Family Practice Vol. 21, No. 2, 221
Family Practice Vol. 21, No. 2 © Oxford University Press 2004, all rights reserved.
Correspondence |
Diagnosis of acute otitis media in primary care
Division of Primary Care Public and Occupational Health, Department of Primary Care and General Practice, Primary Care Clinical Sciences Building, Edgbaston, Birmingham B15 2TT, UK
E-mail: r.j.mcmanus{at}bham.ac.uk
We read with interest Blomgren's article suggesting that GPs over-diagnose otitis media compared with a single ENT physician using specialized equipment.1 Before taking this result at face value, we feel that a number of important issues need to be addressed. The first is a lack of an adequate reference standard in this work. As stated by the authors themselves, definitive diagnosis of otitis media is not possible without examination of middle ear secretions. Without this invasive investigation, it is difficult to unravel the precise cause of the discrepancies in diagnosis recorded. We suggest that at least part of the variation in diagnosis might be explained by variation in the spectrum of disease seen in primary care as compared with hospital practice.2 Secondly, although the use of specialist tools such as tympanometry may improve diagnosis, simple signs and symptoms such as ear pain and colour of the tympanic membrane have respectable diagnostic performance.3 Thirdly, in comparing like with like, the time taken in assessing each patient is important (at least it is when you have a full waiting room expecting to see you). Do the authors have any data on this? Finally and perhaps most importantly, were the management strategies arising from these cases compared? Many cases of milder otitis media can be treated safely with simple analgesia and without the use of antibiotics.4 What difference in practical terms would the variation in diagnostic labels have made?
References
1 Blomgren K, Pitkaranta A. Is it possible to diagnose acute otitis media accurately in primary health care? Fam Pract 2003; 20: 524–527.
2 Knottnerus JA. Between introtropic stimulus and interiatric referral: the domain of primary care research. J Clin Epidemiol 2002; 55: 1201–1206.[Medline]
3 Rothman R, Owens T, Simel DL. Does this child have acute otitis media? J Am Med Assoc 2003; 290: 1633–1640.
4 Little P, Gould C, Williamson I, Moore M, Warner G, Dunleavey J. Pragmatic randomised controlled trial of two prescribing strategies for childhood acute otitis media. Br Med J 2001; 322: 336–342.
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