Letters from Maine

'Ya gotta do it!'


 

"You’re my hero, doctor!" The comment came as quite a surprise because I had only just met the adulator and I was currently in the process of scooping some soft wax out of her 2-year-old’s ear with a curette.

It turns out that she and her family had recently moved to Brunswick from an extremely populous city on the East Coast. According to her, the pediatrician they had been seeing didn’t remove cerumen. Instead, she would have to take her son to an ear-nose-and-throat specialist for this procedure. She had always wondered why the pediatrician hadn’t been doing what she saw as a rather simple but critical task. This mother’s experience is unusual, but it represents the tip of what I suspect is a rather embarrassing iceberg.

In recent months we have seen another surge of suggestions/guidelines to help us improve our ability to accurately diagnose acute otitis media (AOM). One study suggests that bilaterality doesn’t necessarily indicate that the child needs to be treated. In February, the American Academy of Pediatrics published a new clinical practice guideline for AOM diagnosis and treatment (Pediatrics 2013;131:e964-e999 [doi:10.1542/peds.2012-3488]). This newspaper’s headline on the story about this read, "Tympanic membrane now is key to AOM diagnosis" (Pediatric News, March 2013, p. 1).

As I read and reread the headline, I kept asking myself, "What did the key used to be?" I always thought that I was supposed to be looking at the tympanic membranes to make a diagnosis of AOM. Over the last three and a half decades of looking in ears, however, I have come to realize that there must be a significant number of physicians who aren’t seeing tympanic membranes when they examine ears.

Now, I’m not talking about the situation in which one physician has seen a normal tympanic membrane at 4 in the afternoon and at 7 in the morning the same ear has drained. I know that infections can advance that rapidly – I’ve seen it myself scores of times. And no, I’m not talking about the situation when a small flake of wax can fall off the wall of the canal and obscure a clear view of the tympanic membrane that the previous observer reported. It happens.

What I’m talking about is a child has been diagnosed with an otitis on one day and on the next day I must remove a significant collection of cerumen to visualize what is often a normal tympanic membrane. I am at a loss to explain this phenomenon using accepted anatomic and physiologic principles. Cerumen doesn’t accumulate that rapidly, nor do tympanic membranes miraculously heal.

When it comes to the diagnosis and treatment of AOM, the elephant in the room is cerumen. We can talk about the appearance and the mobility of the drum until we are blue in the face, but a significant fact is that too many physicians are accepting a cerumen-obscured view of the tympanic membrane.

Removing cerumen isn’t always easy, and yes, from time to time it can be uncomfortable for the child. Rarely, there may be a small amount of bleeding. But if you want to make an accurate diagnosis, "ya gotta do it!"

Clearly, cerumen removal and insufflation have become lost skills. In many cases, they were never there to be lost, but it’s not too late to learn or relearn them. Find someone in the community who is skilled with a curette to show you his or her tricks. (I’d be happy to share some of mine.) Experiment with several different types to discover a style that works best for you. Practice the skill during well-child visits by removing insignificant collections of cerumen when there is less pressure. It takes time, "soft" hands, and plenty of patience. With time, though, families and patients become more accustomed to the process.

Acute bacterial rhinosinusitis has no objective physical findings, so making the diagnosis doesn’t require much skill, but if you truly want make an accurate diagnosis of AOM, you must see the tympanic membrane. And this is likely to mean removing some cerumen. "Ya gotta do it!"

Dr. Wilkoff practices general pediatrics in a multispecialty group practice in Brunswick, Maine. E-mail him at pdnews@frontlinemedcom.com.

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