When things are going poorly, some of us grouse about them, and most of us keep our blinders on and just muddle along.
But every now and then, someone grabs the wheel and tries to get the ship back on course. Dr. Michael Pichichero seems to be among those saintly few. In a recent column, Dr. Pichichero reported the results of a longitudinal multiyear study.
The patients in the study group were begun on high-dose amoxicillin/clavunate, but the choice of antibiotics was adjusted using the results of bacterial testing on middle ear fluid obtained by tympanocentesis. The results were dramatic. Compared with a control group of patients in the same practice whose parents had declined tympanocentesis, the patients in the individualized care group had 250% fewer repeat ear infections. When compared to a broader community control group, the repeat ear infections were reduced by 460%. The reduction in the number of ear surgeries among these groups was even more dramatic.
Not surprisingly, these results have led Dr. Pichichero to recommend that tympanocentesis be in the curriculum of all pediatric residency training programs. He also encourages the rest of us to learn the skill or at least designate someone in our practices to become adept at ear taps.
In a perfect world, Dr. Pichichero’s findings and his recommendations make perfect sense. Why haven’t we been treating otitis media using the same principles we apply to most other infections? Define the organism, determine antibiotic sensitivities, and then adjust therapy to the narrowest and most effective drug.
Of course, the problem is that old this-is-the-real-world thing. I am sure I am the only physician in town and probably in the state of Maine who has done a tympanocentesis on an unanesthetized pediatric patient. As a house officer 4 decades ago, I participated in a small study of antibiotic sensitivities. The cohort of physicians who preceded me often "lanced" eardrums to provide prompt pain relief. But now we have indoor plumbing and central heating. Either for convenience or because of the fear of malpractice, outpatient pediatrics has become less procedure oriented. Few of us suture wounds or put on casts in our offices. Even removing cerumen with a curette seems to have become a procedure too edgy for many pediatricians.
To do a proper tympanocentesis or even diagnose otitis, the physician must have a good look at the eardrum and know what she or he is looking at. Sadly, we need to get ourselves back up to speed at removing cerumen and looking at tympanic membranes before we will be ready to do ear taps.
Dr. Pichichero observes that "the most common reason for children to receive ear tubes is repeated ear infections... ." I wonder if this is really true. I think it’s probably more correct to say that the most common reason for the placement of PE (pressure equalization) tubes is pressure from parents who think that their children have had too many ear infections. Sometimes this may be the result of overdiagnosis. Or it often occurs when the physician has failed to convince the family that a history of three or four episodes of otitis in a season is within an acceptable range and not a reason to do surgery.
Some of Dr. Pichichero’s dramatic results may be in part due to the fact that the parents of children in the individualized care groups were willing to listen to the physician and accept his or her plan to stick needles in their papoosed children’s ears. Parents this compliant would be less likely to ignore the physician’s conservative recommendations and seek surgery on their own.
While I don’t think I’m going to see scores of pediatricians signing up for tympanocentesis training in the near future, I think we owe Dr. Pichichero our gratitude for injecting some good science into the diagnosis of otitis. The fact that he was able to secure funding to expand and replicate the study in the Rochester, N.Y., area gives me great hope.
Dr. Wilkoff practices general pediatrics in a multispecialty group practice in Brunswick, Maine. E-mail him at pdnews@frontlinemedcom.com.