Otitis media with effusion, AKA Serous Otitis Media, is a slowly progressive disease characterized by the accumulation of non-purulent effusion in the middle ear cleft behind an intact tympanic membrane without signs and symptoms of acute infection. If it persists for more than 3 months it is termed Chronic OME. It is caused by eustachian tube dysfunction and/or increased secretion in the middle ear. Any adult with unilateral persistent middle ear fluid should have their nasopharynx investigated for nasopharyngeal tumor with biopsy of suspicious lesions. OME is usually self-limited. It can be observed for 3 months in non-at risk patients.
OME is the most common cause of paediatric hearing loss, and is associated with language delay and behavioral issues. OME commonly affects children 5-8 years old. Boys are affected more than girls.
- Causes of OME
- Eustachian tube dysfunction (chronic blockage of the eustachian tube)
- Adenoid hyperplasia
- Chronic rhinosinusitis
- Chronic tonsillitis
- Tumors of the nasopharynx
- Cleft palate, Palatal paralysis
- Allergy causing oedema of the eustachian tube
- Unresolved otitis media (causes low-grade infection which stimulates goblet cellls)
- Viral URTI (may invade the middle ear and stimulate goblet cells)
- Eustachian tube dysfunction (chronic blockage of the eustachian tube)
- Pathophysiology
- Persistent fluid following acute otitis media (50% of AOM cases have persistent fluid at 1 month, 10% have persistent fluid at 3 months)
- Eustachian tube dysfunction (following an URTI)
- Patient History
- Young child
- History of URTI with mild ear ache
- Signs and symptoms
- Hearing loss: gradual, conductive, does not exceed 40dB
- Delayed and defective speech (because of hearing loss)
- Mild ear ache
- Repeated ear infections
- Behavioural problems
- Loss of balance
- Tinnitus
- Sensitive to loud sounds due to loss of acoustic reflex
- Otoscopic findings
- Dull and opaque tympanic membrane: loss of light reflex, bulging, some degree of retraction
- Fluid levels and air bubbles in the middle ear (if the tympanic membrane is transparent)
- Reduced mobility of the tympanic membrane
- Investigations
- Pneumatic otoscopy: Gold standard diagnostic test
- Audiogram: CHL > 30dB
- Tympanometry
- Conservative Treatment
- Nasal decongestant
- Antihistamines
- Antibiotics if there is unresolved AOM
- Middle ear aeration with repeated Valsava, chewing gum, blowing into balloon
- Surgical Treatment
- Myringotomy and aspiration of fluid
- Grommet insertion to provide continuous aeration to the middle ear. Indicated if:
- Unilateral OME > 6 months with hearing loss > 30dB
- Bilateral OME > 3 months with hearing loss > 30dB
- Tympanotomy or Cortical Mastoidectomy to remove loculated thick fluid or a cholesterol granuloma
- Surgical treatment of predisposing factors e.g. Adenoidectomy, Tonsillectomy, Wash-out of maxillary antra
- Complications of OME
- Atrophy of the tympanic membrane (the fibrous layer is dissolved)
- Ossicular necrosis (most commonly the long process of incus)
- Tympanosclerosis
- Retraction pockets
- Cholesteatoma
- Cholesterol granuloma (due to stasis of secretions in the middle ear and mastoid)
