they do not present any symptoms.[17] Ticks were encountered in two patients during the routine ear examination without
causing any symptoms. We may have encountered ticks because the region where the study
was performed is rural. The patients were 11 and 13 years old. The ticks were removed
with alligator forceps without any need for general anesthesia. An infection consultation
was performed for both patients and they underwent a close follow-up. The follow-ups
of the patients who did not present with any symptoms such as fever or muscle pain
and who did not develop thrombocytopenia, leucopoenia and coagulation disorder in
the laboratory assessments were finished one week later. It is critical to diagnose
these patients considering both the systematic and ontological effects the ticks may
cause even if they are asymptomatic.
Congenital cholesteatoma is seen as a white mass behind a normal intact tympanic membrane.[18] It is difficult to diagnose, since it is asymptomatic in the early phase.[19] It may cause irreversible damages both in hearing and in the temporal bone if the
diagnosis is delayed. The fact that many children are asymptomatic and otoscopic findings
are obscure makes it difficult for the doctor to diagnose.[20] The diagnosis of the 3-year-old boy in our study was performed by the pediatrician
through an otoscopy. The pathological results of the patient confirmed the diagnosis.
When there is a suspicion of congenital cholesteatoma, a careful otoscopic examination
may bring about the diagnosis.
The tympanic membrane helps the transmission of sound to the ossicles by means of
vibration.[21] If the tympanic membrane is perforated, the surface area where this transmission
is allowed will be reduced. Therefore, hearing will be impacted.[22] Its retraction, which is defined as tympanic membrane retracted to middle ear may
also impact the hearing function. If untreated, it can cause perforation of the tympanic
membrane, damage in the ossicular chain, and cholesteatoma.[23] Both perforation of the tympanic membrane and its retraction can have serious effects
on hearing and, consequently, on the mental development of children. To this end,
patients must be monitored closely through hearing tests and otoscopic examinations
in case they need to be submitted to surgical treatment.
In the literature review, we have not encountered any studies providing otologic findings
of patients without such otorhinolaryngological complaints. Only Kocyigit et al[7] researched the incidence of OME. We have evaluated all otologic findings in the
present study. The limitation of the present study can be the fact that it has been
designed for children and only to evaluate otologic findings. More comprehensive data
can be obtained by evaluating total ENT conditions in broader patient scales. We think
different results can be achieved from studies in which a higher number of physicians
and broader patient scales are included in multiple centers. In the present study,
the rate of false positive diagnosis by the pediatrician was of 1.2%. But one of the
limitations of the study was the inability to calculate false negative diagnostic
rates. Studies in which all patients are assessed by both a pediatrician and an otorhinolaryngologist
can be designed.
Conclusion
Family doctors, pediatricians and internal medicine specialists performing overall
evaluations of patients should not ignore the ENT examination. As seen in the present
study, pathologies that are likely to result in sequela in the future may be diagnosed
through simple examination methods. Early diagnosis and treatment may prevent these
sequelae. The otoscopic examination is even adequate when there are suspicions of
ailments. Advanced diagnosis and treatment may avoid the formation of sequelae.
