Applied Evidence

An algorithmic approach to otitis media with effusion

Author and Disclosure Information

How you proceed will depend on the risk or presence of associated speech, language, and learning delays and the severity of hearing loss.


 

References

PRACTICE RECOMMENDATIONS

› Perform a hearing test when otitis media with effusion is present for 3 months or longer, or whenever you suspect a language delay, learning problems, or a significant hearing loss. C
› Use the results of the hearing test to guide management decisions. C

Strength of recommendation (SOR)

A Good-quality patient-oriented evidence
B Inconsistent or limited-quality patient-oriented evidence
C Consensus, usual practice, opinion, disease-oriented evidence, case series

CASE › A mother brings in her 3-year-old son for a regular check-up. Her only concern is that for the past 2 weeks, he has not been sleeping through the night. She indicates that the sleeping problem began after he was diagnosed with and treated for an ear infection. Fortunately, this hasn’t affected his daily activity or energy, she says.

The child’s appetite is good and he speaks clearly, in 5-word sentences. He is meeting his developmental milestones, and appears well—sitting in his mother’s lap and playing with her smartphone. His head, eyes, ears, nose, and throat exam only turns up fluid behind his left tympanic membrane, which is not red or bulging. The right membrane appears normal, and he has no cervical lymphadenopathy. The rest of his exam is normal. How would you manage a patient like this?

"Glue ear" is often asymptomatic

Otitis media with effusion (OME) is defined as middle-ear effusion (MEE) in the absence of acute signs of infection. In children, OME—also referred to as “glue ear”—most often arises after acute otitis media (AOM). In adults, it often occurs in association with eustachian tube dysfunction, although OME is a separate diagnosis. (To learn more, see “What about OME in adults?”1,2.)

Experts have found it difficult to determine the exact incidence of OME because it is often asymptomatic. In addition, many cases quickly resolve on their own, making it challenging to diagnose. A 2-year prospective study of 2- to 6-year-old preschoolers revealed that MEE, diagnosed via monthly otoscopy and tympanometry, occurred at least once in 53% of the children in the first year and in 61% of the children in the second year.3 A second study followed 7-year-olds monthly for one year and found a 31% incidence of MEE using tympanometry.4 In the 25% of children found to have persistent MEE, the researchers noted spontaneous recovery after an average of 2 months.

We believe that nearly all children have experienced one episode of OME by the age of 3 years, but the prevalence of OME varies with age and the time of year. It is more prevalent in the winter than the summer months.5 OME is more common in Caucasian children than in African American or Asian children.6

Etiology remains elusive

Risk factors for children include a family history of OME, bottle-feeding, day care attendance, exposure to tobacco smoke, and a personal history of allergies.7,8 One study conducted on mice suggested that inherited structural abnormalities of the middle ear and eustachian tube may play a role as well.9 Some have suggested that effusions of OME in children result from chronic inflammation, for example, after AOM, and that the effusions are sterile; however, recent studies have demonstrated that a biofilm is formed by bacterial otopathogens in the effusion.10-12 The common pathogens found include nontypeable Haemophilus influenza, Streptococcus pneumoniae, and Moraxella catarrhalis. Inflammatory exudate or neutrophil infiltration is rare in the fluid, however.

The contribution of allergies to OME in children remains somewhat controversial. A retrospective review from the United Kingdom of 209 children with OME found a history of allergic rhinitis, asthma, and eczema in 89%, 36%, and 24%, respectively.13 However, this study was done at an allergy clinic, and it is possible that the data from the clinic’s specialized patient population are not generalizable. Gastroesophageal reflux may also be associated with OME in children. However, studies measuring the concentration of pepsin and pepsinogen in middle-ear fluid have provided conflicting results.14,15

Look for these signs and symptoms

OME is often asymptomatic. If a patient has clinical signs of an acute illness, including fever and an erythematous tympanic membrane, it’s important to evaluate for another cause. OME can present with hearing loss or a sense of fullness in the ear. While an infant cannot express the hearing loss, the parent may detect it when observing and interacting mwith the child. Parents are also likely to report that the child is experiencing sleep disturbances.16

Vertigo may occur with OME, although not often. It may manifest itself if the child stumbles or falls. An older child or adult with vertigo may say that it feels like the room is spinning.

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