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Symptoms or Symptom-Based Scores Cannot Predict

Acute Otitis Media at Otitis-Prone Age
WHAT’S KNOWN ON THIS SUBJECT: Acute symptoms and scores
are used as tools in the diagnosis and management of AOM.
However, their predictive value for AOM is not known for young
children whose parents suspect AOM.
WHAT THIS STUDY ADDS: The occurrence, duration, and severity
of symptoms are not predictive for AOM at otitis-prone age.
Symptom-based scores cannot differentiate AOM from
respiratory tract infection. Tympanic-membrane examination is
crucial for the diagnosis and scoring of AOM.

OBJECTIVE: Acute symptoms are used to diagnose and manage acute
otitis media (AOM). We studied whether AOM could be predicted by the
reason for parental suspicion of AOM or by the occurrence, duration,
and/or severity of symptoms. We also compared scores including or excluding tympanic-membrane examination of children with and without AOM.
PATIENTS AND METHODS: Children aged 6 to 35 months with parental
suspicion of AOM were eligible. Before tympanic-membrane examination, we registered on a structured questionnaire the reason for parental suspicion of AOM, symptoms, and score components.
RESULTS: Of 469 children studied, 237 had AOM and 232 had respiratory tract infection without AOM. The most common reason for parental
suspicion of AOM, restless sleep, was not predictive for AOM (RR: 1.0
[95% CI: 0.8 –1.2]), nor was ear-rubbing (relative risk [RR]: 0.7 [95%
confidence interval (CI): 0.5–1.0]). Neither the occurrence of fever (RR:
1.2 [95% CI: 1.0 –1.4]) nor the highest mean temperature within 24
hours predicted AOM, nor did the occurrences of ear-related, nonspecific, respiratory, or gastrointestinal symptoms. The duration and severity of symptoms were not predictive for AOM, although rhinitis
lasted longer and conjunctivitis was more severe in children with AOM.
The clinical/otologic score (median: 4.0 vs 2.0; P ⫽ .000) and the AOM
total-severity index (11.0 vs 6.0; P ⫽ .000), both including symptoms
and tympanic-membrane examination, were higher in those with AOM.
The AOM severity-of-symptom scale, based solely on symptoms, was
equal in children with and without AOM (6.0 vs 6.0; P ⫽ .917).

AUTHORS: Miia K. Laine, MD,a Paula A. Ta¨htinen, MD,a
Olli Ruuskanen, MD, PhD,a Pentti Huovinen, MD, PhD,b and
Aino Ruohola, MD, PhDa
aDepartment of Pediatrics, Turku University Hospital, Turku,
Finland; and bDivision of Health Protection, National Institute for
Health and Welfare, Turku, Finland

acute disease, diagnosis, otitis media, respiratory tract
infections, signs and symptoms
AOM—acute otitis media
OS-8 — otoscopy score, 8 grades
AOM-Si—AOM total-severity index
AOM-SOS—AOM severity-of-symptom scale
AAP—American Academy of Pediatrics
RR—relative risk
CI— confidence interval
RTI—respiratory tract infection
This trial has been registered at
(identifier NCT00299455).
Accepted for publication Dec 4, 2009
Address correspondence to Aino Ruohola, MD, PhD, Department
of Pediatrics, Turku University Hospital, PL 52, 20521 Turku,
Finland. E-mail:
PEDIATRICS (ISSN Numbers: Print, 0031-4005; Online, 1098-4275).
Copyright © 2010 by the American Academy of Pediatrics
FINANCIAL DISCLOSURE: The authors have indicated they have
no financial relationships relevant to this article to disclose.

CONCLUSIONS: AOM cannot be predicted by the occurrence, duration,
or severity of symptoms at otitis-prone age. Likewise, solely symptombased scores do not differentiate between respiratory tract infections
with or without AOM. Thus, tympanic-membrane examination is crucial
in the diagnosis and severity classification of AOM in clinical practice
and research settings. Pediatrics 2010;125:e1154–e1161


LAINE et al

Downloaded from by guest on March 3, 2015

hyperemia. The highest measured temperature (ⱖ38°C) within 24 hours was recorded.5 days).ARTICLES Acute symptoms play a crucial role in the diagnosis of acute otitis media (AOM). and (3) symptoms and signs of acute infection. Thus. MD). and treatment PEDIATRICS Volume 125. translucency. The study protocol was approved by the ethical committee of the Hospital District of Southwest Finland. which is the age group with the highest incidence of AOM. These symptoms. and which ear had the worse status. and no compensation for participation was given. mucus vomiting (retching and throwing up swallowed mucus).5–8 Clinical experience gives the impression that symptoms occurring at the time of AOM are variable. the severity was classified as mild or severe: excessive crying. we systematically assessed the middle-ear status (position. microbiology. poor appetite. Ta¨htinen. We also compared scores from recent literature that included or excluded tympanic-membrane examination of children with and without AOM. McCormick. Parents evaluated their child’s overall condition with the AOM-faces scale. MO) was used to document the findings. children aged 6 to 35 months were brought for an outpatient visit because of parental suspicion of AOM based on suggestive symptoms.3 to study only 1 severity grade of AOM. nasal congestion. All visits were free of charge. Of the 5 study physicians.2 In clinical trials of AOM. cough. decreased or absent mobility. ear-rubbing. rhinitis. He agreed with 95% of our AOM diagnoses. Number 5. at worst within 24 hours and at the time of the visit (used with the kind permission of David P.12 scoring 1 to 7. restless sleep. the otoscopy score (8 grades) (OS-8)13. May 2010 of AOM at the primary care level. The duration of symptoms was measured in days (with an accuracy of 0. there is a lack of data on the predictive value of the occurrence. such as ear pain and fever. Symptom Questionnaire Before tympanic-membrane examination. NY]). mobility of the tympanic membrane.9–11 All of the studies have included children with verbal skills. vomiting (throwing up partially digested foods and drinks).4 and as the primary outcome in randomized trials that assess the effect of antimicrobial treatment. After telephone contact by parents. and severity of 17 symptoms by using a standardized. Digital pneumatic video otoscopy (Jedmed. For the occurrence and duration of fever. or airfluid interfaces). (2) at least 1 acute inflammatory sign of the tympanic membrane (distinct erythematous patches/streaks or increased vascularity over full/bulging/yellow convexity).1 Parents base their suspicion of AOM on the symptoms of their child. Only a few studies have focused on symptoms of AOM in the outpatient setting. the study physician asked the reason for parental suspicion of AOM and the occurrence. and diarrhea. and Ruohola) made more than 90% of the diagnoses and had an excellent agreement (␬ values from 0. moderate. Before examining the study population. all study physicians were validated to assess the tympanicmembrane findings and the OS-8. we also accepted the parents’ assessment of fever with no temperature measurement. and severity of symptoms in children aged 6 to 35 months. After careful cerumen removal. color. and possible airfluid interfaces) by using pneumatic otoscopy (Macroview otoscope model 23810 [Welch Allyn]).aappublications. Skaneateles by guest on March 3.92). structured questionnaire. and none have examined the severity of symptoms. In the following symptoms. Scores On the basis of our detailed symptom questionnaire and tympanicmembrane examination. hoarse voice. abnormal color or opacity not caused by scarring. and irritability. we calculated Downloaded from pediatrics. The guidelines advise physicians to use the severity of symptoms to choose the most appropriate treatment (antimicrobial therapy versus observation option) of AOM and to follow-up the episode of AOM. Severity was classified as mild.80 to 0. light reflex. 2015 e1155 . are included in the diagnostic criteria of AOM. St Louis. PATIENTS AND METHODS Study Population This study was conducted between November 2006 and December 2008 and was part of a project examining the diagnosis. duration. The diagnosis of AOM required 3 criteria: (1) middle-ear fluid detected by pneumatic otoscopy (at least 2 of the following signs on the tympanic membrane: bulging position. duration. or severe for the following symptoms: ear pain reported by parents and the child’s verbal expression of ear pain.3. symptoms have been used for severity scoring to assign children to different treatment groups. less playful or active. 3 of us (Drs Laine. and/or severity of symptoms. duration. We studied the symptoms of children in this otitis-prone age group when their parents sought medical attention because AOM was suspected. Tympanic-Membrane Examination The study physicians first performed tympanometry (MicroTymp2 [Welch Allyn. An ear-nosethroat specialist assessed the images and videos of 150 children without knowing their symptoms and/or our diagnosis. conjunctivitis. Written informed consent was obtained from a parent of each child before any study procedure was performed. The aim of this study was to find out if AOM could be predicted by the occurrence.

P ⫽ . In fact. Reasons for Parental Suspicion of AOM The most common reason for parental suspicion of AOM was restless sleep. The AOM-SOS score consisted of ear-rubbing. A score range of 0 to 14 was the result.5–1.8 days [non-AOM group]. redness of tympanic membrane. scored as 0 (none). Furthermore. irritability. excessive crying. However. mucus vomiting.7 [95% CI: 0. and fever.0 – 1. and ⱖ39°C as 2 (a lot). The statistical analyses were performed by using the SPSS 16. Accordingly. for 48% (68 of 141) of children with no previous AOM. We did not analyze these 3 scores or the AAP’s definition for illness severity e1156 LAINE et al if 1 or more components of a score (except measured temperature) were missing. excessive crying. we used the modified AOM totalseverity index (AOM-Si) as suggested by McCormick et al4 who used this score to determine the severity of AOM for studying the treatment of nonsevere AOM only.508) (Fig 2) and the duration of fever (2. and severe or prolonged rhinitis/cough were rare reasons for parental suspicion and could not predict AOM. restless sleep could not pre- dict AOM (RR: 1.2 The child had severe illness if ear pain (parentally reported and/or reported by the child verbally) was moderate or severe and/or the highest temperature within 24 hours was ⬎39°C. Almost all parents reported that their child had ear pain. Characteristics of children in the AOM and non-AOM groups are shown in Table 1. conjunctivitis. Second. restless sleep. Duration.aappublications.2]) (Fig 1). Respiratory symptoms. 38.9°C as 1 (a little).0 statistical package (SPSS Inc. we assessed illness severity according to the American Academy of Pediatrics (AAP) 2004 guidelines for the diagnosis and management of AOM. The likelihoods were estimated by calculating the relative risk (RR) with respective 95% confidence intervals (CIs). Earrubbing tended to be more common in children who did not have AOM (70% [AOM group] vs 78% [non-AOM group]. The occurrences of nonspecific symptoms (irritability.4]). less playful or active. vomiting. rather. The AOM-Si score (range: 1–14) was calculated by including the highest OS-8 in pneumatic otoscopy (measuring the severity of tympanic-membrane inflammation [range: 0 –7]) and the highest AOM-faces scale (measuring parental perception of their child’s worst overall condition within 24 hours [range: 1–7]). We classified temperature of ⬍38°C as 0 (none). 61 children (26%) had unilateral or bilateral middle-ear fluid. but when ear-rubbing was a reason for suspicion. restless by guest on March 3.3 scores used in previous literature. AOM was improbable (RR: 0. Chicago. In addition. the highest mean temperature within 24 hours (38. Ear pain (parentally reported or reported by the child verbally). The symptoms of these 61 children did not differ from those with completely healthy ears. P ⫽ . IL). and for 52% (169 of 325) of children with previous AOM.9]). poor appetite.0]). the child had nonsevere illness. The duration of symptoms had no predictive value for AOM in children having RTI with and without AOM except for rhinitis that had lasted ⬃1 day longer in those with AOM compared with children with no AOM (Table 2).1 days [AOM group] vs 1.6 – 0. less playful or active. If the child had had fever and the temperature had not been measured within 24 hours. listed for 134 of 468 (29%) children (data missing for 1 child in the AOM group). and poor appetite) were not predictive for AOM.050).2 [95% CI: 1. Occurrence.0) created by Shaikh et al16 to measure the outcome in clinical studies of AOM. and bulging position were scored from 0 to 3. including our categories mild and moderate). Third. fever. and Severity of Symptoms The occurrence of ear-related symptoms could not predict which children had AOM (Table 2).0 [95% CI: 0.234) did not differ between the groups. irritability. The means were compared with the t test and the medians with the MannWhitney U test. parental suspicion of AOM proved to be correct for 51% of all children.8 –1. RESULTS The study population comprised 469 children: 237 had AOM (AOM group) and 232 had respiratory tract infection (RTI) without AOM (non-AOM group). First. we used the clinical/otologic score14 primarily developed by Dagan et al15 to determine the severity of AOM and to measure the treatment outcome of AOM (temperature. and diarrhea could not predict which children had AOM. The relationships between the scores were assessed by Spearman correlation coefficients. P ⫽ . In the non-AOM group. 1 (a little. Parents suspected AOM because of ear-rubbing in 64 children (14%). the latter tended to have more severe symptoms (data not shown). nor could irritability that had evoked parents’ suspicion of AOM in 84 children (18%). 2015 . Statistical Analysis The proportions were compared with ␹2 test or Fisher’s test as applicable.0°C to 38. irritability suggested that the child did not have AOM (RR: 0. we used the AOM severity-of-symptom scale (AOMSOS) (version 3. for a total range of 0 –12). or 2 (a lot.6°C [non-AOM group]. we used the highest measured mean temperature of his or her study group. although children themselves had rarely expressed it verbally. including our category severe). Occurrence of fever could not predict AOM (RR: 1. Downloaded from pediatrics.7°C [AOM group] vs 38. Otherwise.7 [95% CI: 0.

087). bulging) 7 (erythema. 68% of children with AOM and 60% of children without AOM would have been categorized as having severe illness (P ⫽ . The same applied to the scoring of the overall condition of the child by the AOM-faces scale. Data were missing for 4 children in the non-AOM group. P ⫽ . n/N (%) Current use of pacifier. According to the AAP’s definition for illness severity. d Tympanic membrane had full or bulging position in 90% (44 of 49) of the children. duration.547 . May 2010 severe in those children who had AOM compared with those with only RTI.0 vs 6. of previous AOM episodes. Similarly. n/N (%) Duration of breastfeeding. opacification. n (%) 6–11 mo 12–23 mo 24–35 mo Male gender. because symptoms are used in the diagnosis and management of AOM. mean (range). The most common reason given was restless sleep.0. and none of the reasons for suspicion could predict AOM. we analyzed the reasons parents had when they suspected AOM in their child. Scores The clinical/otologic score was significantly higher in children who had AOM than in children who had only RTI (median: by guest on March 3. Our study design requiring AOM suspicion might explain why almost all parents reported ear pain in their child. no effusion) 2 (erythema. These results are important.000).0.0 vs 6.001 . and gastrointestinal symptoms were equally severe in both groups (Table 3).001 ⬍. no opacification) 4 (erythema. mo Age. moa No. Number 5. n (%) White Caucasian-African Age at first AOM episode. no bulging) 6 (erythema. mean (range). Only conjunctivitis was more PEDIATRICS Volume 125.956 ⬍. n (%) 0 (normal or effusion. opacification with air-fluid level. n/N (%) A (more than ⫺100 dPa) C (less than ⫺100 dPa) B (no peak) AOM Group (N ⫽ 237) Non-AOM Group (N ⫽ 232) 16 (6–35) 16 (6–35) 87 (37) 103 (43) 47 (20) 130 (55) 93 (40) 98 (42) 41 (18) 122 (53) 237 (100) 0 (0) 10 (0–27) 230 (99) 2 (1) 10 (0–29) 68/237 (29) 130/237 (55) 31/237 (13) 8/237 (3) 129/237 (54) 129/236 (55) 68/236 (29) 126/237 (53) 8 (0–30) 73/229 (32) 107/229 (47) 37/229 (16) 12/229 (5) 131/229 (57) 89/229 (39) 60/228 (26) 134/229 (59) 8 (0–24) 0 (0) 0 (0) 0 (0) 0 (0) 206 (89)c 23 (10) 3 (1) 0 (0) 49 (21)d 0 (0) 81 (34)e 0 (0) 84 (35) 23 (10) 0 (0) 0 (0) 16 (7) 0 (0) 221 (93) 159 (69) 42 (18) 31 (13) 0 (0) 5 (2) 40 (17) 192 (81) 171 (74) 32 (14) 28 (12) 1 (0.547 .ARTICLES TABLE 1 Characteristics of 469 Children With Parental Suspicion of AOM Age. n/N (%) Daycare attendance.001 ⬍. respiratory. and irritability did not differ between children with and without AOM (Fig 3). clear fluid) 3 (erythema. complete effusion. fewer than one-fifth Downloaded from pediatrics.457 . n/N (%) Tobacco-smoke exposure. air-fluid level. although it should be noted that it was not predictive for AOM.308 . mob OS-8 score at the visit.917). The AOM-Si score was likewise higher in the AOM group than in the non-AOM group (11. bulging. solely symptom-based scores could not differentiate children with AOM from those without AOM. b The severity of parentally reported ear pain.0 vs 2.001 26/172 (15) 22/172 (13) 124/172 (72) 96/188 (51) 78/188 (41) 14/188 (7) a Data were missing for 77 children in the AOM group and 94 children in the non-AOM group. no erythema) 1 (erythema only.244 . Furthermore.aappublications. Furthermore. opacification. complete effusion. 2015 e1157 . P ⫽ . nonspecific. mean (range). P ⫽ . the AOM-SOS score based solely on symptoms was equal between the AOM and non-AOM groups (6. DISCUSSION Our main finding was that the occurrence. no bulging) 5 (erythema. and severity of symptoms did not predict AOM in children at otitis-prone age when their parents suspected AOM. complete effusion.9–11 In our study. c No effusion in 72% (148 of 206) of the children. n (%) Normal Retracted Full or bulging Quality of middle-ear fluid. However. For a new perspective.001 ⬍. n (%) No visible fluid Clear or serous Cloudy Purulent Tympanogram (peak pressure). n/N (%) 0 1–3 4–6 ⬎6 Sibling(s) in the household.0. n (%) Race. e All tympanic membranes had full position.623 .327 . the symptom that most disturbs the parents’ own life.245 .4) P . In contrast.712 . the occurrence of parentally reported or the child’s verbal expression of ear pain could not predict AOM. Ear pain has been the symptom commonly associated with AOM. ear-rubbing. Parents of almost half of the children suspected AOM on the basis of a nonspecific symptom. child’s verbal expression of ear pain.000) (Fig 4). the severity of ear pain did not differentiate children with and without AOM. bulla formation) Position of tympanic membrane.

25 The occurrence. da AOM Group Non-AOM Group P 1.945 .9.6 1.9.2 (1.026 .5) 1.5) 2.8–1.4 2.7 2. and severity of nonspecific symptoms were equal in children with and without AOM.591 .8–1.741 .9–11 the occurrence of fever did not predict AOM in young children.21 As in our study.318 .7–1. As others have shown. nonspecific symptoms are not predictive for AOM at otitisprone age.18 Shaikh et al16 excluded ear pain from the AOM-SOS score.0 (0.3) 1.9–1.8 (0.28.0 3.8–1.427 .9 6.124 1.0 (0.27 but has a limited role in predicting AOM because of its rare occurrence. of these young children verbally expressed ear pain. 2015 . We found it surprising that earrubbing tended to be more common in children without AOM than in children with AOM.9.20.9 However. we recommend against using ear-rubbing as evidence of ear pain or as a sign of AOM.6–1.943 . we asked separately about actual vomiting and mucus Downloaded from pediatrics.7 (0.809 . In previous studies. Baker19 reported that if earrubbing was a child’s only complaint. which was more severe in children with AOM than in children with only RTI.223 .1.811 44 (19) 31 (13) 165 (70) 102 (43) 206 (87) 206 (87) 205 (87) 112 (47) 150 (63) 222 (94) 177 (75) 187 (79) 81 (34) 44 (19) 25 (11) 3 (1) 31 (13) 180 (78) 81 (35) 216 (93) 204 (88) 199 (86) 104 (45) 148 (64) 220 (95) 171 (74) 172 (74) 82 (35) 33 (14) 24 (10) 5 (2) 22 (10) RR (95% CI) for AOM Mean Duration.025 .3) 1.9) 1.910 .2 (0.8 3.8 .5 2.0 (0.9.204 .org by guest on March 3. On the basis of these results.0 (0.11 Gastrointestinal symptoms were not predictive for AOM.0) 1.8–1. points to parental difficulties with assessing ear pain in children at this preverbal and otitis-prone age.661 .2) 1.2 (0.aappublications.0–1.1 3.0 (0. 30 in non-AOM group) suspected AOM for a miscellaneous reason or for several reasons.29 However.17. n (%) AOM Group (N ⫽ 237) Non-AOM Group (N ⫽ 232) P 219 (92) 213 (92) .1 (0.8–1. a Parents of 62 children (32 in AOM group.6 2. TABLE 2 Occurrence and Mean Duration of Symptoms in 469 Children With Parental Suspicion of AOM Symptom Parentally reported ear pain Child’s verbal expression of ear pain Ear-rubbing Fever Irritability Excessive crying Restless sleep Less playful or active Poor appetite Rhinitis Nasal congestion Cough Hoarse voice Conjunctivitis Mucus vomiting Vomiting Diarrhea a Occurrences.800 . which. a finding that agrees with previous study results.4 3. although pediatric textbooks describe fever as indicative of AOM.9 (0.2 5.076 .5 3.712 .11 Respiratory symptoms could not predict AOM. the occurrence of vomiting was more than 10 times higher than in our study.5) 1.3 .5 2.861 Duration of each symptom among those children who had the symptom.5 3.9 6. fever might be associated with the viruses causing RTI rather than specifically with AOM. then no child had AOM.791 .9.0 (0.9 7.2–4.6 3. Consistent with the results of previous studies.11.5.5 2.3 2. Ear-rubbing has been used almost as a synonym for ear pain. infants may rub their ear because of a blocked ear or merely when becoming acquainted with their body.2 (1.1 3.22–24 The distribution of the highest mean temperature in children with and without AOM was surprisingly similar. in young children.4.9–1.193 .8) 1.071 .6 5.4 2.4) 1.821 .9–1.7 1.6–0. with the exception of conjunctivitis.598 .0 (0.3) 1.2) 0.7–1.134 .7–1.7 (0.8 2.4 3.3) 1. This finding disagrees with the results of Niemela¨ et al.204 . and frequently with no infection.6 2.5 3.050 .4) 1.4) 0.0 (0. Furthermore. For this reason.11.4) 0.304 .3–1.7 0.9–1.FIGURE 1 RR for AOM according to the reasons for parental suspicion of AOM and the occurrence of each symptom in children diagnosed as having AOM (AOM group) and in children with RTI without AOM (non-AOM group).9 who included children with any e1158 LAINE et al kind of acute illness. The so-called conjunctivitis-otitis syndrome is well known26. Nonspecific symptoms occur during viral infections. fever usually has occurred in less than half of the AOM population.1 1.377 .2) 1. as in our results. duration.8 6.2 4.234 .260 .0–1.946 .219 0.17.6 .500 .

specifically to measure outcome in clinical studies of AOM. our physicians also used tympanometry and had excellent interobserver agreement. This study has several strengths. and antimicrobial agents may cause mainly actual vomiting. illness severity could not predict the probability of by guest on March 3.31. mild. the AOM-SOS score based solely on symptoms gave equal scores to children having RTI with and without AOM.2 Our AOM group had typical findings of positive bacterial culture: full/bulging position of tympanic membrane. we recommend validating scoring systems that would include tympanic-membrane examination.24. Downloaded from pediatrics.ARTICLES FIGURE 2 The highest measured temperature within 24 hours in children diagnosed to have acute otitis media (AOM group) and in children with RTI without AOM (non-AOM group). child’s verbal expression of ear pain (B). vomiting and found that mucus vomiting was reported 10 times more frequently than actual vomiting.2 In our study population.7°C [AOM group]. purulent middle-ear fluid.aappublications. our nonAOM group had typical findings of negative bacterial culture or nonexist- FIGURE 3 Severity (none. 2015 e1159 . Data were collected before tympanicmembrane examination. moderate. the symptom-based components did not differ. It should be noted that Shaikh et al16. ence of middle-ear fluid: retracted position of tympanic membrane and tympanometric C curve. rather. Although our AOM diagnosis was based on pneumatic otoscopy.24.33 Our approach was based on what is daily encountered in an outpatient setting: an acutely ill. The AAP’s criteria for PEDIATRICS Volume 125. or severe) of parentally reported ear pain (A). Similar to the AOM-faces scale. both based on symptoms and ear-related signs. structured questionnaire for the symptom survey. were significantly higher in children with AOM than in children with only RTI. and tympanometric B curve. The horizontal lines show the highest measured mean temperature of each group (38. even stricter than that of the AAP. Because solely symptom-based scores and the AAP’s definition of illness severity lead to similar results in young symptomatic children with and without AOM. which is somewhat subjective. Number 5. May 2010 severe illness is designed to determine the optimal treatment for AOM. because mucus vomiting is a respiratory symptom rather than a gastrointestinal symptom. Applying the scores from recent literature to our data raised interesting and new considerations.32 In contrast. it would be important to report these 2 symptoms separately. ear-rubbing (C). We had a prespecified definition for AOM. 38.508). We used a standardized. It is important to note that this was because of the ear-related signs of the scores. P ⫽ .30 developed the AOM-SOS score not to determine the severity of AOM but. and irritability in the AOM and non-AOM groups (D).6°C [non-AOM group]. The clinical/otologic score and the AOM-Si score. On the basis of this new finding. by guest on March 3.011 . and researchers is that the symptom-based scores can poorly differentiate young children with AOM from those with only RTI.202 .928 . The significance of this study for the otitis media authorities.429 Percentages may not total 100% because of rounding. and the role of tympanic-membrane examination should be emphasized in the FIGURE 4 Distributions of the score values in the AOM and non-AOM groups. a Data were missing for 1 child in the AOM group. and also positive between AOM-SOS and AOM-faces scale within the AOM group (r ⫽ 0.001). P ⬍ . n (%) None Mild Severe None Mild Severe 31 (13) 32 (14) 125 (53) 86 (36) 15 (6) 60 (25) 48 (20) 156 (66) 193 (81) 212 (89) 234 (99) 206 (87) 128 (54) 73 (31) 93 (39) 100 (42) 101 (43) 103 (43) 121 (51) 67 (28) 30 (13) 23 (10) 3 (1) 27 (11) 78 (33) 132 (56) 19 (8) 51 (22) 121 (51) 74 (31) 67 (28) 14 (6) 14 (6) 2 (1) 0 (0) 4 (2) 28 (12) 33 (14) 128 (55) 84 (36) 12 (5) 61 (26) 60 (26) 149 (64) 199 (86) 208 (90) 227 (98) 210 (91) 124 (53) 64 (28) 88 (38) 99 (43) 121 (52) 88 (38) 120 (52) 68 (29) 31 (13) 22 (9) 4 (2) 20 (9) 80 (34) 135 (58) 16 (7) 49 (21) 99 (43) 83 (36) 52 (22) 15 (6) 2 (1) 2 (1) 1 (0) 2 (1) P . The limitations also must be elucidated. each child has a different spectrum of symptoms in different episodes of infections caused by different microbes. Therefore.001). children with AOM in our study may have had a different profile of symptoms than did children with accidentally diagnosed AOM. Furthermore. the diagnosis and management of AOM cannot be made by telephone contact.462. In addition.550 . Children without AOM in our study may have had more severe symptoms than did children with RTI in general. Our results cannot be generalized to older children with verbal skills. Even if children have the same diagnosis.910 . CONCLUSIONS AOM cannot be predicted by the occurrence. the methodology could have been improved by asking the parents to complete the questionnaire.aappublications. Accordingly.996 . The Spearman correlation coefficient between the clinical/otologic and AOM-Si scores was positive within the AOM group (r ⫽ 0.828 . treatment recommendations should not be entirely based on symptom severity. P ⬍ .992 . All children with symptoms that cause parental anxiety deserve careful clinical examination. 2015 . including cerumen removal followed by pneumatic otoscopy. each one has an individual spectrum of symptoms. e1160 LAINE et al Downloaded from pediatrics. The message of our study for clinicians and parents is that symptoms cannot predict AOM at otitis-prone age. P ⬍ . solely symptom-based scores do not differentiate RTI with and without AOM. duration.001) and within the non-AOM group (r ⫽ 0. Therefore.746 .344.258.001) and within the non-AOM group (r ⫽ 0.386. if the severity scores are based solely on symptoms. guideline- makers. or severity of symptoms at otitis-prone age.118 . 50th (median). We propose that the scores also include evaluation of the tympanic membrane.438 . our results are not applicable to the entire age group. Fi- nally. young child with anxious parents who suspect AOM.TABLE 3 Severity of Symptoms in Children in the AOM and Non-AOM Groups Symptom Excessive crying Restless sleep Less playful or active Poor appetite Rhinitis Nasal congestion Cougha Hoarse voice Conjunctivitis Mucus vomiting Vomiting Diarrhea AOM Group (N ⫽ 237). n (%) Non-AOM Group (N ⫽ 232). Because we focused on children with parental suspicion of AOM. P ⬍ . and 75th quartiles together with the minimum and maximum values of each score. The boxplots show the 25th. the scoring actually depends more on the occurrence of the symptoms than on the severity of the symptoms.

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