Otitis Media with Effusion Glue Ear

What is otitis media with effusion?

Otitis media with effusion (OME), also called glue ear, is characterised by a collection of fluid in the middle-ear cleft. There is chronic inflammation but without signs of acute inflammation. OME is the most common cause of hearing impairment (and the most common reason for elective surgery) in childhood, where it usually follows an episode of acute otitis media (AOM). It is uncommon in adults, in whom Eustachian tube dysfunction is the predominant cause and suspicious aetiologies should be considered^[1] .

Ear diagram and glue ear

Most cases of otitis media with effusion will resolve spontaneously. However, in affected ears the average hearing loss is 20 decibels (dB) but may be as much as 50 dB. Surgery, in the form of grommet insertion, with or without adenoidectomy, is the most effective treatment in persistent, symptomatic cases^[2] .

Epidemiology^[1]

• Otitis media with effusion is the most common cause of acquired hearing loss in childhood.
• It is more common between the ages of 6 months to 4 years.
• More than 50% of children will experience otitis media with effusion in the first year of life.
• 1 in 8 primary school children (5-6 years) have fluid in one, or both ears.
• In children with Down's syndrome or cleft palate the prevalence is 60-85%.
• It is at its most common in the winter months.
• It is much less common in adults^[3] .

Risk factors (children)^[1]

• Otitis media with effusion is most common in the winter.
• Many cases are thought to follow an episode of AOM, particularly in children aged under 3 years.
• Impaired Eustachian tube function associated with cleft palate.
• Down's syndrome (increased susceptibility to infection due to impaired immunity and craniofacial malformation).
• Primary ciliary dyskinesia.
• Adenoidal infection or hypertrophy.
• Allergic rhinitis.
• Frequent upper respiratory tract infection
• Daycare attendance.
• Having older siblings.
• Lower parental socio-economic group.
• Parents who smoke.
• One study found a link between gastro-oesophageal reflux in children and OME: it is postulated that reflux increases the level of inflammatory cytokines present in the nasopharynx and middle ear^[4] .

Risk factors (adults)^[3]

Middle ear fluid in adults needs to be viewed with suspicion, particularly if unilateral. In one series of cases with otitis media with effusion over a 10-year period, 59 patients were unilateral and 26 were bilateral. A nasopharyngeal mass was documented in 69% of cases. In 4.7% of cases, the mass was malignant.

• Acute otitis media is uncommon in adults and is thus not a common precursor to otitis media with effusion.
• Eustachian tube dysfunction (ETD) is the main aetiological factor in adults. Causes of ETD include:
• Infection/inflammation:
• Severe nasopharyngeal infection (eg, sinusitis) inflames the Eustachian tube openings, resulting in ETD.
• Severe or chronic allergy may produce the same effect.
• Anatomical blockage:
• Severe nasal septal deviation with an obstructed airway.
• The presence of tonsils and adenoids with obstruction to Eustachian tubes.
• A nasopharyngeal tumour near Eustachian tube openings.
• Radiation to the head and neck following cancer treatments.
• Radical head and neck surgery, on maxillary sinuses and/or palate, that transects the Eustachian tube.
• Secondary inflammation from allergic rhinitis.
• Frequent upper respiratory infection. Some viruses may directly damage the Eustachian tube lining, decreasing ciliary clearance.
• Trauma (usually barotrauma - eg, after a dive or flight).

Spectrum of otitis media^[5]

Otitis media (OM) is an umbrella term for a group of complex infective and inflammatory conditions affecting the middle ear. All OM involves pathology of the middle ear and middle ear mucosa. OM is a leading cause of healthcare visits worldwide and its complications are important causes of preventable hearing loss, particularly in the developing world^[6] .

There are various subtypes of OM. These include AOM, OME, chronic suppurative otitis media (CSOM), mastoiditis and cholesteatoma. They are generally described as discrete diseases but in reality there is a great degree of overlap between the different types. OM can be seen as a continuum/spectrum of diseases:

• Acute otitis media is acute inflammation of the middle ear and may be caused by bacteria or viruses. A subtype of AOM is acute suppurative OM, characterised by the presence of pus in the middle ear. In around 5% the eardrum perforates.
• Otitis media with effusion is a chronic inflammatory condition without acute inflammation, which often follows a slowly resolving AOM. There is an effusion of glue-like fluid behind an intact tympanic membrane in the absence of signs and symptoms of acute inflammation.
• CSOM is long-standing suppurative middle ear inflammation, usually with a persistently perforated tympanic membrane.
• Mastoiditis is acute inflammation of the mastoid periosteum and air cells, occurring when AOM infection spreads out from the middle ear.
• Cholesteatoma occurs when keratinising squamous epithelium (skin) is present in the middle ear as a result of tympanic membrane retraction.

Otitis media with effusion symptoms in children^[1]

History

• The result of the newborn hearing screening test.
• Hearing loss is the usual presenting symptom, although this is easily missed in very young children. Hearing loss is not invariably present. Hearing loss in children may present as:
• Mishearing, difficulty with communication in a group, listening to the TV at excessively high volumes or needing things to be repeated.
• Lack of concentration, withdrawal.
• Impaired speech and language development.
• Impaired school progress.
• Mild intermittent ear pain with fullness or popping.
• There may be a history of recurrent ear infection, upper respiratory tract infections or nasal obstruction.
• Occasionally balance problems may be a feature.
• Assess the severity of the hearing loss and impact on the child's life by asking about:
• Fluctuations in hearing.
• Lack of concentration or attention, or being socially withdrawn.
• Changes in behaviour.
• Listening skills and progress at school or nursery.
• Speech or language development.
• Balance problems and clumsiness.

Examination findings

• Examine the ears with an otoscope:
• Opacification of the drum (other than due to scarring).
• There are usually no signs of inflammation or discharge on examination.
• Loss of the light reflex, or a more diffused light reflex.
• Indrawn, retracted, or concave drum.
• Decreased or absent mobility of the drum.
• Presence of bubbles or fluid level.
• Yellow or amber colour change to the drum.
• Fullness or bulging of the drum, although this is not typical.
• Examine the nose and throat to exclude predisposing factors.
• Pneumatic otoscopy is achievable in general practice but is not widely used^[7] .
• Tympanometry provides quantitative information about fluid in the ear but is generally considered a specialist investigation.

Otitis media with effusion symptoms in adults^[8]

Adult otitis media with effusion is more often unilateral than in children, which may reflect the underlying causes.

Typical symptoms include:

• Otitis media with effusion in adults usually presents with hearing loss.
• A feeling of aural fullness.
• Crackling or popping tinnitus.
• A foreign body sensation in the external auditory canal.
• Mild, diffuse aural pain.
• Complaints of acute ear pain (rare).
• A vague sense of unsteadiness without true vertigo may be seen.

Investigations in children^[1]

Children with persistent symptoms or signs should be referred for a hearing test or directly to an ENT specialist if GP access to audiometry is not available.

Not all cases require referral. Spontaneous resolution often occurs, so it's worth observing for three months to see whether the symptoms and signs resolve ('active observation')^[9] . One study found that 50% of children with 20 dB hearing loss will recover in three months without treatment.

Hearing assessment

• Hearing tests typically show a mild conductive hearing loss.
• A UK National Screening Committee review in 2019 concluded that uncertainties remained on:
• How many children starting school with temporary hearing loss would be identified by a national programme.
• The accuracy of screening tests for permanent hearing loss in children starting school
• The advantage to screening children at school entry age

It was not clear whether the best course of action was to discontinue or extend school age screening. They recommend that screening should continue only where it is already implemented while further research is undertaken to evaluate its effectiveness^[10] .

• The McCormick Toy Test and the distraction tests are suitable for children younger than 4 years^[11] These tests do not provide a quantitative level of loss.
• A hearing loss of 25 dB or greater in the better ear is usually important:
• With a hearing loss of 30 dB, normal conversation may sound like a soft whisper^[12] .
• The National Institute for Health and Care Excellence (NICE) recommends a second hearing test three months after the first^[9] .

Investigations in adults^[2]

Otitis media with effusion has a lower prevalence in adults and is frequently associated with other underlying diagnoses. Unilateral OME in an adult is a suspicious finding.

Paranasal sinus disease is the main underlying cause of OME in adults, accounting for two thirds of cases in one series. However, other causes include head and neck tumours.

Adults with otitis media with effusion should therefore be fully evaluated for underlying conditions.

Nasopharyngeal tumours are relatively more common in patients of Southern Chinese ethnicity. One study in Taiwan suggested that all adults with OME in whom a cause is not clearly understood should have full nasopharyngeal evaluation, including biopsy^[13] .

Otitis media with effusion treatment and management^{[1, 9]}

OME management in children

Advice
Give written information about OME to parents of affected children and reassure parents that:

• OME is a self-limiting illness and 90% of children will have complete resolution within one year, although recurrence is common.
• There is no proven benefit from treatment with any medication or alternative therapy.
• Parental smoking increases the risk of OME.
• Advise parents of children with hearing loss to assist them by:
• Facing their child when speaking to them.
• Slowing their speech.
• Keeping speech clear.
• Increasing speech volume slightly.
• Turning off competing stimuli such as radio or TV.
• Encouraging daily reading, which helps language development.

Hearing aiding

• NICE recommends hearing aids for children with bilateral OME and hearing loss where surgery is not acceptable or is contra-indicated.
• Each case needs to be considered on its own merits: the need to assist hearing during a period of active observation, for example, has to be weighed against evidence that the use of aids in children can increase anxiety^[14] .

Pharmacological^{[15, 16]}

Medical management (eg, antibiotics, topical or systemic antihistamines or decongestants) is not recommended.

• A Cochrane review found that current guidelines, developed by both the UK's National Collaborating Centre for Women's and Children's Health (2008) and the American Academy of Pediatrics (2004), recommends against using oral or topical nasal steroids in treating children with OME.
• High-quality evidence of multiple short- and long-term outcomes repeatedly and unequivocally demonstrated no benefit for use of antihistamines and decongestants over placebo for treating OME. Additionally, the reviewed studies found evidence of side-effects and harms with the use of these medications.
• A second Cochrane review looked at the use of antibiotics in OME in over 3,000 children and concluded that the results do not support the routine use of antibiotics for children up to 18 years of age with OME. The largest effects of antibiotics were seen with continuous use over weeks or months but these were felt to be balanced by the potential adverse effects of this approach, including side-effects and increased bacterial resistance.
• The treatment of adults with uncomplicated OME is generally extrapolated from that of children. If there is an underlying cause then this should be treated appropriately. There is a lack of clear evidence on the treatment of uncomplicated OME in adults.

Referral

• Most children who present with OME can be safely managed with active observation.
• Earlier referral may be considered for children with significant hearing difficulties, particularly if there are developmental, social or educational difficulties, or if there is pre-existing hearing impairment.
• Active observation is not appropriate for children who have significant disability or who have associated high-risk conditions - eg, Down's syndrome, cleft palate.
• Children with hearing loss demonstrated by the second hearing test should be referred to ENT.

Active observation^[9]
The use of surgical treatment for OME has fallen dramatically in recent years with the recognition that many cases resolve with active observation.

Autoinflation^[17]

• This is a harmless technique used to induce a Valsalva manoeuvre. NICE considers that evidence on the safety and efficacy of balloon dilation for Eustachian tube dysfunction is adequate to support the use of this procedure, provided that standard arrangements are in place for clinical governance, consent and audit.
• There is a number of devices available for purchase. The Otovent® device is available on NHS prescription. A balloon is inflated by blowing into it from one nostril, while sealing the other nostril with a finger. This action results in an increase in intranasal pressure and opening of the Eustachian tube (ie a Valsalva manoeuvre).

Surgery^{[9, 1]}
NICE recommends that children who most benefit from surgery are those:

• With persistent bilateral OME lasting three or more months.
• With a hearing loss in the best ear of 25-30 dB or worse, averaged at 0.5, 1, 2 and 4 kHz.
• Who are children with better hearing but who have social, educational or developmental difficulties. They may exceptionally also benefit from surgical treatment.

The application of these criteria has generated concern that surgery may be withheld from children who would otherwise benefit from it.

Insertion of grommets - ventilation tubes^{[9, 1]}
This is the first-line treatment.

• NICE concludes that insertion of grommets results in an improvement in hearing over a twelve-month period, which starts to tail off after six months. There is little evidence that language or speech development improves in the long term.
• Tympanosclerosis frequently occurs after grommet insertion, although the long-term consequences of this are uncertain.
• Infection after grommet insertion may occur and there is also a slightly increased incidence of chronic perforation.
• Grommet insertion has traditionally been performed under general anaesthetic, although it is possible to perform the procedure under local anaesthetic. Topical anaesthetic is applied to the ear canal approximately 30 minutes prior to the procedure.

A Cochrane review of 2011 concluded that^[15] :

• In children with hearing loss induced by OME the effect of grommets on hearing appears small and diminishes after 6-9 months (by which time natural resolution leads to improved hearing in those children not treated surgically).
• No effect was found on other child outcomes but data were sparse in this area.
• No study has been performed in children with established speech, language or developmental problems, so no conclusion can be drawn in the case of these children.

Adenoidectomy
Adenoidectomy is recommended only if recurrent upper respiratory tract symptoms are a feature.

Grommets and adenoidectomy reduce time with OME and improve hearing in the short term. Both treatments have associated harms. Large, well-controlled studies could help resolve the risk:benefit ratio by measuring acute otitis media recurrence, functional outcomes, quality of life and long-term outcomes. Further research is needed to support treatment decisions in sub-populations, particularly in patients with comorbidities^[18] . One study of 50 children found that adenoid tissue size and location have no effect on hearing thresholds and the duration of effusion in otitis media with effusion^[19] .

Laser myringotomy^{[20, 21, 22]}

• Myringotomy is an incision in the tympanic membrane. Historically, in the pre-antibiotic era, it was performed with a myringotomy knife to allow drainage (or suction) of middle ear fluid (it was described by Sir Ashley Cooper in 1802). It was popular until the arrival of antibiotics in the 1940s.
• Laser myringotomy (also called laser fenestration) uses a laser diode to incise the tympanic membrane, with a view to allowing middle ear fluid sampling or drainage without general anaesthetic or grommet insertion. (Laser diodes are tiny, portable, low-voltage lasers which produce a cone rather than a cylinder of light.) Laser myringotomy is safe, quick and painless and the hole it leaves in the tympanic membrane remains patent for longer than those made by incision with a blade. However, the duration of patency it produces is still too short (3-4 weeks) to achieve long-term clearance of the effusion in OME in adults or children.
• Laser diodes may also be used to perform myringotomy prior to ventilation tube insertion.

Otitis media treatment and management in adults

Adults with persisting OME and no sinister underlying cause which needs treatment are managed as for children. Outcomes for surgery and myringotomy appear to be similar.

Complications

• Otitis media with effusion may adversely affect speech, language development, behaviour and education:
• Evidence shows only a weak association between OME and delayed speech and language development. Most studies suggest that any adverse effect is temporary in the majority of children^[1] .
• One study found an increased incidence in anxiety/depression disorders and attention deficit disorders compared with controls^[23] .

Otitis media with effusion prevention

• One study found that A (H1N1) pandemic influenza vaccine afforded a two- to nine-fold protection against OME^[4] .
• Pneumococcal vaccine did not confer similar benefits^[24] .

Prognosis^[1]

• Otitis media with effusion (OME) usually resolves spontaneously within three months.
• Older children are more likely to resolve within this time: 22% at 1 year; 50% at 3 years; 70% at 5 years; 95% at 10 years .
• Persistence is more likely when a larger number of contributory factors is present, eg:
  • Bilateral OME, winter months, and a personal or sibling history of acute recurrent otitis media.
  • Persistence for six months in a child younger than 2 years of age has been measured as varying from 25-60%.

• It is not clear whether adult OME not associated with malignancy is the same disease as that which occurs in childhood or whether it is a different condition. The chronic form tends to persist longer than that seen in childhood. However, evidence suggests that adults with OME tend to have had a history of OME in childhood^[3] .

Dr Mary Lowth is an author or the original author of this leaflet.