The effect and acceptability of tympanometry and pneumatic otoscopy in general practitioner diagnosis and management of childhood ear disease

BACKGROUND Tympanometry and pneumatic otoscopy are recommended for diagnosis of otitis media, but are not frequently used by general practitioners (GPs). We examined how, after targeted short training, GP diagnosis and management of childhood ear disease was changed by the addition of these techniques to non-pneumatic otoscopy. We further explored factors influencing the uptake of these techniques. METHODS Between 2011 and 2012, we used a crossover experimental design to determine associations between tympanometry and pneumatic otoscopy and the GP diagnosis and management of ear disease in children aged 6 months to 6 years. GPs recorded a diagnosis and management plan after examining ears using non-pneumatic otoscopy, and another after using either tympanometry or pneumatic otoscopy. We compared diagnosis, prescription of oral antibiotics and planned GP follow-up at these two steps between the tympanometry and pneumatic otoscopy groups. We interviewed participants about their views regarding these techniques and analysed these data thematically. RESULTS Thirteen GPs recorded 694 ear examinations on 347 children: 347 examinations with non-pneumatic otoscopy; then 196 using tympanometry; and 151 using pneumatic otoscopy. Tympanometry was more likely to be associated with changes in diagnosis (χ (2) = 28.64, df 1, p < 0.001) and planned GP follow-up (χ (2) = 9.24, df 1, p < 0.01) than pneumatic otoscopy. Change in oral antibiotic prescription was no different between the two techniques. GPs preferred tympanometry to pneumatic otoscopy, but cost was a barrier to ongoing use. Pneumatic otoscopy was considered the more difficult skill. GPs were not convinced that the increased detection of middle ear effusion afforded by tympanometry and pneumatic otoscopy resulted in benefit to general practice patients. CONCLUSION Tympanometry was more likely than pneumatic otoscopy to change GP diagnoses and follow-up plans of childhood ear disease. Tympanometry may require less training than pneumatic otoscopy. GPs preferred tympanometry due to ease of use and interpretation; however, perceived high cost inhibited their intent to use it in the future. Training, cost and perceived lack of patient benefit are barriers to the use of tympanometry and pneumatic otoscopy in general practice.