Otitis Media with Effusion (Glue ear)

Question 1

Definition of otitis media with effusion

Answer 1

A condition characterised by a collection of fluid within the middle ear space without signs of acute infection. Also called secretory or non-suppurative otitis media.

Question 2

Main complication of otitis media

Answer 2

Associated with significant hearing loss (conductive), especially when it is bilateral and lasts for longer than 1 month

Question 3

Causes of otitis media

Answer 3

• Over 50% of cases are thought to follow an episode of AOM, especially in children under 3 years of age
• Low grade viral or bacterial infection
• Persistent local inflammatory reaction
• Impaired eustachian tube functioning (poor aeration)
• Adenoidal infection

Question 4

Prevalence of OME, peak age of onset

Answer 4

• OME is most common in children between 6 months and 4 years
• Most common cause of hearing impairment in children
• More than 50% of children will experience OME in the first year of life
• Prevalence in children with Down’s syndrome/ cleft-palate is 60-85% (children with Down’s or cleft palate should be regularly assessed (3-6 months) for OME by ENT

Question 5

Risk factors for OME

Answer 5

Same as AOM:

Cleft palate or craniofacial malformation (impaired eustachian tube), Downs syndrome (impaired immunity and susceptibility to infection), primary ciliary dyskinesia, allergic rhinitis, exposure to other children, families with more than four members per household

Question 6

Complications of OME

Answer 6

• Conductive hearing loss- most common cause. Usually mild but may have a severe impact on the child, particularly if it is bilateral and persists for a longer time
• Educational, developmental, behavioural, and social difficulties: effects speech and language as well as balance and motor function
• Chronic damage to the tympanic membrane (may present with atrophy)

Question 7

Investigations

Answer 7

• Esults of newborn hearing screening test
• Audiometry and typanometry (abilility of eardrum to react to sound- gives an accurate diagnosis
• Otoscopy

Question 8

What will be seen on otoscopy

Answer 8

• A normal looking tympanic membrane does not exclude OME (usually no signs of discharge and inflammation on examination)
• Usually, fluid level is visible
• Effusion can be serous, mucoid or purulent
• These will present with abnormal drum colour (yellow, amber, blue), loss of light reflex, opacification

Question 9

How will OME present

Answer 9

• Any hearing loss- usually the presenting symptom which can be missed in infants and young children. May present as mishearing, difficulty communicating in groups
• Mild intermittent ear pain with ‘fullness’ or ‘popping’
• Aural discharge- persistent foul smelling discharge requires urgent referral
• Recurrent ear infections, URTIs, frequent nasal obstruction
• Interference with normal speech development, changes in behaviour (difficulty concentrating, listening skills and progress in nursery), balance problems and clumsiness

Question 10

Differentials for OME

Answer 10

• AOM- often precedes OME, with symptoms of shorter duration, should be distinguished clinicaly
• Mastoiditis (a complication)
• Otitis externa- more common in swimmers and adults
• Other causes of hearing loss: foreign body in the ear canal, impacted ear wax, perforated tympanic membrane, sensorineural hearing loss
• Other causes of developmental problems: speech and language disorders including dyslexia, behavioural disorders (conduct disorder, school refusal etc.), inattention due to ADHD or ID

Question 11

Differences between AOME and OME

Symptoms, appearance of effusion and drum

Answer 11

Question 12

An improtant consideration with ehavioural problems in young children

Answer 12

Hearing difficulty

Question 13

Management of OME in children with Down’s syndrome

Answer 13

Children with Down’s syndrome or cleft palate, who are suspected to have OME require immediate referral for specialist assessment (ENT)

Question 14

Initial management of OME

Answer 14

Active observation (‘watchful waiting’) for 3 months is appropriate for most children, since spontaneous resolution is common

• Need to re-evaluate signs + symptoms as well as impact on speech and language/ development
• Should include two hearing tests using pure tone audiometry 3 months apart, as well as tympanometry
• Decision to refer to ENT will then be made based on degree of hearing loss and delay in development
• Abx, corticosteroids, antihistamines, mucolytics and decongestants are NOT RECOMMENDED since there is no evidence to support their use

Question 15

What further treatment can be offered (after referral to ENT) if symptoms persist

Answer 15

• Non-surgical options: Autoinflation (usually for older children- ballon into nostril which ventilates middle ear and drains fluid- Valsalva manoeuvre), Hearing aids (usually bilateral, considered where surgery is inappropriate)
• Surgical options: Myringotomy and insertion of grommets
• Improves hearing only while the tubes are in place and has not been shown to improve other aspects of development
• Should be offered as an alternative to hearing aids in children with cleft palate who have OME and persistent hearing loss

Question 16

When should children with grommets be followed up, what are some complications of gromets

Answer 16

They should be followed up periodically (generally stop working after around 10 months) and 1/3 will require reinsertion within 5 years

Complications: Otorrhoea (ear discharge), infection, tympanic perforation, fibrosis, cholesteatoma, bleeding

Grommets usually cause few problems and work their way out of the ear in time (can live normal life including flying, swimming should not be discouraged- no increased risk of infection)