> Table of Contents > Otitis Media with Effusion
Otitis Media with Effusion
Hobart Lee, MD, FAAFP
image BASICS
DESCRIPTION
  • Also called serous otitis media, mucoid otitis media, or “glue ear”
  • Otitis media with effusion (OME) is defined as the presence of fluid in the middle ear in the absence of acute signs or symptoms of infection.
  • More commonly, a pediatric disease
  • May occur spontaneously from poor eustachian tube function or as an inflammatory response after acute otitis media
EPIDEMIOLOGY
Incidence
Approximately 90% of children have OME before school age, mostly between the ages of 6 months and 4 years.
Prevalence
  • Approximately 2.2 million new cases annually in the United States
  • Less prevalent in adults and is usually associated with an underlying disorder
ETIOLOGY AND PATHOPHYSIOLOGY
  • Chronic inflammatory condition where an underlying stimulus causes an inflammatory reaction with increased mucin production creating a functional blockage of the eustachian tube and thick accumulation of mucin-rich middle ear effusion
  • Young children are more prone to OME due to shorter and more horizontal eustachian tubes, which become more vertical around 7 years of age.
  • Biofilms, anatomic variations, and acute otitis media (AOM) caused by viruses or bacteria have been implicated as stimuli causing OME. The common pathogens causing AOM include nontypeable Haemophilus influenzae, Streptococcus pneumoniae, and Moraxella catarrhalis.
  • In adults, OME is often associated with paranasal sinus disease (66%), smoking-induced nasopharyngeal lymphoid hyperplasia and adult onset adenoidal hypertrophy (19%), or head and neck tumors (4.8%).
RISK FACTORS
  • Risk factors include a family history of OME, early daycare, exposure to cigarette smoke, bottlefeeding, and low socioeconomic status (1).
  • Eustachian tube dysfunction may be a predisposing factor, although the evidence is unclear (2).
  • Gastroesophageal reflux is associated with OME (2).
GENERAL PREVENTION
OME is generally not preventable, although lowering smoke exposure, breastfeeding, and avoiding daycare centers at an early age may decrease the risk (3).
image DIAGNOSIS
PHYSICAL EXAM
  • Cloudy tympanic membrane (TM) with distinctly impaired mobility. Air-fluid level or bubble may be visible in the middle ear (1,2).
  • Color may be abnormal (yellow, amber, or blue), and the TM may be retracted or concave (2).
  • Distinct redness of the tympanic membrane may be present in approximately 5% of OME cases (1).
  • Clinical signs and symptoms of acute illness should be absent in patients with OME (1).
DIFFERENTIAL DIAGNOSIS
  • Acute otitis media
  • Bullous myringitis
  • Tympanosclerosis (may cause decreased/absent motion of the TM)
  • Sensorineural hearing loss
DIAGNOSTIC TESTS & INTERPRETATION
Diagnostic Procedures/Other
  • The primary standard to make the diagnosis is pneumatic otoscopy, which demonstrates reduced/absent mobility of the TM secondary to fluid in the middle ear. Pneumatic otoscopy has 94% sensitivity and 80% specificity for diagnosing OME. Accuracy of diagnosis with an experienced examiner is between 70% and 79% (1)[C].
  • Myringotomy is the gold standard but is not practical for clinical use (2)[C].
  • Tympanometry may also be used to support or exclude the diagnosis in infants >4 months old, especially when the presence of middle ear effusion is difficult to determine (1)[C].
  • Acoustic reflectometry (64% specificity and 80% sensitivity) may be considered instead of tympanometry (4)[B].
  • Audiogram may show mild conductive hearing loss (2)[C].
  • Hearing tests are recommended for OME lasting >3 months (1)[C].
  • Language testing is recommended for children with abnormal hearing tests (1)[C].
image TREATMENT
  • OME improves or resolves without medical intervention in most patients within 3 months, especially if secondary to AOM (1)[C].
  • Current guidelines support a 3-month period of observation with optional serial exams, tympanometry, and language assessment during that wait time (1,2)[C].
  • Adults found to have OME should be screened for an underlying disorder and treated accordingly (2)[C].
MEDICATION
  • The 2004 AAFP/AAOHNS/AAP guideline and a 2012 Cochrane review recommend against routine use of antibiotics in treatment of OME. No long-term benefits of antibiotics have been proven, and often prescribed antibiotics have adverse side effects such as diarrhea, vomiting, rashes, and allergic reactions (1)[C],(5)[A].
  • The 2004 AAFP/AAOHNS/AAP and a 2006 Cochrane review found that antihistamines and decongestants have no benefit over placebo in the treatment of OME with possible adverse side effects such as insomnia, hyperactivity, and drowsiness (1)[C],(5)[A].
  • The 2004 AAFP/AAOHNS/AAP guideline recommends against administering oral or intranasal corticosteroids. No long-term benefit was shown and adverse side effects such as weight gain and behavioral changes are possible (1)[C].
  • P.745

  • In adults, eustachian tube dysfunction secondary to allergic rhinitis or recent upper respiratory infection can be the cause of OME. It is unknown whether decongestants, antihistamines, or nasal steroids improve outcomes in adults.
ISSUES FOR REFERRAL
The following are indications for referral to a surgeon for evaluation of tympanostomy tube placement (6)[C]:
  • Chronic bilateral OME (≥3 months) with hearing difficulty
  • Chronic OME with symptoms (e.g., vestibular problems, poor school performance, behavioral issues, ear discomfort, or reduced quality of life)
  • At-risk children (speech, language, or learning problems due to baseline sensory, physical, cognitive, or behavioral factors) with chronic OME or type B (flat) tympanogram
ADDITIONAL THERAPIES
  • Hearing aids may be an acceptable alternative to surgery (2)[C].
  • Autoinflation, which refers to the process of opening the eustachian tube by raising intranasal pressure (e.g., by forced exhalation with closed mouth and nose) may be beneficial in improving patients' tympanogram or audiometry results beyond 1 month (6)[A].
SURGERY/OTHER PROCEDURES
  • Tympanostomy tubes are recommended as initial surgery. Risks include purulent otorrhea, myringosclerosis, retraction pockets, and persistent tympanic membrane perforations (1,2)[C].
  • Adenoidectomy with myringotomy has similar efficacy to tympanostomy tubes in children >4 years of age but with added surgical and anesthetic risks (1)[C].
  • Adenoidectomy should not be performed in children with persistent OME alone unless there is a distinct indication for the procedure for another problem (e.g., adenoiditis/chronic sinusitis/nasal obstruction) (1)[C].
  • Adenoidectomy (and concurrent tube placement) may be considered when repeat surgery for OME is necessary (e.g., when effusion recurs after tubes have fallen out or are removed). In these cases, adenoidectomy has been shown to decrease the need for future procedures for OME (1,2)[C].
  • Tonsillectomy or myringotomy alone is not recommended for treatment (1)[C].
image ONGOING CARE
FOLLOW-UP RECOMMENDATIONS
Patient Monitoring
  • Children who are at risk for speech, language, or learning problems and whose OME persists for ≥3 months should undergo hearing evaluation (1)[C].
  • Reevaluation and repeat hearing tests should be performed every 3 to 6 months until the effusion has resolved or until the child develops an indication for surgical referral (1)[C].
PROGNOSIS
Approximately 50% of children >3 years of age have OME resolution within 3 months.
REFERENCES
1. American Academy of Family Physicians, American Academy of Otolaryngology-Head and Neck Surgery, American Academy of Pediatrics Subcommittee on Otitis Media With Effusion. Otitis media with effusion. Pediatrics. 2004;113(5):1412-1429.
2. Qureishi A, Lee Y, Belfield K, et al. Update on otitis media—prevention and treatment. Infect Drug Resist. 2014;10:15-24.
3. Owen MJ, Baldwin CD, Swank PR, et al. Relation of infant feeding practices, cigarette smoke exposure, and group child care to the onset and duration of otitis media with effusion in the first two years of life. J Pediatr. 1993;123(5):702-711.
4. Shekelle P, Takata G, Chan LS, et al. Diagnosis, natural history, and late effects of otitis media with effusion. Evid Rep Technol Assess (Summ). 2002; (55):1-5.
5. Griffin G, Flynn CA. Antihistamines and/or decongestants for otitis media with effusion (OME) in children. Cochrane Database Syst Rev. 2011;(9): CD003423.
6. Perera R, Haynes J, Glasziou P, et al. Autoinflation for hearing loss associated with otitis media with effusion. Cochrane Database Syst Rev. 2006;(4): CD006285.
Additional Reading
&NA;
  • Browning GG, Rovers MM, Williamson I, et al. Grommets (ventilation tubes) for hearing loss associated with otitis media with effusion in children. Cochrane Database Syst Rev. 2010;(10):CD001801.
  • Casselbrant ML, Mandel EM, Rockette HE, et al. Adenoidectomy for otitis media with effusion in 2-3-year-old children. Int J Pediatr Otorhinolaryngol. 2009;73(12):1718-1724.
  • Rosenfeld RM, Schwartz SR, Pynnonen MA, et al. Clinical practice guideline: tympanostomy tubes in children. Otolaryngol Head Neck Surg. 2013;149 (1 Suppl):S1-S35.
  • Simpson SA, Lewis R, van der Voort J, et al. Oral or topical nasal steroids for hearing loss associated with otitis media with effusion in children. Cochrane Database Syst Rev. 2011;(5):CD001935.
  • van Zon A, van der Heijden GJ, van Dongen TM, et al. Antibiotics for otitis media with effusion in children. Cochrane Database Syst Rev. 2012;(9): CD009163.
Codes
&NA;
ICD10
  • H65.90 Unspecified nonsuppurative otitis media, unspecified ear
  • H65.00 Acute serous otitis media, unspecified ear
  • H65.20 Chronic serous otitis media, unspecified ear
Clinical Pearls
&NA;
  • Otitis media with effusion (OME) is defined as the presence of a middle ear effusion in the absence of acute signs of infection.
  • In children, OME most often arises following an acute otitis media. In adults, it often occurs in association with eustachian tube dysfunction.
  • The primary standard for diagnosis is pneumatic otoscopy.
  • There is no benefit to the routine use of antibiotics, antihistamines, decongestants, or corticosteroids for the treatment of OME in children.
  • Management includes watchful waiting and surgery (when indicated); which strategy is chosen depends on many factors, including the risk/presence of any associated speech, language, or learning delays and on the severity of any associated hearing loss.