Background Information
Definition
Collection of fluid within the middle ear space, in the absence of acute infection
Causes and Risk Factors
Most common in 6 m/o – 4 y/o
The most significant risk factors:
- Down syndrome / cleft palate (prevalence of OMEOtitis media with effusion in these children is 60-85%)
- Down syndrome is associated with an increased risk of cleft palate
- >50% cases follow an episode of acute otitis media
- Primary ciliary dyskinesia
- Allergic rhinitis
Other risk factors:
- Eustachian tube dysfunction
- Household smoking
- Adenoidal hypertrophy / infection
- Recurrent URTIsUpper respiratory tract infections
Complications
- Conductive hearing loss – most common cause of hearing impairment in childhood (>50% of children will experience OME in first year of life)
- Hearing loss in early childhood → impairment in speech and language development and communication skills
- Chronic damage to the tympanic membrane (retraction pockets, cholesteatomatous changes
Glue ear (otitis media with effusion) increases the risk of developing cholesteatoma primarily through chronic middle ear inflammation and persistent eustachian tube dysfunction, which lead to negative middle ear pressure and tympanic membrane retraction.
This retraction, especially in the pars flaccida or pars tensa, can form a retraction pocket that accumulates keratin debris and loses its ability to self-clean, setting the stage for cholesteatoma formation.
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Diagnosis
Clinical Examination
Otoscopic findings – changes to the tympanic membrane:
- Loss of light reflex
- Air fluid level / air bubbles
- Retracted tympanic membrane
- Opacification
A normal-looking tympanic membrane does NOT exclude OME.
The presence of a red, bulging tympanic membrane should raise suspicion of acute otitis media.
Investigations and Diagnosis
If OME is suspected based on history and clinical examination (including otoscopic findings), perform:
- Diagnostic tests
- 1st line: pneumatic otoscopy
Standard otoscope fitted with a rubber bulb used to gently puff air at the tympanic membrane and assess mobility.
(qualitative) – showing reduced / absent movement of the tympanic membrane- Highly sensitive/specific, however, accuracy is operator-dependent and may be limited by patient cooperation or obstructing cerumen[Ref]
- Confirmatory: tympanometry
An objective, instrument-based test (using a tympanometer) measuring tympanic membrane mobility by changing air pressure inside the ear canal.
(quantitative) – showing a type B curve (flat) suggestive of middle ear effusion
- 1st line: pneumatic otoscopy
- Audiometry – to assess the degree of conductive hearing loss associated with OMEOtitis media with effusion
Pneumatic otoscopy and tympanometry are both sensitive for detecting middle ear effusion but cannot distinguish between acute otitis media and otitis media with effusion.
Both conditions can produce a middle ear effusion, yielding reduced or absent tympanic membrane mobility and a type B (flat) tympanogram.
The key differentiator of acute otitis media (vs OME) is the presence of acute inflammatory signs (especially bulging of the tympanic membrane) on otoscopy, not the results of tympanometry or pneumatic otoscopy alone.[Ref]
Management
Referral Criteria
Consider referral to ENT in the following scenarios:
- Down syndrome, cleft palate or other craniofacial anomalies
- Complicated hearing loss
- Any level of hearing loss that is associated with a significant impact on the child’s developmental, social or educational status
- Structurally abnormal tympanic membrane
- Possible cholesteatoma (e.g., presence of persistent, foul-smelling discharge)
Unilateral OME in adults is a red flag for nasopharyngeal malignancy (esp. those of Chinese or Southeast Asian descent are at highest risk).
These patients need urgent ENT referral, including flexible nasoendoscopy and possible imaging.
Management Algorithm (0 – 12 y/o)
1st line management (acute Lasting <3 months
- Active observation involves regular follow-up with repeated history and examination, audiology assessment and speech and language assessment
- Advise that OME will often get better over time without treatment
- Consider recommending autoinflation
Non-invasive mechanical technique that aims to ventilate the middle ear and promote clearance of middle ear fluid by increasing nasopharyngeal pressure. It is typically done via a nasal balloon or similar device.
(only in older children who have no ear pain)
Pharmacological treatments Antibiotics, antihistamines, mucolytics, decongestants, corticosteroids, leukotriene receptor antagonists, proton-pump inhibitors or anti-reflux medications.
Surgical Interventions
Indications for surgical intervention:
- Typically if there is persistent / chronic OME AND documented hearing difficulties OR other attributable symptoms
Attributable symptoms include:
- Vestibular problems
- Poor school performance
- Behavioural problems
- Ear discomfort
- Reduced quality of life
Surgical intervention options:
- Myringotomy
Small incision is made in the tympanic membrane to allow for middle ear drainage.
- Grommet insertion
Ventilation tubes that perform the function of the eustachian tube (i.e., pressure equalisation) and enable continuous drainage of middle ear effusions.
They often become less effective at 6-9 months and will fall out as the myringotomy incision heals.
Water precautions should be considered for 2 weeks after the operation
Non-Surgical Interventions
Consider hearing aids
- Usually if there is persistent bilateral OME and hearing loss and surgery is not appropriate