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Otitis Media With Effusion

Frederick T. Searight; Rahulkumar Singh; Diana C. Peterson.

Author Information
Last Update: February 12, 2019.

Introduction
Otitis media with effusion (OME) is a condition in which there is fluid in the middle ear, but no
signs of acute infection. As fluid 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 defined 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 different. 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 influence the
development of OME. [3] Children with development anomalies including the palate, palate
muscles, decreased muscle tone for palate 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 affects 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, fluid builds up in the middle ear, inhibiting vibration of
the tympanic membrane and subsequent transmission of sound into the inner ear. With this
deficit, 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 biofilms. Such bacterial growth can cause inflammation that would also
facilitate blockage and fluid build-up within the middle ear. [14]

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Histopathology
The first 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 significant elevation of these immunoglobulins in effusions, these defense systems
may be overactive in OME. [7]

Toxicokinetics
Otitis may also be caused by inflammation driven by viruses or allergies. While allergy is a
significant risk factor for otitis media, clinical practice guidelines (2004) concluded that there
was little evidence to support specific 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 difficulties, 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 opacification of the tympanic membrane
and loss of the light reflex. 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 modified cartilage
augmentation tympanoplasty. [9][1]

Evaluation
Age appropriate audiometry and tympanometry should be tested in patients with otitis media
with effusion. A ‘flat’ tympanogram will support a diagnosis of otitis media with
effusion. [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 different 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.
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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 effusion generally resolves spontaneously with watchful waiting. However, if it
is persistent, myringotomy with tympanostomy tube insertion is considered an effective
treatment. [13] In this treatment, a ventilation tube allows for air entry into the middle ear,
preventing re-accumulation of fluid. 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 affect 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 specific patient include
a variety of factors.

Comorbidities of the patient

The severity of hearing loss

OME presence unilaterally or bilaterally

Effusion 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]

Differential Diagnosis

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OME needs to be distinguished from acute otitis media [23], and in adults, OME can be caused
by a nasopharyngeal carcinoma infiltrating 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 influence this
complication. [27]

Pertinent Studies and Ongoing Trials

Several different therapies have been tried to find effective treatment options for OME. The use
of oral steroids in children has shown some benefit. However, it is unknown whether these
benefits are clinically significant. [28] Otic drops have also been utilized to
maintain tympanostomy tube patency. These trials showed no statistical differences 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 significantly 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 first-line measure. In cases where OME
persists, a specialist referral may be made to assess for surgical treatment options. [30]

Toxicity and Side Effect 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 affected. In young children,
hearing deficits can cause learning problems or delayed language development. The impact of

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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-insufflation,
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 fluid, 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 effusion 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.

Questions
To access free multiple choice questions on this topic, click here.

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