Otitis Media With E Usion

5/1/2019 Otitis Media With Effusion Article - StatPearls
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Otitis Media With E usion Share
Article Author:
Frederick Searight
Article Author (Archived):
Rahulkumar Singh
Article Editor:
Diana Peterson
Updated:
3/14/2019 5:33:05 PM
PubMed Link:
Otitis Media With E usion (https://www.ncbi.nlm.nih.gov/books/n/statpearls/article-
26425)
Introduction
Otitis media with e usion (OME) is a condition in which there is uid in the middle ear,
but no signs of acute infection. As uid builds up in the middle ear and Eustachian tube,
it places pressure on the tympanic membrane. The pressure prevents the tympanic
membrane from vibrating properly, decreases sound conduction, and therefore results
in a decrease in patient hearing. Chronic OME is de ned as OME that persists for 3 or
more months on examination or tympanometry, although some clinicians recommend
reserving the term, ‘chronic otitis media’ for patients in which the tympanic membrane
has perforated. [1]
Etiology
Risk factors for OME include passive smoking, bottle feeding, day-care nursery, and
atopy. [2] Both children and adults can develop OME. However, the etiology of these
populations are di erent. The Eustachian tube is positioned more horizontally in
younger children. As the child develops into an adult, the tube elongates and angles
caudally. Therefore, OME is more common in children, and the position of the head at
this age can in uence the development of OME. [3] Children with development
anomalies including the palate, palate muscles, decreased muscle tone for palate
https://www.statpearls.com/kb/viewarticle/26425/ 1/10
muscles, or bone development variations are at increased risk of development of OME,

e.g., cleft palate, Down Syndrome. [4] Beyond these anatomical variations, patients with
Downs syndrome can have mucociliary function disorders that increase the risk of
developing OME. [2][5]
Epidemiology
OME is one of the most frequent infectious diseases in children and is the most
common cause of acquired hearing loss in childhood. [6] The disease commonly a ects
children between the ages of 1 and 6. There is a higher prevalence at the age of 2,
which drops after the age of 5. OME is more prevalent during the winter months,
corresponding to higher patient rates of upper respiratory infections.
Pathophysiology
After an acute otitis media in children, uid builds up in the middle ear, inhibiting
vibration of the tympanic membrane and subsequent transmission of sound into the
inner ear. With this de cit, children may have a decreased ability to communicate in
noisy environments. The child may show signs of inattention or decreased academic
performance.
In patients with large adenoids, the adenoids can obstruct the Eustachian tube resulting
in a poorly ventilated middle ear. This type of blockage may result in OME. Because the
adenoids are a lymphatic structure, it is possible that they can transmit bacteria into the
Eustachian tube and allow growth of bio lms. Such bacterial growth can cause
in ammation that would also facilitate blockage and uid build-up within the middle
ear. [14]
Histopathology
The rst line of defense in the middle ear is thought to be the mucociliary defense
system in the Eustachian tube. Immunoglobulins produced by the mucosa contribute to
this defense system. Due to the signi cant elevation of these immunoglobulins in
e usions, these defense systems may be overactive in OME. [7]
Toxicokinetics
Otitis may also be caused by in ammation driven by viruses or allergies. While allergy is
a signi cant risk factor for otitis media, clinical practice guidelines (2004) concluded that
there was little evidence to support speci c management strategies for allergy induced
OME. However, it is logical to conclude that aggressive treatment of allergic rhinitis may
assist patients that develop OME in conjunction with allergies. [8]
History and Physical
Hearing loss, although not always present, is the most common complaint in OME
patients. Patients or parents of patients may complain of communication di culties,
withdrawal, and lack of attention. During an exam, a clinician may notice impaired
speech and language development. Otalgia, earache, can be intermittent in these
patients. In many instances, they will have the symptom of aural fullness or a sensation
that the ear is popping. In adults, OME is more often unilateral. Adult patients may
report tinnitus and the sensation of a foreign body in the external auditory canal. In
either children or adults, OME commonly occurs concurrently with upper respiratory
infections. Therefore, it is good to ask patients about prior or recurrent ear infections,
nasal obstruction, and upper respiratory tract infections.
During a physical examination, signs of OME include opaci cation of the tympanic
membrane and loss of the light re ex. There may also be a retraction of the tympanic
membrane with decreased mobility. If gross retraction of the tympanic membrane is
observed, intervention may be required to prevent the formation of a retraction pocket,
such as modi ed cartilage augmentation tympanoplasty. [9][1]
Evaluation
Age appropriate audiometry and tympanometry should be tested in patients with otitis
media with e usion. A ‘ at’ tympanogram will support a diagnosis of otitis media with
e usion. [10]Hearing can be tested in infants with the use of auditory brainstem
responses (ABR). This exam tests the electrical activity of the brainstem to acoustic
stimuli. The test detects both the frequency range and sound intensity levels in which
the patient’s brain responds. Patients do not need to be able to speak and do not even
need to be awake to perform the test. Therefore, it is ideal for children from birth to 5
years of age. [11]
With older children and adults, although ABR testing can still be performed, it is more
common to do a classic audiology exam. This exam consists of playing sounds to the
patient’s left and right ears at di erent tones and intensities. Patients are requested to
raise either the right or left hand when they hear a sound in the right or left ears,
respectively. Results will identify the frequency range and normal hearing levels of the
patient.
Individuals with normal hearing can detect lower frequencies at a lower decibel (i.e.,
intensity) than higher frequencies, meaning that a normal individual needs a sound to
be louder to perceive high frequencies than lower frequencies. During an audiology
exam, the range of frequencies that an individual can perceive is plotted on an
audiograph. The decibel (dB) range of individuals with OME is decreased in the
audiograph.
Hearing loss levels (reduction in hearing thresholds from normal levels):
Slight impairment: 26-40 dB

Moderate impairment: 41-60 dB
Severe impairment: 61-80 dB
Severe hearing loss: 71-90 dB
Profound impairment including deafness: 81 dB or higher. [12]
Treatment / Management
Otitis media with e usion generally resolves spontaneously with watchful waiting.
However, if it is persistent, myringotomy with tympanostomy tube insertion is
considered an e ective treatment. [13] In this treatment, a ventilation tube allows for air
entry into the middle ear, preventing re-accumulation of uid. After this procedure,
many patients do not need additional therapy due to the growth and development of
the Eustachian tube angle, which will allow for drainage.
Adenoidectomy is currently utilized in cases of OME that involve enlarged adenoids and
is an important addition to management in patients with OME. [14]
Childhood hearing loss can a ect language development [15]. Therefore hearing aids
may be considered as a non-invasive option to treat OME. [16]
Clinician decisions for the correct interventional treatment of OME for a speci c patient
include a variety of factors.
Comorbidities of the patient

The severity of hearing loss
OME presence unilaterally or bilaterally
E usion duration
Age of patient
Social factors
Cost to patient
Patient’s likelihood of adherence to treatment
Familial assistance with treatment
A patient-focused approach should be adopted when assessing hearing disability. How

the child is coping socially and at school is more important than the results of
audiometry investigations. [17][18][19] Although most OME patients will warrant a
conservative management approach as opposed to more invasive interventions, all
physical and social factors should be examined to provide a patient-centered treatment
plan that optimizes outcomes for the patient.[20][21][22]
Di erential Diagnosis
OME needs to be distinguished from acute otitis media [23], and in adults, OME can be
caused by a nasopharyngeal carcinoma in ltrating the Eustachian tube. [24]
Surgical Oncology
Although patients with OME may show no signs or symptoms except for the loss of
hearing associated with OME, 5.7% of patients develop the OME due to an obstruction
caused by a nasopharyngeal carcinoma. Examination of the nasopharynx, as well as the
external acoustic meatus, is suggested with OME patients. If abnormalities are observed
within the nasopharynx, a biopsy of the postnasal space is suggested. [25]
Radiation Oncology
In patients with nasopharyngeal carcinoma, OME can be induced by radiation
treatments. This type of OME may persist over several months. [26] More research is
needed to determine the risks of developing OME post-radiotherapy, and how
irradiation dosages may in uence this complication. [27]
Pertinent Studies and Ongoing Trials

Several di erent therapies have been tried to nd e ective treatment options for OME.
The use of oral steroids in children has shown some bene t. However, it is unknown
whether these bene ts are clinically signi cant. [28] Otic drops have also been utilized to
maintain tympanostomy tube patency. These trials showed no statistical di erences in
the occlusion rate between patients that received the drug therapy and control (no drug)
conditions. [29]
Treatment Planning
OME is most commonly caused by either viral or allergy related factors, not a bacterial
infection. Therefore, the use of antibiotics is not recommended. Also, corticoids for the
treatment of allergies have not signi cantly proven to impact the outcomes of OME in
patients. For these reasons, antibiotics and corticoids are not recommended to treat
OME. The best practice for OME patients is watchful waiting for three months as a rst-
line measure. In cases where OME persists, a specialist referral may be made to assess
for surgical treatment options. [30]
Toxicity and Side E ect Management

Ototopical drops can be ototoxic if they enter the middle ear and reach the inner
ear [31]. However, ototopical drops are not routinely used to treat OME.
Medical Oncology
Radiotherapy after nasopharyngeal carcinoma can produce various complications. The
most common complication is xerostomia (i.e., dry mouth caused by a lack of saliva). In
some cases, a persistent OME may develop, facilitating the need for additional therapy
or surgical intervention. [31]
Prognosis
Most cases of OME resolve on their own. In persistent cases, the condition impedes a
patient's ability to hear. Therefore, communication and socialization can be a ected. In
young children, hearing de cits can cause learning problems or delayed language
development. The impact of OME on these factors has not been fully
studied. [32] Unusual complications of OME include dizziness, behavioral disorders, and
clumsiness. [33]
Complications
Long term changes of the middle ear and tympanic membrane may occur with
persistent OME, resulting in permanent hearing loss. Ventilation tubes are used to try
and prevent these long-term complications. However, even in treated patients,
complications such as tympanosclerosis may occur. [34]
Postoperative and Rehabilitation Care

Alongside medical and surgical treatment of OME, Eustachian tube rehabilitation may
also be useful in management. Rehabilitation of the Eustachian tube can include muscle
strengthening exercises for the tensor veli palatini and levator veli palatini muscles via
auto-insu ation, breathing exercises, and education for improvement of nasal
hygiene. [35]
Consultations
Contact with a wide range of medical professionals, including audiologists and
otolaryngologists are important in OME to ensure holistic care for these patients.
Deterrence and Patient Education

To avoid the potential of ventilation tube complications, many doctors and parents
prefer non-invasive therapies, e.g., hearing aid usage. Reassurance and explanation of
the ‘watchful waiting’ approach is an important part of management for patients who do
not have speech, language, or developmental problems and for those in whom
audiometry shows normal hearing. If ‘watchful waiting” is utilized, the patient should be
watched closely for changes in symptoms or signs of increased pressure on the
tympanic membrane, as rupture would induce a poor prognosis for the future audition
in these patients.
Parents of children with recurrent OME should be informed and educated about the
anatomy of the middle ear. Clinicians should identify the family activities of the child in
relation to the head position (e.g., breastfeeding, sleeping patterns). Manipulation of the
head position during these activities may allow for optimal drainage and assist the child
in the prevention of subsequent episodes of OME into the future.
Enhancing Healthcare Team Outcomes

Management goals of OME include: eliminating middle ear uid, improving hearing, and
preventing future episodes. In all cases, communication between health care providers,
nurse practitioner, patients, and patients' families will assist clinicians to identify optimal
treatment plans for patients with OME.
Children in whom ‘watchful waiting’ is the adopted strategy should be reassessed every
3-6 months until there is a resolution of the e usion or intervention is required. Also,
families should be informed about signs and symptoms indicative of progressed
pathology. In these instances, subsequent conversations about alterations to the
treatment plan may be needed. The outcome for most children is good.
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5/1/2019 Otitis Media With Effusion Article - StatPearls

HOME (/KB/) / OTITIS MEDIA WITH EFFUSION

Otitis Media With E usion Share

muscles, or bone development variations are at increased risk of development of OME,

History and Physical

Hearing loss levels (reduction in hearing thresholds from normal levels):

Slight impairment: 26-40 dB

Profound impairment including deafness: 81 dB or higher. [12]

Comorbidities of the patient

A patient-focused approach should be adopted when assessing hearing disability. How

Pertinent Studies and Ongoing Trials

Toxicity and Side E ect Management

Postoperative and Rehabilitation Care

Deterrence and Patient Education

Enhancing Healthcare Team Outcomes

[14] Miller BJ,Gupta G, Adenoidectomy . 2018 Jan [PubMed PMID: 30570973]

[30] Núñez-Batalla F,Jáudenes-Casaubón C,Sequí-Canet JM,Vivanco-Allende A,Zubicaray-Ugarteche J, Diagnosis

Take 5 Question Quiz on Otitis Media With E usion (/quiz/createarticleq

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