Continuing Education Activity

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 decreased hearing. This activity reviews the pathophysiology and presentation of otitis media with effusion and highlights the role of the interprofessional team in its management.

Objectives:

• Describe the risk factors for otitis media with effusion.
• Explain the presentation of a patient with otitis media with effusion.
• Summarize the treatment options for otitis media with effusion.
• Review the importance of improving care coordination among interprofessional team members to improve outcomes for patients affected with otitis media with effusion.

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, daycare nursery, and atopy. [2] Both children and adults can develop OME. However, the etiology of these populations is 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 the growth of biofilms. Such bacterial growth can cause inflammation that would also facilitate blockage and fluid build-up within the middle ear.

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 and 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. 

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 the 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. The most common complication is the development of persistent otorrhea. Otorrhea is seen in nearly 1 in 6 (16%) of children within 4 weeks of surgery, and in 26% of children during the entire period, the tube is in place.

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 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

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 benefits. 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 bacterial infection. Therefore, the use of antibiotics is not recommended. Also, corticoids for the treatment of allergies have not been 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 Adverse 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 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 the improvement of nasal hygiene.[35]

Consultations

Contact with a wide range of medical professionals, including audiologists and otolaryngologists, is 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 future hearing 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 in 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 practitioners, 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.