An algorithmic approach to otitis media with effusion

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Applied Evidence

An algorithmic approach to otitis media with effusion

J Fam Pract. 2013 December;62(12):700-702,704-706

By

Leanne Zakrzewski, MD

Daniel T. Lee, MD

How you proceed will depend on the risk or presence of associated speech, language, and learning delays and the severity of hearing loss.

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References

1. Lesinskas E. Factors affecting the results of nonsurgical treatment of secretory otitis media in adults. Auris Nasus Larynx. 2003:30:7-14.

2. Chole RA, HH Sudhoff. Chronic otitis media, mastoiditis, and petrosis. In: Flint PW, Haughey BH, Lund VJ, et al, eds. Cummings Otolaryngology: Head and Neck Surgery. 5th ed. Maryland Heights, MO. Mosby;2010:chap 139.

3. Casselbrant ML, Brostoff LM, Cantekin EI, et al. Otitis media with effusion in preschool children. Laryngoscope. 1985;95:428-436.

4. Lous J, Fiellau-Nikolajsen M. Epidemiology of middle-ear effusion and tubal dysfunction: a one year prospective study comprising monthly tympanometry in 387 non-selected seven-yearold children. Int J Pediatr Otorhinolaryngol. 1981;3:303-317.

5. Tos M, Holm-Jensen S, Sørensen CH. Changes in prevalence of secretory otitis from summer to winter in four-year-old children. Am J Otol. 1981;2:324-327.

6. Vernacchio L, Lesko SM, Vezina RM, et al. Racial/ethnic disparities in the diagnosis of otitis media in infancy. Int J Pediatr Otorhinolaryngol. 2004;68:795-804.

7. 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;123:702-711.

8. Gultekin E, Develio˘gu ON, Yener M, et al. Prevalence and risk factors for persistent otitis media with effusion in primary school children in Istanbul, Turkey. Auris Nasus Larynx. 2010;37:145-149.

9. Depreux FF, Darrow K, Conner DA, et al. Eya4-deficient mice are a model for heritable otitis media. J Clin Invest. 2008;118:651-658.

10. Poetker DM, Lindstrom DR, Edmiston CE, et al. Microbiology of middle ear effusions from 292 patients undergoing tympanostomy tube placement for middle ear disease. Int J Pediatr Otorhinolaryngol. 2005;69:799-804.

11. Hall-Stoodley L, Hu FZ, Gieseke A, et al. Direct detection of bacterial biofilms on the middle-ear mucosa of children with chronic otitis media. JAMA. 2006;296:202-211.

12. Brook I, Yocum P, Shah K, et al. Microbiology of serous otitis media in children: correlation with age and length of effusion. Ann Otol Rhinol Laryngol. 2001;110:87-90.

13. Alles R, Parikh A, Hawk L, et al. The prevalence of atopic disorders in children with chronic otitis media with effusion. Pediatr Allergy Immunol. 2001;12:102-106.

14. Lieu JE, Muthappan PG, Uppaluri R. Association of reflux with otitis media in children. Otolaryngol Head Neck Surg. 2005;133:357-361.

15. O’Reilly RC, He Z, Bloedon E, et al. The role of extraesophageal reflux in otitis media in infants and children. Laryngoscope. 2008;118 (7 part 2, suppl 116):S1-S9.

16. Rosenfeld RM, Goldsmith AJ, Tetlus L, et al. Quality of life for children with otitis media. Arch Otolaryngol Head Neck Surg. 1997;123:1049-1054.

17. 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;113:1412-1429.

18. Perera R, Glasziou PP, Heneghan CJ, et al Autoinflation for hearing loss associated with otitis media with effusion. Cochrane Database Syst Rev. 2013;5:CD006285.

19. Stangerup SE, Sederberg-Olsen J, Balle V. Autoinflation as a treatment of secretory otitis media. A randomized controlled study. Arch Otolaryngol Head Neck Surg. 1992;118:149-152.

20. Williams RL, Chalmers TC, Stange KC, et al. Use of antibiotics in preventing recurrent acute otitis media and in treating otitis media with effusion. A meta-analytic attempt to resolve the brouhaha. JAMA. 1993;270:1344-1351.

21. Mandel EM, Casselbrant ML, Kurs-Lasky M, et al. Efficacy of ceftibuten compared with amoxicillin for otitis media with effusion in infants and children. Pediatr Infect Dis J. 1996;15:409-414.

22. Chan KH, Mandel EM, Rockette HE, et al. A comparative study of amoxicillin-clavulanate and amoxicillin. Treatment of otitis media with effusion. Arch Otolaryngol Head Neck Surg. 1988; 114:142-146.

23. Griffin G, Flynn CA. Antihistamines and/or decongestants for otitis media with effusion (OME) in children. Cochrane Database Syst Rev. 2011;(9):CD003423.

24. Mandel EM, Casselbrant ML, Rockette HE, et al. Systemic steroid for chronic otitis media with effusion in children. Pediatrics. 2002;110:1071-1080.

25. 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.

PRACTICE RECOMMENDATIONS

› Perform a hearing test when otitis media with effusion is present for 3 months or longer, or whenever you suspect a language delay, learning problems, or a significant hearing loss. C
› Use the results of the hearing test to guide management decisions. C

Strength of recommendation (SOR)

A Good-quality patient-oriented evidence
B Inconsistent or limited-quality patient-oriented evidence
C Consensus, usual practice, opinion, disease-oriented evidence, case series

CASE › A mother brings in her 3-year-old son for a regular check-up. Her only concern is that for the past 2 weeks, he has not been sleeping through the night. She indicates that the sleeping problem began after he was diagnosed with and treated for an ear infection. Fortunately, this hasn’t affected his daily activity or energy, she says.

The child’s appetite is good and he speaks clearly, in 5-word sentences. He is meeting his developmental milestones, and appears well—sitting in his mother’s lap and playing with her smartphone. His head, eyes, ears, nose, and throat exam only turns up fluid behind his left tympanic membrane, which is not red or bulging. The right membrane appears normal, and he has no cervical lymphadenopathy. The rest of his exam is normal. How would you manage a patient like this?

"Glue ear" is often asymptomatic

Otitis media with effusion (OME) is defined as middle-ear effusion (MEE) in the absence of acute signs of infection. In children, OME—also referred to as “glue ear”—most often arises after acute otitis media (AOM). In adults, it often occurs in association with eustachian tube dysfunction, although OME is a separate diagnosis. (To learn more, see “What about OME in adults?”^1,2.)

Experts have found it difficult to determine the exact incidence of OME because it is often asymptomatic. In addition, many cases quickly resolve on their own, making it challenging to diagnose. A 2-year prospective study of 2- to 6-year-old preschoolers revealed that MEE, diagnosed via monthly otoscopy and tympanometry, occurred at least once in 53% of the children in the first year and in 61% of the children in the second year.³ A second study followed 7-year-olds monthly for one year and found a 31% incidence of MEE using tympanometry.⁴ In the 25% of children found to have persistent MEE, the researchers noted spontaneous recovery after an average of 2 months.

We believe that nearly all children have experienced one episode of OME by the age of 3 years, but the prevalence of OME varies with age and the time of year. It is more prevalent in the winter than the summer months.⁵ OME is more common in Caucasian children than in African American or Asian children.⁶

Etiology remains elusive

Risk factors for children include a family history of OME, bottle-feeding, day care attendance, exposure to tobacco smoke, and a personal history of allergies.^7,8 One study conducted on mice suggested that inherited structural abnormalities of the middle ear and eustachian tube may play a role as well.⁹ Some have suggested that effusions of OME in children result from chronic inflammation, for example, after AOM, and that the effusions are sterile; however, recent studies have demonstrated that a biofilm is formed by bacterial otopathogens in the effusion.^10-12 The common pathogens found include nontypeable Haemophilus influenza, Streptococcus pneumoniae, and Moraxella catarrhalis. Inflammatory exudate or neutrophil infiltration is rare in the fluid, however.

The contribution of allergies to OME in children remains somewhat controversial. A retrospective review from the United Kingdom of 209 children with OME found a history of allergic rhinitis, asthma, and eczema in 89%, 36%, and 24%, respectively.¹³ However, this study was done at an allergy clinic, and it is possible that the data from the clinic’s specialized patient population are not generalizable. Gastroesophageal reflux may also be associated with OME in children. However, studies measuring the concentration of pepsin and pepsinogen in middle-ear fluid have provided conflicting results.^14,15

Look for these signs and symptoms

OME is often asymptomatic. If a patient has clinical signs of an acute illness, including fever and an erythematous tympanic membrane, it’s important to evaluate for another cause. OME can present with hearing loss or a sense of fullness in the ear. While an infant cannot express the hearing loss, the parent may detect it when observing and interacting mwith the child. Parents are also likely to report that the child is experiencing sleep disturbances.¹⁶

Vertigo may occur with OME, although not often. It may manifest itself if the child stumbles or falls. An older child or adult with vertigo may say that it feels like the room is spinning.