Predictive value of serologic tests for syphilis in otology.

Otologic syphilis (luetic inner ear disease) usually is diagnosed by positive serologic tests and by exclusion of other possible causes. Because the FTA-ABS for syphilis is exquisitely sensitive in all but early primary cases, a positive FTA-ABS result and coincident inner ear disease often are thought to be diagnostic of syphilitic inner ear disease. The result is a management dilemma: are there false-positive results in misdiagnosed cases? Over 4 years, the authors performed a prospective study with time-matched controls to determine the predictive value of serologic tests and prevalence of syphilis in otology. Thirty-one cases of otologic syphilis were diagnosed in 5,439 new (different) patients with otologic complaints. In the geographic area studied, this prevalence (570/100,000) was 25-fold greater than that of all reported cases of syphilis in the general population (22.7/100,000). The defined sensitivity of the FTA-ABS (100%) was nearly twofold greater than the measured sensitivity of the rapid plasma reagin (RPR, 55%) in otologic syphilis. Specificities were comparable; therefore, a positive FTA-ABS had higher predictive value than a positive RPR. The prevalence-related predictive value of a positive FTA-ABS (22%) was more than twice that of the RPR (9%) in otology. The predictive value of a positive FTA-ABS in otology was 11-fold greater than that of the FTA-ABS in the general population (2%). Therefore, in suspect cases the FTA-ABS should be used to screen for otologic syphilis in an otologic practice. At a prevalence of 570 cases in 100,000 patients, only 22% of otologic patients with positive FTA-ABS results actually have otologic syphilis. Because disease morbidity can be far worse than treatment morbidity, however, positive results should be considered true-positives to avoid misdiagnosis in potentially infected patients. In suspect cases with positive FTA-ABS, therefore, treatment should be recommended unless specific contraindications exist.