Overview
Definition:
Otitis media with effusion (OME), also known as serous otitis media or glue ear, is a condition characterized by the presence of fluid in the middle ear space without signs or symptoms of acute infection
This fluid, typically serous or mucoid, accumulates behind an intact tympanic membrane.
Epidemiology:
OME is extremely common in children, with prevalence rates of up to 50% in toddlers and 20-30% in preschool and school-aged children
It is the leading cause of acquired hearing loss in children and is often a sequela of acute otitis media or upper respiratory infections.
Clinical Significance:
Persistent middle ear effusions can lead to significant conductive hearing loss, impacting speech and language development, learning, and behavior in children
Early identification and appropriate management are crucial to prevent long-term sequelae and ensure optimal developmental outcomes.
Clinical Presentation
Symptoms:
Subtle or absent
Possible symptoms include hearing impairment, feeling of fullness in the ear, ear discomfort (otalgia) or popping sensations
Children may exhibit inattentiveness, poor school performance, delayed speech development, or behavioral changes
Tugging at the ear is less common than in acute otitis media
Often discovered incidentally during routine examination or hearing screening.
Signs:
Otoplastic examination typically reveals a retracted or bulging tympanic membrane, impaired mobility on pneumatic otoscopy, amber or grey coloration, visible air-fluid levels or air bubbles, and loss of normal light reflex
The tympanic membrane may appear dull or opaque
Mastoid or tympanic membrane perforation is absent.
Diagnostic Criteria:
Diagnosis of OME is based on physical examination findings and confirmed by objective audiological assessment
Key findings include: 1
Presence of middle ear fluid (identified by pneumatic otoscopy, tympanometry, or acoustic reflectometry)
2
Impaired tympanic membrane mobility
3
Absence of acute suppurative signs (fever, otalgia, purulent otorrhea).
Diagnostic Approach
History Taking:
Focus on recent or recurrent ear infections, upper respiratory tract infections, allergies, daycare attendance, exposure to smoke, and family history of ear problems
Inquire about changes in child's hearing, speech, or behavior
Ask about any treatment tried and its effectiveness
Identify red flags like sudden hearing loss, unilateral symptoms, or associated neurological deficits.
Physical Examination:
A thorough otoscopic examination is paramount, assessing the tympanic membrane for color, contour, mobility (using pneumatic otoscopy), presence of air-fluid levels, or bubbles
Check for any signs of acute infection or perforation
Bilateral examination is essential
A complete head and neck examination, including assessment of nasopharynx and cervical lymph nodes, should be performed.
Investigations:
Objective confirmation of middle ear effusion and associated hearing loss is crucial
Tympanometry (Type B tympanogram is characteristic of OME, indicating reduced compliance)
Acoustic reflectometry (useful in young children)
Audiometry (pure-tone and speech audiometry to quantify hearing loss, typically conductive)
Otomicroscopy for detailed tympanic membrane assessment
Rarely, a diagnostic myringotomy may be considered if diagnosis is unclear.
Differential Diagnosis:
Conditions to consider include acute otitis media (presence of acute inflammatory signs), otitis media with perforation (visible tympanic membrane defect), cholesteatoma (retracted tympanic membrane with keratin debris), middle ear atelectasis, Eustachian tube dysfunction (without effusion), and nasopharyngeal masses obstructing the Eustachian tube
Other causes of conductive hearing loss like external auditory canal obstruction.
Hearing Impact And Evaluation
Hearing Loss Type:
OME typically causes a mild to moderate conductive hearing loss, usually ranging from 20-30 dB HL
This level of hearing loss can significantly impact auditory processing, speech discrimination, and learning, particularly in noisy environments
The degree of hearing loss may fluctuate.
Impact On Development:
Persistent OME and associated hearing loss can impede speech and language acquisition, leading to delayed articulation, reduced vocabulary, and difficulties with sentence structure
It can also affect social interaction, emotional development, and academic performance, manifesting as inattention and behavioral issues.
Audiological Assessment:
A comprehensive audiological evaluation is essential for children diagnosed with OME
This includes tympanometry to assess middle ear pressure and compliance, and pure-tone audiometry to determine the degree and type of hearing loss
Speech audiometry is important to assess speech understanding, especially at different intensity levels.
Management And Tubes Criteria
Watchful Waiting:
For uncomplicated OME in children without significant hearing loss or developmental concerns, a period of watchful waiting (typically 3 months) is often recommended
Many effusions resolve spontaneously within this timeframe
Frequent re-evaluation is necessary.
Medical Management:
Systemic antibiotics are generally NOT recommended for uncomplicated OME without acute infection
Decongestants, antihistamines, and mucolytics have not demonstrated consistent efficacy and are not routinely advised
Management focuses on addressing underlying causes like allergies or adenoid hypertrophy if present.
Indications For Tympanostomy Tubes:
Tympanostomy tube (grommet) insertion is indicated for OME in children meeting specific criteria: 1
Persistent bilateral OME for at least 3 months with conductive hearing loss of >= 25 dB HL
2
Recurrent acute otitis media (AOM) – typically 3 or more episodes in 6 months or 4 or more episodes in 12 months, especially if associated with OME
3
OME with structural abnormalities of the tympanic membrane (e.g., retraction pockets)
4
OME with complications like cholesteatoma or tympanosclerosis
Consideration for unilateral OME if significant functional impact.
Surgical Procedure And Follow Up:
Tympanostomy tube insertion is a short surgical procedure performed under general anesthesia
A small incision is made in the tympanic membrane, and a tube is inserted to ventilate the middle ear
Post-insertion follow-up includes regular otoscopic checks and audiological assessments to monitor middle ear status and hearing
Tubes typically extrude spontaneously within 6-18 months.
Complications
Early Complications:
Bleeding from the incision site
Persistent perforation after tube extrusion
Granulation tissue formation around the tube
Early extrusion of the tube.
Late Complications:
Chronic middle ear effusion
Recurrent acute otitis media
Tympanic membrane atelectasis or scarring
Cholesteatoma formation (rare)
Persistent perforation of the tympanic membrane
Myringosclerosis
Impaired hearing if effusion or perforation persists.
Prevention Strategies:
Preventing OME involves reducing risk factors such as avoiding exposure to secondhand smoke, managing allergies, ensuring appropriate immunization (e.g., pneumococcal and influenza vaccines), and prompt treatment of acute otitis media
For children with recurrent AOM, prophylactic antibiotics may be considered in select cases before tube insertion.
Key Points
Exam Focus:
Understand the definition, commonality, and impact of OME on hearing and development
Differentiate OME from acute otitis media
Know the diagnostic hallmarks and investigatory tools (tympanometry Type B)
Critically, master the strict criteria for tympanostomy tube insertion (duration of effusion, degree of hearing loss, recurrent AOM).
Clinical Pearls:
Always perform bilateral otoscopic examination and pneumatic otoscopy
Tympanometry is key for objective assessment
If a child has a speech or developmental delay, consider OME as a primary cause
Counsel parents thoroughly on the implications of hearing loss and the rationale for tube insertion.
Common Mistakes:
Over-reliance on antibiotics for OME
Not performing objective hearing assessments
Premature tympanostomy tube insertion without meeting established criteria
Failure to adequately follow up post-tube insertion
Misinterpreting tympanometry findings.