Given these two studies demonstrating effective and safe use of the observation option in the emergency department, together with more than 20 years of Dutch experience with observation, it would seem likely that there should be a decrease in the antibiotic prescribing rate for AOM in the emergency department. This does not appear to be the case. Fischer et al. demonstrated no decrease in antibiotic prescribing for children with AOM during the years 1996-2004.¹⁴

Why is this so? Several possible explanations exist.

First, it's possible that the word simply has not gotten out to enough emergency physicians in a sufficiently convincing way that AOM is a disease with a high rate of spontaneous resolution, and that antibiotics are not needed in the majority of the cases.

In addition, concerns about the lack of patient follow-up may make emergency physicians uncomfortable with the idea of not giving antibiotics.

Because ACEP has not yet endorsed the observation option, perhaps this lack of a "seal of approval," as it were, has given emergency physicians pause regarding the use of the observation option in clinical practice.

Furthermore, in the hectic and harried environment of the emergency department, diagnostic accuracy for AOM may be even harder to achieve than in other clinical environments, triggering antibiotic use when AOM may not even exist.

The goal of diagnostic accuracy in AOM is an elusive one, and diagnostic certainty is often hard to achieve.

Examining the tympanic membrane (TM) of an uncooperative child who is in pain is often challenging. As mentioned previously, the AHRQ definition of AOM requires the presence of a middle ear effusion. Except for a bulging TM, which correlates closely with the presence of middle ear fluid, it is difficult to determine the presence of middle ear fluid by visual inspection of the TM alone.

Pneumatic otoscopy is often rather glibly referred to in the literature as the diagnostic tool to be used to identify a middle ear effusion.

Pneumatic otoscopy, however, is not at all an easy test to perform. It requires a perfect seal of the external auditory canal, an unobstructed view of the TM and the insufflation of air into the ear canal of an already uncomfortable child, giving the examiner but a fleeting moment to assess whether or not the TM is moving normally.