ENT

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Also
“Serous Otitis Media”, Mucoid Otitis Media”,
Glue Ear”, “Middle Ear Effusion”- Often abbreviated as “OME”
Dr. Ghulam Sequlain
ENT 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 Malfunction
Cleft Palate
Submucous cleft palate
Palatal palsy
Altered Mucuciliary System
Infection (Nose, Sinuses, tonsils, adenoids, pharynx)
Allergy. Middle ear effusion may occur as a part of nasal allergy.
Surfactant deficiency
Ultrastructural changes in cilia.
Fibrocystic disease
Hormonal factors
Other factors
Nasopharyngeal Disproportions
Craniofacial abnormalities
Racial facors affeting the shape and function of eustachian tube and
nasopharynx.
Adenoids
Neoplasms.

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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 PRESENTATION
It 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 conditions
Rhinosinusitis
Allergy.
Recurrent otalgia and hearing impairment with only occasional occasional
otorrhoea, few URTIs, occasional mild nasal obstruction and / or mild allergy
Acute URTIs which are infequentluy tonsillitis, leading to otalgia, with
hearing impairment and occasional otorrhoea
Cases 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 ASSESSMENT
PURE 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% accuracy
The 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: OME
When 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 COUNSELLING
What 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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