Tag Archives: glue ear

How ‘otitis media with effusion’ is diagnosed?

Ear has three parts outer, middle and inner ear.

Middle ear is air filled cavity, separated from external ear by ear drum and is connected to space behind the back of nose (nasopharynx) by Eustachian tube.

Function of Eustachian tube is to drain fluid from middle ear which then can be swallowed and to provide ventilation of middle ear space.

If Eustachian tube gets blocked because of some reason middle ear air replacement fails and potential vacuum forms, this vacuum draws fluid inside the middle ear, condition known as otitis media with effusion.

Diagnsis is important specially to differentiate it (fig on right hand side) from incipient acute otits  media (fig on left side)-


incipient acute-otitis-media

1. Clinical History is important in diagnosis.

Otitis media with effusion may have no symptoms at all.

Most frequent presentation is covert and overt hearing loss which is mostly fluctuating with season and may be affected with changing position. Child may describe it as plugged ear or stuffy or wooly feeling in the ear.

Only sign by which parents come to know that the condition exists may be loud talking, not responding to verbal commands and turning up the volume of the television or music system,  sometimes it is detected on routine audiometry (test of hearing).

Hearing loss can slow up language and academic skill development; children may develop behavioral and social problems like he may appear to be distracted, or inattentive.

Infant and young children may present as delayed or defective speech development.

There may be mild earache (pain in the ear) especially with upper respiratory tract infection.

2. Otoscopy and pneumatic otoscopy:

Otoscope is an instrument to see magnified view of ear drum.

Doctor first removes any ear wax in order to visualize ear drum clearly.

Ear drum may be dull and opaque instead of usual transparent or pearly white colour. It may be pulled inside or may be bulged out. Sometimes characteristic fluid level or air-bubble may be seen.

Pneumatic otoscope has a rubber bulb attachment, air is pushed inside on pressing the bulb and reduced mobility of ear drum can be judged.

3. Use of operating microscope:

It gives more magnification and better visualization of minute details of ear drum.

4. Hearing tests:

Tuning fork tests and pure-tone audiometry may be helpful in children above 4 years and may show some conductive type of deafness.

Tympanometry is rapid and reliable even in infants.

5. Definitive and direct evidence of diseases is only when presence of fluid in the middle ear is confirmed by myringotomy.

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Risk factors for development of fuid in middle ear

Certain factors predispose a child for development of fluid in the middle ear like:-

  • Allergy
  • Enrolment in day care
  • Exposure to second hand smoke
  • Bottle feeding
  • Use of pacifier
  • Lower socioeconomic group because of overcrowding and poor hygiene
  • Certain syndromes like downs, hunter and hurler’s syndrome, some kids with skull base or nasopharyngeal abnormalities like cleft palate and immunosuppressive disorders, such as HIV are more likely to develop OME.
  • Parents who smoke or pregnant woman who drink alcohol put their babies at risk.

Management of fluid in middle ear or ‘glue ear’

fluid in middle earPopularly known as ‘glue ear’,  Otitis media with Effusion or fluid in the middle ear is the commonest cause of hearing difficulty and most frequent reason for visits to Otorhinolaryngology (ENT) clinic in children. More common during the age when child is developing speech and language skills by hearing to his surroundings,  because it is not painful, it may present as speech and language delay or defects.

Underlying mechanism in collection of fluid in the middle ear may be either Blockage of Eustachian tube or Increased production of mucus in middle ear:

Children have shorter and more horizontal tubes and immune system are not well developed, that is the reason which explains more common ear infection in a child. If Eustachian tube gets blocked because of some reason middle ear air replacement fails and potential vacuum forms, this vacuum draws fluid inside the middle ear.

This could be basis of effusion in Baro-trauma, adenoids, viral infections (as evidenced by association of OME with influenza), second hand smoke, allergy, immunological factors, birth defects(such as cleft palate), cystic fibrosis, or cilia abnormality (as in Kartageners syndrome).

In some cases Eustachian tube is patent; here other factors like increased mucus production in the middle ear as is seen in upper respiratory infection or allergy, may play a role.

Benign and malignant tumor should always be ruled out in adult having otitis media with effusion in one ear.

Treatment: –

Medical treatment:

There is high rate of spontaneous resolution; most episodes are short lived and 75% of cases resolve in 3 months so normally a ‘wait and watch’ policy is advised.

According to ‘American Academy of Otorhinology-Head and Neck Surgery’ (AAO-HNS): –

  • Child is kept under observation with regular follow ups for first three months.
  • If condition lasts longer than 3 months, a hearing test is conducted and child re-evaluated. If hearing is within normal range (below 20 decibels) child is prescribed with antibiotics and kept on periodic check-ups for 4-6 months.

Management is aimed to encourage natural process; useful measures are control of environment factors, management of allergy, nasal decongestant drops, and  Valsalva’s maneuver (Forced expiration with both the mouth and nose closed à Increased air pressure in nasopharynx à opening of the Eustachian tube).

Surgical treatment:

Child is considered for surgical treatment if OME lasts for more than 4-6 months, or there is hearing loss more than 20 decibels or child is at risk of developmental delays because of recurrent problem.

Mainstay of treatment is myringotomy (a small incision is made in ear drum and fluid is suctioned out) and placement of ventilation tubes (Grommets).

Procedure takes less than 30 minutes, ear tube falls out after few months and incision heals spontaneously. Ear tube relieves pain and restores hearing.

There are chances of relapses in 20%-50% children and tube placement may have to be repeated.

Sometimes removal of adenoids is to be done along with tubal placement.

Management of risk factors: –

  • Well balanced healthy diet with fresh fruits and vegetables rich in antioxidants and lacto bacillus.
  • Avoidance of bottle feeding and pacifiers
  • Restricting exposure to day care
  • Wash hands and toys frequently
  • Avoidance of passive smoking
  • Management of associated nasal conditions
  • Avoidance and management of allergy
  • Pneumococcal and flu vaccine

Studies have evaluated that antibiotics and other medicines have short term effect and no long term cure. Putting ventilation tubes is effective but some newer studies have questioned the role in view of spontaneous resolution and frequent need for repeat tubal placement.

Several studies are being conducted but there are still so many unanswered questions and still need for proper research.