The Magic Puff

"What’s that thing in your mouth for?"

"It’s so I can blow on his eardrum to see if it moves. It’s the same idea as one of these." I fumble in a drawer to find a more traditional hand-operated bulb insufflator. The surprised parent replies, "I haven’t seen one of those either." I stifle the urge to climb on my soapbox labeled, "Every pediatrician should be using one" and begin to explain what I understand about middle ear anatomy and the importance of tympanic membrane mobility in the diagnosis and management of otitis media.

It’s a scenario I’ve participated in hundreds, no probably thousands, of times. Recently, I was being trailed by a third-year medical student who had already completed 3 months of a pediatric and family medicine experience. And, sadly, he had never seen, let alone heard about, tympanic membrane insufflation.

I must admit that my style of insufflation, which involves a length of latex tubing and a plastic mouthpiece, is a bit untraditional, and I don’t recall where I learned it. But its great advantage is that it allows me much more freedom with my hands to stabilize squirmy or uncooperative patients. You might think that putting an object in my mouth that is occasionally accessible to the drool-covered hands of toddlers puts me at risk for a cornucopia of infections. But my theory is that the more germs there are lined up waiting on the surface of my body, the more likely it is that by the time one gets to the front of the line, it will have lost its enthusiasm for pathogenicity.

It is clear that otitis media is at or near the top of pediatric diagnoses and certainly a leading trigger for antibiotic prescriptions. It is also clear that physicians are not terribly skillful at examining ears. This sad irony results in an unacceptable level of misdiagnosis, usually of the overdiagnosis variety. In an attempt to correct this situation, the September 2012 edition of AAP News has included a snippet from a new study, "Development of an Algorithm for the Diagnosis of Otitis Media" (33:2 [doi:10.1542/aapnews.2012339-2]).

It’s a pretty simple algorithm that hinges on the presence of a bulging tympanic membrane (TM). If the TM is bulging, it’s acute otitis media (AOM), although 8% of the AOMs did not have a bulging drum. If the nonbulging TM was opacified or had an air fluid level, then the diagnosis was otitis media with effusion (OME).

In a note accompanying the algorithm, there is an observation: "All of the children with no effusion had normal mobility, compared with 32% of those with OME and none of those with AOM [my emphasis]." Why has tympanic membrane mobility fallen out of the decision tree? It appears that the investigators have thrown in the towel and given up on getting clinicians to insufflate TMs.

To my eye, it is much easier to detect TM mobility than to accurately perceive bulging. To see bulging, one must see all or almost all of the eardrum. And, let’s be honest, how often do you get to see the entire tympanic membrane? (The dying art of cerumen removal is another sad story of atrophying clinical skills.) However, if I see only a third of the TM and it’s moving, I know I’m not dealing with AOM. And I know that the child has no effusion, an important finding if I am following up on a previous AOM.

If you are a techie, you might ask, "Why not a use a tympanometer?" My first answer is I trust my eyes more. My second answer is that the machine doesn’t excuse you from having a good look in the ear. What is the tympanometer tracing of an insect in the ear? Not every earache is an infection. In my mind, a tympanometer is a shaky crutch you can bill for.

I urge you to find your insufflator in the back of that spare parts drawer, make sure the head of your otoscope seals properly, and give a few little magic puffs. They will help you clear up that murky diagnosis of otitis media.

Dr. Wilkoff practices general pediatrics in a multispecialty group practice in Brunswick, Maine. E-mail him at [email protected].

"What’s that thing in your mouth for?"

"It’s so I can blow on his eardrum to see if it moves. It’s the same idea as one of these." I fumble in a drawer to find a more traditional hand-operated bulb insufflator. The surprised parent replies, "I haven’t seen one of those either." I stifle the urge to climb on my soapbox labeled, "Every pediatrician should be using one" and begin to explain what I understand about middle ear anatomy and the importance of tympanic membrane mobility in the diagnosis and management of otitis media.

It’s a scenario I’ve participated in hundreds, no probably thousands, of times. Recently, I was being trailed by a third-year medical student who had already completed 3 months of a pediatric and family medicine experience. And, sadly, he had never seen, let alone heard about, tympanic membrane insufflation.

I must admit that my style of insufflation, which involves a length of latex tubing and a plastic mouthpiece, is a bit untraditional, and I don’t recall where I learned it. But its great advantage is that it allows me much more freedom with my hands to stabilize squirmy or uncooperative patients. You might think that putting an object in my mouth that is occasionally accessible to the drool-covered hands of toddlers puts me at risk for a cornucopia of infections. But my theory is that the more germs there are lined up waiting on the surface of my body, the more likely it is that by the time one gets to the front of the line, it will have lost its enthusiasm for pathogenicity.

It is clear that otitis media is at or near the top of pediatric diagnoses and certainly a leading trigger for antibiotic prescriptions. It is also clear that physicians are not terribly skillful at examining ears. This sad irony results in an unacceptable level of misdiagnosis, usually of the overdiagnosis variety. In an attempt to correct this situation, the September 2012 edition of AAP News has included a snippet from a new study, "Development of an Algorithm for the Diagnosis of Otitis Media" (33:2 [doi:10.1542/aapnews.2012339-2]).

It’s a pretty simple algorithm that hinges on the presence of a bulging tympanic membrane (TM). If the TM is bulging, it’s acute otitis media (AOM), although 8% of the AOMs did not have a bulging drum. If the nonbulging TM was opacified or had an air fluid level, then the diagnosis was otitis media with effusion (OME).

In a note accompanying the algorithm, there is an observation: "All of the children with no effusion had normal mobility, compared with 32% of those with OME and none of those with AOM [my emphasis]." Why has tympanic membrane mobility fallen out of the decision tree? It appears that the investigators have thrown in the towel and given up on getting clinicians to insufflate TMs.

To my eye, it is much easier to detect TM mobility than to accurately perceive bulging. To see bulging, one must see all or almost all of the eardrum. And, let’s be honest, how often do you get to see the entire tympanic membrane? (The dying art of cerumen removal is another sad story of atrophying clinical skills.) However, if I see only a third of the TM and it’s moving, I know I’m not dealing with AOM. And I know that the child has no effusion, an important finding if I am following up on a previous AOM.

If you are a techie, you might ask, "Why not a use a tympanometer?" My first answer is I trust my eyes more. My second answer is that the machine doesn’t excuse you from having a good look in the ear. What is the tympanometer tracing of an insect in the ear? Not every earache is an infection. In my mind, a tympanometer is a shaky crutch you can bill for.

I urge you to find your insufflator in the back of that spare parts drawer, make sure the head of your otoscope seals properly, and give a few little magic puffs. They will help you clear up that murky diagnosis of otitis media.

Dr. Wilkoff practices general pediatrics in a multispecialty group practice in Brunswick, Maine. E-mail him at [email protected].

"What’s that thing in your mouth for?"

"It’s so I can blow on his eardrum to see if it moves. It’s the same idea as one of these." I fumble in a drawer to find a more traditional hand-operated bulb insufflator. The surprised parent replies, "I haven’t seen one of those either." I stifle the urge to climb on my soapbox labeled, "Every pediatrician should be using one" and begin to explain what I understand about middle ear anatomy and the importance of tympanic membrane mobility in the diagnosis and management of otitis media.

It’s a scenario I’ve participated in hundreds, no probably thousands, of times. Recently, I was being trailed by a third-year medical student who had already completed 3 months of a pediatric and family medicine experience. And, sadly, he had never seen, let alone heard about, tympanic membrane insufflation.

I must admit that my style of insufflation, which involves a length of latex tubing and a plastic mouthpiece, is a bit untraditional, and I don’t recall where I learned it. But its great advantage is that it allows me much more freedom with my hands to stabilize squirmy or uncooperative patients. You might think that putting an object in my mouth that is occasionally accessible to the drool-covered hands of toddlers puts me at risk for a cornucopia of infections. But my theory is that the more germs there are lined up waiting on the surface of my body, the more likely it is that by the time one gets to the front of the line, it will have lost its enthusiasm for pathogenicity.

It is clear that otitis media is at or near the top of pediatric diagnoses and certainly a leading trigger for antibiotic prescriptions. It is also clear that physicians are not terribly skillful at examining ears. This sad irony results in an unacceptable level of misdiagnosis, usually of the overdiagnosis variety. In an attempt to correct this situation, the September 2012 edition of AAP News has included a snippet from a new study, "Development of an Algorithm for the Diagnosis of Otitis Media" (33:2 [doi:10.1542/aapnews.2012339-2]).

It’s a pretty simple algorithm that hinges on the presence of a bulging tympanic membrane (TM). If the TM is bulging, it’s acute otitis media (AOM), although 8% of the AOMs did not have a bulging drum. If the nonbulging TM was opacified or had an air fluid level, then the diagnosis was otitis media with effusion (OME).

In a note accompanying the algorithm, there is an observation: "All of the children with no effusion had normal mobility, compared with 32% of those with OME and none of those with AOM [my emphasis]." Why has tympanic membrane mobility fallen out of the decision tree? It appears that the investigators have thrown in the towel and given up on getting clinicians to insufflate TMs.

To my eye, it is much easier to detect TM mobility than to accurately perceive bulging. To see bulging, one must see all or almost all of the eardrum. And, let’s be honest, how often do you get to see the entire tympanic membrane? (The dying art of cerumen removal is another sad story of atrophying clinical skills.) However, if I see only a third of the TM and it’s moving, I know I’m not dealing with AOM. And I know that the child has no effusion, an important finding if I am following up on a previous AOM.

If you are a techie, you might ask, "Why not a use a tympanometer?" My first answer is I trust my eyes more. My second answer is that the machine doesn’t excuse you from having a good look in the ear. What is the tympanometer tracing of an insect in the ear? Not every earache is an infection. In my mind, a tympanometer is a shaky crutch you can bill for.

I urge you to find your insufflator in the back of that spare parts drawer, make sure the head of your otoscope seals properly, and give a few little magic puffs. They will help you clear up that murky diagnosis of otitis media.

Dr. Wilkoff practices general pediatrics in a multispecialty group practice in Brunswick, Maine. E-mail him at [email protected].