Otitis media with effusion

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Otitis media with effusion (OME) is also known as glue ear, serous otitis media or secretory otitis media. It is a very common condition in children and sometimes affects adults.

Contents

Aetiology

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  • Parents smoking cause glue ear.
  • This is not the only factor

The fundamental pathology of OME is Eustachian tube dysfunction. Several factors may contribute to this.

  • It is a very common condition
    • 40% of all children at 2 years
    • 1% at 11 years
  • OME is more common in children exposed to cigarette smoke in the household, is more common in blacks than in whites, and in children who breastfeed for more than 4 months.[1]
  • Associated with small nasopharynx, including conditions such as Down's syndrome
  • Allergy is common
  • Recurrent upper respiratory tract infections
  • Adenoids may contribute. It is thought that adenoids enlarged due to repeated infection contribute towards the source of pathogenic bacteria, rather than physical obstruction. There is no difference in incidence and prevalence of effusion between children who have large versus small adenoids.

Pathology

LogoKeyPointsBox.pngThe fundamental pathology of glue ear is eustachian tube dysfunction.

A number of factors contribute towards sub-atmospheric ("negative") middle ear pressure. Eustachian tube respiratory mucosa can become inflamed due to allergy, infection or irritation. A narrow nasopharynx in children also contributes to Eustachian tube dysfunction. The middle ear mucosa becomes inflamed and this leads to the production of a thick, tenacious mucus rich in glycoproteins and mucoproteins, known as glue. This mucus also becomes filled with inflammatory cells. The clinical picture is usually of repeated episodes of blockage followed by resolution. In persistant cases, there may be long term damage and atrophy of the tympanic membrane.

Clinical features

An otoscopic view of a right sided otitis media with effusion

Symptoms are highly variable. Not all cases are clinically apparent, and not all cases need investigation or treatment.

  • Conductive hearing loss on one or both sides
  • Learning difficulties or speech delay
  • Recurrent infections (uncommon)
  • Effusion seen on otoscopy
    • Orange or grey fluid
    • Drum may buldge, be retracted, or neither
    • Air bubbles may be seen
    • A fluid level may be seen

Investigations

The best investigation is a hearing test of some sort!

Management

This will depend on the severity of the condition. In most cases, the effusions will cease as the child grows older. In all cases, audiograms or impedence audiometry should be carried out 3 months apart to establish whether the condition is persistent or not.

  • Surgical myringotomy and insertion of ventilation tubes (grommets)
  • Adenoidectomy as well as grommets
  • Antihistamines have no role to play
  • Long term antibiotics, such as trimethoprim for 6 weeks may offer short term improvement
  • Otovent balloon devices produce some benefit, but are less effective than grommets
  • Short term hearing aids are a non-surgical alternative for moderate or profound hearing loss

Infections and grommets

Occasionally, children with grommets develop ear infections. The best management for such infections is aural toilet, and treatment with antibiotic/steroid drops[2]. The use of antibiotics is controversial, but it is thought that the presence of infection is more likely to cause permenent hearing loss that aminoglycocide drops. The British association of otolaryngologists and head and neck surgeons recommend the use of fluoroquinolones such as ciprofloxacin, although these drugs are not licenced for use in the ear in the UK.

Swimming and grommets

There is no good evidence that swimming with grommets and unoccluded ears increases the risk of infection, although most ENT surgeons would advise caution. The use of ear plugs and swimming hats is recommended, as well as avoiding diving. Soapy water has a lower surface tension, and so can travel through grommets more easily. The use of head-rings and ear plugs when washing hair or during bathtime is recommended.

References

  1. Paradise JL, Rockette HE, Colborn DK et alOtitis media in 2253 Pittsburgh-area infants: prevalence and risk factors during the first two years of life. Pediatrics (1997) 99:318-33
  2. Otitis media with effusion. In Key topics in Otolaryngology, NJ Roland, RDR McRae and AW McCombe. Second edition. Bios Scientific publishers Ltd. pp 213-215
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