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Also“Serous Otitis Media”, Mucoid Otitis Media”,

Glue Ear”, “Middle Ear Effusion”- Often abbreviated as “OME”

Dr. Ghulam SequlainENT Surgeon

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“Otitis Media with Effusion”

is the presence of fluid in the middle ear

cavity with an eardrum that is not inflamed.

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Otitis media with effusion is one of the commonest chronic otological conditions of

childhood.

Acute and Chronic forms have been

classified according to the mode of onset

or according to duration,

but this distinction is not very clear.

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PREVALENCE

At any point in time 5-10% of children aged 1-6 years will have OME in both ears. About 20% will have it in only one ear.OME is more common in winter.Children often outgrow OME at age of 6-7 years. Those children with persisting OME after this age have chronic eustachian tube dysfunction and are very high risk of developing serious complications of OME.

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ETIOLOGY Several Factors:

Eustachian Tube MalfunctionCleft PalateSubmucous cleft palatePalatal palsy

Altered Mucuciliary SystemInfection (Nose, Sinuses, tonsils, adenoids, pharynx)Allergy. Middle ear effusion may occur as a part of nasal allergy.Surfactant deficiencyUltrastructural changes in cilia.Fibrocystic diseaseHormonal factorsOther factors

Nasopharyngeal DisproportionsCraniofacial abnormalitiesRacial facors affeting the shape and function of eustachian tube and nasopharynx.AdenoidsNeoplasms.

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The major underlying factors responsible for production of otitis media with effusion are a combination of EUSTACHIAN TUBE MALFUNCTION with superadded INFECTION.

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The Eustachian Tube:

The middle ear is normally full of air. The moist lining of the middle ear slowly absorbs oxygen and nitrogen from the middle ear at a rate of 1 ml per day. Thus small amounts of air must continually pass up the eustachian tube to ensure the middle ear remains full of air. The ear drum can only vibrate normally when the ear canal and the middle ear are both full of air.

The eustachian tube has three functions:

To allow air to pass up or down the tube,

To allow middle ear secretions to drain into the nasopharynx,

To prevent reflux of fluid back up the tube into the middle ear.

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The eustachian tube is normally closed and only opens momentarily during swallowing and yawning. We normally swallow several times a minute while awake and once every five minutes while asleep.The eustachian tube in children has poor support from the cartilage and bone surrounding the tube, and the Tensor veli palatini muscle is not as strong as it is in adults, with the result that children have much greater difficulty equalizing middle ear pressure.

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The eustachian tube works most efficiently when we are upright. It works at 2/3 efficiency when we are at an angle of 20 deg, and at 1/3 when we are lying flat.A child’s eustachian tube is shorter than an adult’s and almost horizontal. Because of this, middle ear secretions may not drain down the tube very well, and nasopharyngeal secretions and fluids may reflux into the eustachian tube more readily than in an adult.

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DIAGNOSIS & SCREENING

HISTORY

Reduced Hearing especially with background noise like TV or in the classroom.

Educational or behavioral problems. Mood Variations like quiet and withdrawn to loud and aggressive. They can be very difficult to deal with.

In younger children it may present as speech and language delay or as an articulation defect.

Some times attention is drawn to it by frequent episodes of otalgia which indicate an exacerbation of acute suppurative otitis media superimposed on the middle ear effusion.

Sometimes presentation is with complications such as otorrhoea secondary to perforation of the tympanic membrane.

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CLINICAL PRESENTATIONIt is possible to recognize certain clinical subgroups of otitis media with effusion:

Latent or overt hearing impairment without significant post nasal obstruction, otalgia or URTI.Obvious postnasal obstruction with hearing impairment but only occasionally URTI, minimal allergy and rarely otalgia.Upper and Lower RTI with generalized nasal obstruction and hearing impairment without otalgia of which there may be three groups:

Non-specific catarrahal conditionsRhinosinusitisAllergy.

Recurrent otalgia and hearing impairment with only occasional occasional otorrhoea, few URTIs, occasional mild nasal obstruction and / or mild allergyAcute URTIs which are infequentluy tonsillitis, leading to otalgia, with hearing impairment and occasional otorrhoeaCases with chronic irreversible eustachian tube malfunction, eg., cleft palate, Down’s other syndromes with craniofacial anomalies, or ultrastructural cilial abnormalities of the respiratory tract mucosa.

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EXAMINATION

Otological Examination:Use of magnification with an examination microscope or an otoscope may improve diagnostic accuracy,

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Degree of retraction of the pars tensa may be assessed by the extent of splitting and derangement of the light reflex, by the rotation and displacement of the malleus handle, and by the prominence of the lateral process of the malleus.

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The pars flaccida may be indrawn to a variable degree. Attic retraction and sometimes erosion of the outer attic wall may occur at later stage. The degree of retraction of the TM reflects the negative middle ear pressure which reduces the mobility of the TM.The mobility can be assessed by a pneumatic otoscope or Siegle’s pneumatic speculum.

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The colour and loss of translucency of the membrane range from pale grey or amber to a black or so called blue drum. It may be thickened , dull and opaque or thin and reflective. Increased vascularization of radial vessels is very frequent and sometimes of malleolar vessels.

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Fluid levels and air bubbles may be visible within the middle ear cleft.

.

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Atelectatic changes of pars tensa and pars flaccida may be present to a variable degree,

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Tuning Fork Tests:

In children over 4 years

Rinne’s Test: A negative Rinne test predict a hearing loss of 15 to 20 db.

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AUDIOLOGICAL ASSESSMENTPURE TONE AUDIOMETRY

(Limited Diagnostic Value)

It does however, provide some assessment of the severity of the disease and as a guide by which to monitor the progress and the effects of treatment. A hearing loss of 20-40 db is common with OME. A 60 db hearing loss can occaionally occur but this should raise the possibility of an underlying sensorineural hearing loss.(1 in 1000).Audiograms are difficult to obtain in children under 4 years. FFA, Play audiometry, child audiometry are used.

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TYMPANOMETRY (Diagnostic)- 90% accuracyThe impedance meter produces sound in the ear canal at a constant rate of 226 cycles per second and constantly measures the amount of sound returning from the eardrum under different pressure conditions.

Type “A” Tympanogram: Normal The peak of a normal or type A tympanogram should fall within the boundaries of middle ear pressure of -100 to +100 (mmH20 ) and compliance 0.3 to 1.5 (Cm3)

Contd…

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Type “B” Tympanogram: OMEWhen the middle ear is filled with fluid the eardrum does not vibrate well in response to sound wave no matter what pressure is applied to ear drum. The recording is a flat graph. Wax or pus will give a low volume and type B result. Perforated TM or functioning VT will give a very high volume and B result.

Type “C” Tympanogram: Eustachian tube dysfunction.

Type “B/C”Typanogram:This occurs when the middle ear is partly full of fluid and partly full of air.In this situation the hearing loss is same as for OME. The tympanogram has no definable peak, but is not flat. This represents a stage before the middle ear is completely full of fluid, or the earliest stage of resolution of the effusion.

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NATURAL HISTORY

The majority of children with OME of recent onset improve spontaneously within 2-3 months. An important part of treating OME of recent onset is to wait for 2-3 months. The rate of spontaneous improvement after 3 months is very low, and the rate of complications increases- hearing loss, speech and learning delays, behavioural problems and complications involving ear drum and middle ear itself.

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There are numerous forms of treatment of otitis media with effusion and , as yet, a correct management approach remains to be defined (Lim, 1985)

Management of the effect of effusion on hearing thresholds varies according to the duration and severity of the hearing loss.

MANAGEMENT

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PARENT COUNSELLINGWhat can parents do for their child with Otitis Media with Effusion

DO NOT give the baby or child a bottle to drink in its cot or bed.Babies should be breast or bottle fed in a “Head Up” position and not lying flat.Breast feeding helps to protect against ear infections. Breast feed for as long as possible.Although not proven to work it makes good sense for the mother to get her child to blow his or her nose frequently to clear mucous from the nose. It may also force air bubbles up the eustachian tube into the middle ear .Cigarette smoking has been shown to cause OME and other resp. problems as well. Do not smoke in the house, car, or near children.If the child has other evidence of a cow’s milk allergy then a 6-8 week trial of a diet free from dairy foods is worth trying. If the child has Hay Fever try and find the source of the allergy and get rid of it if possible. Ask the teacher to put a child with OME at the front of the classroom and always speak directly to the child. Lip reading helps to reinforce the child in hearing. Tilting the head of the bed up 8-12 inches may improve drainage from the middle ear.

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MEDICAL TREATMENT

Treating nasal allergies : It has been shown in a number of trials that antihistamines and decongestants, when given on their own, donot improve OME. Intranasal steriods may help in Hay Fever. A course of antibiotics: Greatly increase the chance of OME getting better in the short term. Some studies have used ten days antibiotics, and others upto thirty days, both with good results. If the child does not improve after a course of antibiotics this is because of chronic eustachian tube dysfunction and ventilation tube are likely to be needed. Inflation of Middle Ear: Valsalva’s Manoeuvre can be effective in older children and adults. Otovent, a low pressure balloon blown up by the nose increasing intranasal pressure is helpful. Removal of Adenoids: Adenoidectomy reduces the chances of getting a recurrence of OME, but not all benefit from removal of adenoids. Mouth breathers or snorer’s best benefit. Mucolytic Agents are some times helpful.Role of Vasoconstrictor drops:

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SURGICAL TREATMENT

If OME persists for three months despite above measures it can persist for many months or years and may result in a number of complications, therefore surgical intervention is required.

MYRINGOTOMY: SURGICAL DRAINAGE OF MIDDLE EAR FLUID. This allows air back into the middle ear cleft and the child’s hearing returns to normal immediately, but the wound heals within few days and condition my recur.

MYRINGOTOMY WITH VENTILATION TUBE INSERTION: This is done after myringotomy i.e., making a small cut in the TM, fluid is sucked and a small tube is inserted to keep the opening patent from weeks to months.

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What are Ventilation Tubes?

Also called as Tympanostomy tubes, Pressure Equalising Tubes, or Grommets.

These are small dumbell shape tubes with a small hole in the centre that allows air to pass from the ear canal into the middle ear cavity.

They may have a small thread, wire or tail on their outer end.

They act as artificial eustachian tubes

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Are Ventilation tubes a cure for OME?About 50% or more children will require one set of ventilation tubes. Another 50% will require reinsertion. Removal of adenoids will further help to reduce the chance of OME recurring.

Children with recurring OME despite several sets of ventilation tubes are a very difficult group to treat:►Should they have another set of small ventilation tubes which

may last only for few months?►Should they have large ventilation tubes with a high rate of

complications?►Should they have hearing aids?►Should they be left with OME and a hearing loss and also the

risk of middle ear complications.

The underlying problem is chronic eustachian tube dysfunction which may not resolve until 12-15 years of age.

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Should OME in single ear be treated?

It is not necessary to treat OME urgently if it is in one ear only.

Regular followup is required to ensure other ear remains normal, and to check for complications of OME.

It may be worthwhile treating OME in one ear only in following circumstances:

In Recurring acute otitis media,

learning and behavioural problems,

pain or retraction of the ear drum.

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What are Complications of

Ventilation Tubes?

TM perforation occur in 1% children with small tubes and 30% in large tubes. Infection from water getting into the middle ear does occur esp. soapy water.Tympanosclerosis,Fall into the middle ear requiring removal under G/A,Granulation tissue formation around the tube.

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COMPLICATIONS OF OME

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Retraction of Pars Flaccida & Tensa in a case with adhesive otitis media.

Cholesteatoma Formation

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