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Otitis Media With Effusion

Updated: Mar 20, 2018
Author: Thomas S Higgins, Jr, MD, MSPH; Chief Editor: Arlen D Meyers, MD, MBA

Overview
Practice Essentials
Otitis media with effusion (OME) is characterized by a nonpurulent effusion of the
middle ear that may be either mucoid or serous. Symptoms usually involve hearing
loss or aural fullness but typically do not involve pain or fever. In children, hearing
loss is generally mild and is often detected only with an audiogram. Serous otitis
media is a specific type of otitis media with effusion caused by transudate formation
as a result of a rapid decrease in middle ear pressure relative to the atmospheric
pressure. The fluid in this case is watery and clear.[1, 41]

Understanding the difference between otitis media with effusion and other forms of
middle ear infection is important.[2] Otitis media is a generic term defined as an
inflammation of the middle ear without reference to a specific etiology or
pathogenesis. Because all pneumatized spaces of the temporal bone are
contiguous, inflammation of the middle ear may involve inflammation in the other 3
spaces: the mastoid, perilabyrinthine air cells, and the petrous apex. The term otitis
media is often used to describe any of a continuum of related diseases: acute otitis
media (AOM), recurrent acute otitis media (RAOM), otitis media with effusion, and
chronic otitis media with effusion (COME). See the image below.

Anatomy of the external and middle

ear.
Workup

Traditionally, laboratory tests have rarely been used in the workup and diagnosis of
otitis media with effusion (OME) unless another process is suspected. History taking
and physical examination are sensitive and specific enough to facilitate accurate
diagnosis and treatment of the disease.

Computed tomography (CT) scanning is important in attempting to rule out potential

complications of otitis media (eg, mastoiditis, sigmoid sinus thrombosis, erosion of
bone with intracranial extension) or unusual lesions (eg, cholesteatoma). This
imaging modality is particularly important in unilateral otitis media with effusion when
a nasopharyngeal or eustachian tube mass must be ruled out.

Magnetic resonance imaging (MRI) is especially useful in the workup for soft-tissue
masses that may be contributing to middle ear effusions (MEE) because of its
superior ability to delineate borders within soft tissues and to help determine the
extent of potential intracranial extension (often helpful in nasopharyngeal masses). In
addition, MRI and its closely associated variants magnetic resonance venography
(MRV) and magnetic resonance arteriography (MRA) demonstrate complications
such as thrombosis of the intracranial sinuses very well. However, when intracranial
extension is present, either from invasion from the nasopharynx or the temporal
bone, CT scanning helps to define the bony anatomy more specifically and should
be used in conjunction with MRI.

Tympanometry is perhaps the most useful of all tests in association with otitis media
with effusion (OME). This test reveals a type B result (flat) in 43% of cases of otitis
media with effusion and a type C result (negative pressure) in 47% of cases.

Tympanocentesis involves the aspiration of effusion from the middle ear. This
procedure can be performed as an office procedure, even in small children, if
necessary. Tympanocentesis can serve as both a therapeutic procedure and a
diagnostic one.[13]

The criterion standard for documentation of a middle ear effusion is myringotomy,

which has the advantage of increased exposure and better suctioning relative to
tympanocentesis.[14]

Management

An otolaryngologist should be consulted whenever the primary care physician (PCP)

is concerned about persistent conductive hearing loss in children, especially those
with signs of language development delay.

In addition, an otolaryngologist (ENT) should be consulted if the disease is recurrent,

if the appropriate medical therapies available to the primary care physician are
exhausted, and/or if the criteria for surgical intervention have been met.

An allergist, audiologist, and/or a speech therapist may be consulted, when

appropriate. In select cases, an immunologist may be consulted for the workup for a
possible immunocompromised state.
Several investigators have reported mixed results when attempting to determine if
autoinflation, compared with no intervention, improves effusion clearance rates. The
ambiguity in the data may be a result of great variability in autoinflation methods
and/or noncompliance in patients.

Pharmacologic management of otitis media with effusion (OME) includes

administration of antimicrobial agents, steroids, antihistamines and decongestants,
and mucolytics. However, an international consensus conference of the 2017
International Federation of Oto-rhino-laryngological Societies Congress
recommended against the treatment of otitis media with effusion (OME) with
steroids, antibiotics, decongestants, or antihistamines, citing concerns regarding side
effects and cost, as well as a lack of evidence for long-term therapeutic
effectiveness.[38]

Surgery has become the most widely accepted therapeutic intervention for persistent
otitis media with effusion (OME), and it is clearly effective. The interventions include
myringotomy with or without tube insertion, adenoidectomy, or both. Tonsillectomy
has been shown to be of little benefit as a primary treatment of otitis media with
effusion.

See also Otitis Media, Acute Otitis Media, Complications of Otitis Media, Chronic
Suppurative Otitis Media, Emergent Management of Acute Otitis Media, and Ear
Anatomy.

Pathophysiology
Otitis media with effusion (OME) can occur during the resolution of acute otitis media
(AOM) once the acute inflammation has resolved. Among children who have had an
episode of acute otitis media, as many as 45% have persistent effusion after 1
month, but this number decreases to 10% after 3 months.

Classic theory

Two main theories of the cause of acute otitis media exist. The classic explanation
proposes that eustachian tube dysfunction is the necessary precursor. The
eustachian tube has been traditionally described to provide 3 main functions:
equilibration of pressure between the middle and external ears, clearance of
secretions, and protection of the middle ear. Its dysfunction can be caused by any
number of circumstances from anatomic blockage to inflammation secondary to
allergies, upper respiratory tract infection (URTI), or trauma.

If eustachian tube dysfunction is persistent, a negative pressure develops within the

middle ear from the absorption and/or diffusion of nitrogen and oxygen into the
middle ear mucosal cells. If present for long enough and with appropriate magnitude,
the negative pressure elicits a transudate from the mucosa, leading to the eventual
accumulation of a serous, essentially sterile effusion. Because the eustachian tube is
dysfunctional, the effusion becomes a sessile medium ideal for the proliferation of
bacteria and resultant acute otitis media. This classic model is somewhat incorrect,
as multiple studies have revealed that the same pathogenic bacteria are present in
otitis media with effusion as in acute otitis media.

Newer theories

The newer models describe the primary event as inflammation of the middle ear
mucosa caused by a reaction to bacteria already present in the middle ear. Indeed,
Bluestone and others have shown (using radiographic evidence) that reflux up the
eustachian tube is demonstrable in children prone to otitis media.[3] Furthermore,
Crapko et al demonstrated the presence of pepsin in the middle ear space of 60% of
children with otitis media with effusion,[4] although this reflux certainly may also
occur in otherwise healthy individuals.

Similarly, in a prospective study of 129 pediatric patients with otitis media who
underwent myringotomy with tympanostomy tube placement, O’Reilly et al found that
ear samples from 64 patients tested positive for pepsin A, evidence that these
children had aspirated gastric contents into the nasopharynx. The investigators
suggested that this may in turn have initiated inflammation or exacerbated a
preexisting condition.[5]

The inflammatory mediators released as a result of bacterial antigenic challenge

induce the upregulation of mucin genes. The production of a mucin-rich effusion then
provides an ample medium for the proliferation of bacteria and resultant acute otitis
media.

Yilmaz et al published a study that documented significant changes in oxidative

stress in patients with otitis media with effusion.[6] The investigators demonstrated a
significantly improved but not normalized level of oxidants following the placement of
ventilation tubes. However, the role of antioxidants in the treatment of otitis media
with effusion has yet to be fully investigated.

Middle ear effusion

Regardless of the cause of acute otitis media, eustachian tube dysfunction is nearly
universal in otitis media with effusion. As further evidence, ligation of the eustachian
tube in animals invariably leads to the formation of a persistent middle ear effusion
(MEE). Once the acute inflammation and bacterial infection have resolved, a failure
of the middle ear clearance mechanism allows middle ear effusion to persist. Many
factors have been implicated in the failure of the clearance mechanism, including
ciliary dysfunction; mucosal edema; hyperviscosity of the effusion; and, possibly, an
unfavorable pressure gradient.

Otitis media with effusion does not necessarily follow acute otitis media. Theories to
explain the development of middle ear effusion in this case include the secretion of
fluid from inflamed middle ear mucosa. This theory proposes that the middle ear
mucosa is sensitized by previous exposure to bacteria, and continued antigenic
challenge from occasional reflux induces the production of the effusion. Again,
multiple studies have revealed that the same flora of bacteria is present in otitis
media with effusion as in acute otitis media; these findings indicate that this effusion
is not sterile, as was once believed.

Cleft palate

Otitis media with effusion is ubiquitous in children who have a cleft palate. The cause
is simply the lack of proper insertion of the tensor veli palatini muscle in the soft
palate. The muscle is, therefore, unable to open the eustachian tube on swallowing
or wide mouth opening. A functional obstruction of the tube results.[7]

Etiology
The same flora found in acute otitis media can be isolated in otitis media with
effusion.[8] With otitis media with effusion, the inflammatory process has clearly
resolved, and the volume of bacteria has decreased. However, because of the
similarity of these 2 conditions, reviewing the pathogenic organisms in acute otitis
media is worthwhile.

Common pathogens

The most common bacteria in acute otitis media, in order of frequency, are
Streptococcus pneumoniae, Haemophilus influenzae, and Moraxella catarrhalis.
These pathogens are also the most frequent organisms associated with sinusitis and
pneumonia. Together, these pathogens account for 85% of acute ear infections, as
follows:

 S pneumoniae is found in 35% of cases, and the prevalence does not seem to
vary with age; the serotypes most commonly isolated, in order of frequency,
are 19, 23, 6, 14, and 3
 H influenzae is found in 20% of cases; of these cases, 25-45% involve beta-
lactamase production, with a clear trend of increasing resistance
 M catarrhalis is found in 4-13% of cases of acute otitis media, with a great
frequency in winter and autumn; of these cases, 70-100% involve beta-
lactamase production

Additional bacterial pathogens include Streptococcus pyogenes, Staphylococcus

aureus, gram-negative enteric bacteria, and anaerobes. When an effusion is present
for longer than 3 months, Pseudomonas species predominate.

In 30% of examined tympanocentesis specimens, microorganisms are not found. In

a meta-analysis of results from 10 studies of tympanocentesis in acute otitis media
from the early 1990s, 29 (4.4%) of 663 patients had a virus that could be isolated. In
other more recent studies, viruses have been isolated in conjunction with bacteria in
15-20% of cases of acute otitis media. Respiratory syncytial virus (RSV) and
influenza virus were the most frequent.
The relation between viral and bacterial infection is controversial. Because viruses
have been identified as the sole infective agents in only 4-6% of middle ear aspirates
obtained from children with acute otitis media, viruses may promote bacterial
superinfection by impairing eustachian tube function.

The only difference with the pathogens in otitis media with effusion compared with
acute otitis media is that the frequency of S pneumoniae is not as high, and H
influenzae and M catarrhalis are moderately more common.

Predisposing factors

Environmental factors, age, and disruption of the eustachian tube have been
associated with otitis media with effusion.

Environmental factors

Besides the actual pathogens, environmental factors have been shown in numerous
epidemiologic studies to be strongly associated with increased prevalence of otitis
media with effusion. These factors include bottle feeding, feeding while supine,
having a sibling with otitis media, attending daycare, having allergies to common
environmental entities, having a lower socioeconomic status, living in a home in
which people smoke, and having a parental history of otitis media with effusion.[9,
10]

Age

Age is clearly another predisposing factor in the development of otitis media with
effusion. In infants, the eustachian tube has a nearly horizontal orientation (relative
to the ground) and develops the 45° angle (as in adults) after several years. In
addition, the size and shape of the eustachian tube at birth, unlike those in adults,
are unfavorable for ventilation of the middle ear.

Multiple studies of children in Denmark revealed that by the time children were aged
1 year, tympanograms were either type B (flat) or type C (negative pressure) in 24%
of their ears. Improvement occurred in the spring and summer, whereas worsening
was more common in the winter. Type B tympanograms peaked in children aged 2-4
years, and, as expected with the prevalence of otitis media with effusion, decreased
in children older than 6 years.

In adults, recognizing unilateral otitis media with effusion is crucial.[40] This entity
must be considered a nasopharyngeal mass until definitively proven otherwise.

Eustachian tube disruption

Disruptions in the normal opening of the eustachian tube orifice in the nasopharynx
are also associated with an increased prevalence of otitis media with effusion. These
commonly occur in patients who have a cleft palate and in children with Down
syndrome and other disorders affecting the palate. In addition, the decreased
mucociliary clearance and higher viscosity of mucus in cystic fibrosis have been
hypothesized to account for a higher prevalence of otitis media with effusion in
patients with these conditions.

Diet

A study by Choi et al suggested that a high-fat diet is a risk factor for otitis media
with effusion in children but that body mass index category; protein, water, and
sodium intake; and distribution of carbohydrate intake are not.[11]

Other

In contrast to the Choi study, however, a study by Kaya et al suggested that in

children, a link exists between chronic otitis media with effusion (OME) and the
presence of overweight or obesity. The report, which looked at weight-for-height
percentiles in 60 children with chronic otitis media with effusion (OME) and 86
controls, aged 2-10 years, found a higher prevalence of overweight and obesity in
the otitis media group, indicating that overweight and obesity may increase the risk
for chronic otitis media with effusion (OME), or vice versa.[39]

A study by Walker et al found that preschool children with chronic otitis media with
effusion tended to be characterized by nasal obstruction, snoring (always or often), a
greater number of hours per week in daycare, frequent colds, siblings in whom
tympanostomy tube placement had been performed, long labor, and early
introduction of cow’s milk. However, Asian ethnicity and the existence of older
siblings were associated with a lower risk of the condition.[12]

Epidemiology
In the United States, middle ear infections are the most common medical problem in
infants and children of preschool age, and they are the most frequent primary
diagnoses in children younger than 15 years who are examined at physicians'
offices.

Clinical guidelines from a joint commission of specialties document that screening

surveys of healthy children between infancy and age 5 years show a 15-40% point
prevalence in middle ear effusion (MEE). Furthermore, among children examined at
regular intervals for 1 year, 50-60% of child care attendees and 25% of school-aged
children were found to have a middle ear effusion at some point during the
examination period, with peak incidence during the winter months.

Between 84% and 93% of all children experience at least 1 episode of acute otitis
media (AOM). Furthermore, approximately 80% of children have had an episode of
otitis media with effusion (OME) when younger than 10 years. At any given time, 5%
of children aged 2-4 years have hearing loss due to a middle ear effusion that lasts 3
months or longer. The prevalence of otitis media with effusion is highest in those
aged 2 years or younger, and it sharply declines in children older than 6 years.
A 7-year study of otitis media conducted in the greater Boston area revealed the
frequency of acute otitis media. In children younger than 1 year, 62% had at least 1
episode of acute otitis media, and 17% had 3 or more episodes. In children younger
than 3 years, 83% had at least 1 episode of acute otitis media, and 46% had 3 or
more episodes.

In another study, 12.8 million episodes of otitis media occurred in children younger
than 5 years. Of children younger than 2 years, 17% had recurrent disease. Because
at least 30% and as many as 45% of children with acute otitis media had otitis media
with effusion after 30 days, and 10% had otitis media with effusion after 90 days, at
least 3.84 million episodes of otitis media with effusion occurred the year studied; of
these, 1.28 million episodes persisted at least 3 months.

Racial and sexual differences in incidence

The prevalence of otitis media with effusion is higher in Native Americans,

particularly Navajo and Eskimo peoples, than in other races. The reason for the
higher frequency in these populations has been attributed to a number of factors, but
no findings have confirmed the most likely etiologies. No difference in prevalence
rates between white and black populations exists.

Although no statistically significant difference exists between the sexes in terms of

incidence or prevalence, some findings suggest that males may have a slightly
higher frequency.

Prognosis
Otitis media with effusion (OME) is the leading cause of hearing loss in children. This
condition is associated with delayed language development in children younger than
10 years, and the loss is usually conductive, with an average air conduction
threshold of 27.5 decibels (dB), but otitis media with effusion has also been
associated with sensorineural hearing loss. Both prostaglandins and leukotrienes
have been found in high concentrations in middle ear effusions (MEE), and their
ability to cross the round window membrane has been demonstrated. Chronic
exposure to these metabolites of arachidonic acid may cause a temporary and
sometimes permanent sensorineural hearing loss.

In general, the prognosis for otitis media with effusion is good. Most episodes
spontaneously resolve without intervention, and many resolve undiagnosed. Still, 5%
of children who are not treated surgically have persistent otitis media with effusion at
1 year. Surgical intervention significantly improves the clearance of middle ear
effusion in this population, but the benefits for speech and language development as
well as quality of life remain controversial.
Following spontaneous tube extrusion, 20-50% of patients will have a recurrence of
otitis media with effusion, potentially requiring the replacement of pressure
equalization tubes (PETs) and, in most cases, simultaneous adenoidectomy.

Complications

Because otitis media with effusion lacks the inflammation found in acute otitis media,
it has few complications. As noted above, the most important complications and
reasons for treatment are hearing loss and potential language development delay.
Nonetheless, persistent effusion provides an exceptional environment for the
proliferation of bacteria. Therefore, recurrent acute otitis media (RAOM) with its
potential complications is also a threat.

The complications of the various surgical interventions are discussed in Treatment.

Patient Education
On a primary care level, ongoing education of primary care providers (PCPs) and
pediatricians is important and often falls into the responsibility of the
otolaryngologists (ENTs). Equally important is educating parents and teachers to be
aware of the potential for delayed language development in affected children. These
measures make early intervention possible if problems are noted.

Prevention

The following modifications may help decrease the frequency of otitis media with
effusion (OME):

 Avoiding secondhand smoke

 Breastfeeding whenever possible
 Avoiding feeding, either by breast or bottle, while completely supine
 Avoiding exposure to a large number of children, particularly in daycare
centers
 Avoiding exposure to children who are known to be affected

Dietary and activity considerations

Breastfed babies have a lower risk of acute otitis media (AOM) and otitis media with
effusion. Moreover, placing a child in the supine position while bottle feeding
substantially increases the risk of otitis media with effusion, presumably because it
contributes to eustachian tube reflux during swallowing.

During active otitis media with effusion, activity need not be limited. However,
because of potential hearing loss, children may wish to sit closer to the teacher in
their classrooms.
Presentation
History
Otitis media with effusion (OME) nearly always follows acute otitis media (AOM) as it
resolves. However, middle ear effusion (MEE) can be present without preceding
acute otitis media, as in the case of serous otitis media after barotrauma.

Neither the affected children nor their parents describe reports referable to a middle
ear effusion in 40-50% of documented cases of otitis media with effusion. The most
common report involving children comes from parents who are concerned with signs
consistent with decreased hearing. Parents may notice that the television volume is
too loud and that the child sits close to the television, does not respond when called
(new onset), and often asks "What?" However, these signs are not consistent and do
not reliably indicate potential middle ear effusion.

Adults with otitis media with effusion report aural fullness and/or pressure, an ear
being plugged, or decreased hearing. Reports of pain are rare.

Associated findings during history taking may include a recent upper respiratory tract
infection (URTI), a recent plane trip or scuba diving trip, or current environmental
allergies.

Physical Examination
Otoscopic findings of inflammation in acute otitis media (AOM) may include
decreased mobility of the tympanic membrane (which has a bulging contour) that is
manifested by difficulty in assessing the ossicular landmarks, yellowness and/or
redness with hypervascularity, purulent middle ear effusion (MEE), and,
occasionally, bullae. This appearance clearly contrasts with that of otitis media with
effusion.

Findings that suggest the presence of otitis media with effusion include observable
air-fluid levels (which may be vertically oriented), serous middle ear fluid, and a
translucent membrane with diminished mobility. Extensive inflammation and purulent
middle ear effusion should not be evident.

Otitis media with effusion can also be associated with negative pressure in the
middle ear. This negative pressure is suggested by the prominence of the lateral
process, a more horizontal orientation of the malleus, and movement only with
negative pneumatoscopy.
Occasionally, tonsillar hypertrophy can accompany findings of otitis media with
effusion. More commonly, adenoid hypertrophy is present, especially in patients with
prolonged or recurrent condition.

Additional findings may include turbinate bogginess, postnasal drip, rhinorrhea, and
watery and/or erythematous eyes consistent with a concurrent upper respiratory tract
infection (URTI) or environmental allergies.

DDx
Diagnostic Considerations
In adults, recognizing unilateral otitis media (OME) with effusion is crucial. This entity
must be considered a nasopharyngeal mass until definitively proven otherwise. Note
that the single greatest pitfall in otitis media with effusion is the failure to fully
evaluate a potential nasopharyngeal mass in an adult patient who has recurrent
unilateral otitis media with effusion. At minimum, indirect mirror examination or
flexible nasopharyngoscopy should be performed. Imaging studies and possibly
even biopsies may be indicated.

Other pitfalls include the failure to note hearing loss and the failure to recognize a
potential delay in language development in children; these failures could have a
lasting effect in the patient.

The following are conditions that should be considered when evaluating patients with
suspected otitis media with effusion:

 Benign nasopharyngeal masses

 Nasopharyngeal carcinoma
 Acute otitis media (AOM)
 Adenoid hypertrophy
 Congenital defects affecting the eustachian tube and its egress
 Ciliary dyskinesia
 Immunoglobulin G (IgG) subclass deficiencies

Differential Diagnoses
 Eustachian Tube Function
 Malignant Tumors of the Nasal Cavity
 Malignant Tumors of the Temporal Bone
 Middle Ear Function
 Middle Ear, Eustachian Tube, Inflammation/Infection
 Myringitis (Middle Ear, Tympanic Membrane, Inflammation)
 Patulous Eustachian Tube
 Reconstructive Surgery for Cleft Palate
  Sinonasal Manifestations of Cystic Fibrosis

Workup

Workup
Approach Considerations
Traditionally, laboratory tests have rarely been used in the workup and diagnosis of
otitis media with effusion (OME) unless another process is suspected. History taking
and physical examination are sensitive and specific enough to facilitate accurate
diagnosis and treatment of the disease. Obtaining cultures is not routine for this
condition but is in tympanocentesis.

In rare cases, the erythrocyte sedimentation rate (ESR) is obtained to rule out bony
destruction, or the complete blood cell (CBC) count is assessed to rule out active
infection.

In acute otitis media (AOM) histologic studies of the temporal bone reveal vascular
dilatation and hyperplasia, inflammation and metaplasia of the mucosa, gland
formation, edema, and infiltration with a mononuclear cell population. These same
findings may be present, to a lesser degree, in otitis media with effusion.

Radiologic Studies
Plain radiography of the mastoid was once used effectively to screen for otitis media
with effusion (OME), but this imaging study is now rarely used for this purpose, given
the sensitivity of history and physical examination in helping diagnose the disease.

CT scanning

Computed tomography (CT) scanning is extremely sensitive and not needed for
diagnosis. However, CT scanning is important in attempting to rule out potential
complications of otitis media (eg, mastoiditis, sigmoid sinus thrombosis, erosion of
bone with intracranial extension) or unusual lesions (eg, cholesteatoma). This
imaging modality is particularly important in unilateral otitis media with effusion when
a nasopharyngeal or eustachian tube mass must be ruled out.

MRI

Magnetic resonance imaging (MRI) is particularly useful in the workup for soft-tissue
masses that may be contributing to middle ear effusions (MEE) because of its
superior ability to delineate borders within soft tissues and to help determine the
extent of potential intracranial extension (often useful in nasopharyngeal masses). In
addition, MRI and its closely associated variants magnetic resonance venography
(MRV) and magnetic resonance arteriography (MRA) demonstrate complications
such as thrombosis of the intracranial sinuses very well. However, when intracranial
extension is present, either from invasion from the nasopharynx or the temporal
bone, CT scanning helps to define the bony anatomy more specifically and should
be used in conjunction with MRI.

Tympanometry
Tympanometry is perhaps the most useful of all tests in association with otitis media
with effusion (OME). This test reveals a type B result in 43% of cases of otitis media
with effusion and a type C result in 47% of cases.

Previously, compared with myringotomy, a type B tympanogram was an imperfect

measure of otitis media with effusion, with 81% sensitivity and 74% specificity.
Studies later than 2001 have shown a higher rate of sensitivity and specificity, both
around 90%. This is likely because of improvements in the technology used.

This test is particularly useful in small children whose external auditory canals may
be too small or too collapsible to permit adequate visualization of the tympanic
membrane. However, in those younger than 7 months, tympanometry is unreliable
because of excessive compliance of the external auditory canal. The 2003 Agency
for Healthcare Research and Quality (AHRQ) evidence report states that
tympanometry results in children older than 4 years are reliable.

Tympanometry is a cost-effective adjunct to physical examination. Several studies

have compared this test with pneumatic otoscopy in terms of accuracy in detecting
middle ear effusion when compared with the criterion standard of myringotomy.
Nearly all studies show that pneumatic otoscopy is slightly more sensitive, at around
93%, but they differ on specificity, showing rates from 50% to 88%. Many of the
conclusions in these protocols stated that the greatest use for tympanometry is in
aiding the clinician in ruling out middle ear effusion (MEE) for what appears to be an
immobile tympanic membrane on examination.

Language Testing
Language testing has also been advocated in the clinical practice guidelines for
children with hearing loss (pure tone average greater than 20 dB HL on
comprehensive audiometric evaluation). Testing for language delays is important,
because communication is integral to all aspects of human functioning. Young
children with speech and language delays during the preschool years are at risk for
continued communication problems and later delays in reading and writing.
Tympanocentesis and Myringotomy
Tympanocentesis involves the aspiration of effusion from the middle ear. This
procedure can be performed as an office procedure, even in small children, if
necessary. Tympanocentesis can serve as both a therapeutic procedure and a
diagnostic procedure.[13] The therapy consists of the removal of a middle ear
effusion (MEE) that can impair hearing or cause a sensation of aural fullness.

The criterion standard for documentation of a middle ear effusion is myringotomy,

which has the advantage of increased exposure and better suctioning relative to
tympanocentesis.[14] The primary disadvantage is a larger incision with a greater,
albeit small, chance of persistent perforation or otorrhea.

Treatment
Overview of Medical and Surgical Approaches
In general, inpatient care for otitis media with effusion (OME) is not required unless
complications that threaten the stability of the patient's condition are suspected.
Even surgical intervention with pressure equalization tubes (PETs) and
adenoidectomy is typically completed in ambulatory surgery settings.

A number of medical interventions have been suggested for the treatment of otitis
media with effusion, all with controversial but overall poor results. Historically, if a
middle ear effusion (MEE) persisted for 3 months, surgical intervention was
indicated. This dogma has been revised.

Autoinflation

Several investigators have reported mixed results when attempting to determine if

autoinflation, compared with no intervention, improves effusion clearance rates. The
ambiguity in the data may be a result of great variability in autoinflation methods
and/or noncompliance in patients. In a meta-analysis of findings from 6 randomized
controlled studies, results did reveal a benefit with the use of nasal balloons for
autoinflation in children.

An open, pragmatic, randomized trial by Williamson et al also supported the efficacy

of autoinflation, finding that in children with otitis media with effusion, it cleared
effusions and improved symptoms. The study included 320 children aged 4-11
years, who were treated either with a combination of autoinflation (three times per
day for 1-3 months) and usual care or with usual care alone. The investigators
reported that at 1 and 3 months, the rate of normal tympanograms was higher in
children in the autoinflation group. The study also found greater improvement in ear-
related quality of life, in children and parents, in the autoinflation group.[15]

Consultations

An otolaryngologist should be consulted whenever the primary care physician (PCP)

is concerned about persistent conductive hearing loss in children, especially those
with signs of language development delay.

In addition, an otolaryngologist (ENT) should be consulted if the disease is recurrent,

if the appropriate medical therapies available to the primary care physician are
exhausted, and/or if the criteria for surgical intervention have been met.

An allergist, audiologist, and/or a speech therapist may be consulted, when

appropriate. In select cases, an immunologist may be consulted for the workup for a
possible immunocompromised state.

Modification of OME Risk Factors

To the author's knowledge, no randomized controlled trials have been performed to
assess whether a modification of risk factors for otitis media with effusion decreases
its prevalence. However, massive amounts of epidemiologic evidence suggest that
modification of these risk factors is a reasonable primary care intervention.

The following modifications may help:

 Avoiding secondhand smoke

 Breastfeeding whenever possible
 Avoiding feeding, either by breast or bottle, while completely supine
 Avoiding exposure to a large number of children, particularly in daycare
centers
 Avoiding exposure to children who are known to be affected
 Avoiding known allergens

Kouwen and Dejonckere published a study that demonstrated a 40% reduction in the
prevalence of otitis media with effusion in children from the Netherlands who
routinely (at least weekly) chewed gum.[16] Presumably, one hypothesis is that otitis
media with effusion is caused by the increased eustachian tube function secondary
to palatal muscle action.

Pharmacotherapy
Pharmacologic management of otitis media with effusion (OME) includes
administration of antimicrobial agents, steroids, antihistamines and decongestants,
and mucolytics. However, an international consensus conference of the 2017
International Federation of Oto-rhino-laryngological Societies Congress
recommended against the treatment of otitis media with effusion (OME) with
steroids, antibiotics, decongestants, or antihistamines, citing concerns regarding side
effects and cost, as well as a lack of evidence for long-term therapeutic
effectiveness.[38]

Antimicrobial agents

Because otitis media with effusion demonstrates viable pathogenic bacteria,

treatment with appropriate antibiotics has been considered reasonable, albeit with
evidence showing only short-term benefit.[17]

Studies of erythromycin, sulfisoxazole, amoxicillin, amoxicillin-clavulanate, and

trimethoprim-sulfamethoxazole have demonstrated clearance rates faster than those
of a placebo, although the difference is barely statistically significant in most of these
trials.

A large meta-analysis of findings from 10 blinded, randomized controlled trials

involving 1041 children with otitis media with effusion revealed that resolution of
middle ear effusion (MEE) was significantly more likely in the patients treated with
antimicrobials than in those treated with placebo or those receiving no treatment.
The difference was noted at short-term (2- to 5-wk) follow-up. The findings of 2 other
meta-analyses did not demonstrate a difference between antimicrobials and placebo
with 6- to 11-week follow-up period.

When the otitis media with effusion becomes chronic (3 mo), the effectiveness of
antimicrobials diminishes, although this finding is controversial.

Studies published between 2002 and 2004 and cited by the clinical practice
guidelines for otitis media with effusion also demonstrate clearance of middle ear
effusion with antibiotics; however, they also show rapid and frequent recurrence.

A study by Roditi et al indicated that in the United States, 32% of pediatric

ambulatory visits for otitis media with effusion resulted in administration of oral
antibiotics, even when patients had no acute infection, with antibiotics being given
most often in emergency departments.[18]

Steroids

In 3 placebo-controlled randomized clinical trials, oral steroids alone did not improve
otitis media with effusion clearance within 2 weeks of treatment. When oral steroids
are combined with antibiotics, the rate of clearance of middle ear effusion does not
improve compared with the rate with antibiotics alone. A couple of small studies of
topical nasal steroid sprays (vs placebo) have demonstrated fewer effusions at 4 and
8 weeks, as well as improved middle ear pressure at 12 weeks. Empirical evidence
indicates that these medications show promise.
To the author's knowledge, only one randomized study has been published
comparing intranasal steroids (beclomethasone) and antibiotics to antibiotics
alone.[19] This study demonstrated no statistically significant difference between the
2 arms. A 2011 meta-analysis confirmed these findings.[20]

Another study found that topical intranasal steroids, alone or in combination with
antibiotics, have no long- or short-term benefit in the management of children with
otitis media with effusion.[21]

Williamson et al found that topical intranasal corticosteroids are very unlikely to be

effective for treating otitis media with effusion.[22] In a double-blind, randomized,
placebo-controlled trial in 207 children aged 4-11 years with persistent bilateral otitis
media with effusion, children received either mometasone, 50 mcg in each nostril, or
placebo spray once daily for 3 months. Tympanometric clearance in one or both ears
at 1, 3, and 9 months was 40.6%, 58.1%, and 55.6%, respectively, in the steroid
group; in the placebo group, it was 44.9%, 52.3%, and 65.3%, respectively.[22]
Absolute risk reduction at 1 month was -4.3.

Antihistamines and decongestants

In the largest study to date, Cantekin and others randomly assigned 553 children
with chronic otitis media with effusion (COME) to receive an
antihistamine/decongestant or placebo and found no difference in the clearance
rates of the effusion.[23] A 2011 meta-analysis confirmed these findings.[24] That
antihistamines increase the viscosity of secretions may account for this finding. The
viscosity of chronic otitis media with effusion is often substantial; thus, it is aptly
termed glue ear in these cases. This condition can also manifest as a serous
effusion.

However, nasal obstruction, rhinorrhea, and sinusitis often accompany otitis media,
and antihistamines and decongestants may be considered for the relief of these
associated symptoms. This is particularly true if the inciting cause is allergies.
Antihistamines, as the name suggests, prevent the degranulation of mast cells and
subsequent release of histamine, which can lead to mucosal engorgement with
resultant increase in nasal obstruction and an increase in the production of mucus.

Mucolytics

A large, randomized, controlled study of 430 children revealed that clearance rates
for otitis media with effusion did not significantly improve with mucolytics versus
placebo. Findings of 2 smaller trials of other mucolytics confirmed this result.

Indications for Surgical Intervention

Surgery has become the most widely accepted therapeutic intervention for persistent
otitis media with effusion (OME), and it is clearly effective. The interventions include
myringotomy with or without tube insertion, adenoidectomy, or both. Tonsillectomy
has been shown to be of little benefit as a primary treatment of otitis media with
effusion.

The indications for surgical intervention remain controversial. As with all surgery, the
benefits of intervention must outweigh the risks.

Previously, surgical intervention was advocated if fluid persisted beyond 3 months.

However, 2 well-conducted long-term studies showed that in the absence of a
significant hearing loss, children who were only observed compared with those
children who received pressure equalization tubes (PETs) had no difference in
quality of life or overall hearing, speech, and language abilities. Therefore, in the
presence of hearing thresholds better than 20 dB, observation is an option. However,
only 30% of patients who have otitis media with effusion after 3 months duration will
clear that effusion over the next 12 months; therefore, ongoing monitoring of hearing
levels is required.

Again, most cases of otitis media with effusion resolve spontaneously, and such
spontaneous resolution is more common in the spring and summer. Thus, a
conservative approach is often warranted at these times of the year; whereas, in fall
and winter, exacerbations are more common, and surgical intervention is likely to
yield better control.

Certain changes to the tympanic membrane may mandate pressure equalization

tube insertion despite normal hearing. These conditions include posterosuperior
retraction pockets, ossicular erosion, adhesive atelectasis, and retraction pockets
that accumulate keratin debris. Ongoing surveillance is mandatory, because the
frequency of structural damage increases with effusion duration.

For patients with hearing loss and otitis media with effusion, a loss of 40 dB or
greater is felt to be an absolute indication for pressure equalization tube insertion. A
loss in the range of 21-40 dB is a relative indication with a very low threshold for
placement.

Myringotomy
This section will briefly review myringotomy and aspiration of effusion and
myringotomy with pressure equalization tube (PET) insertion.

Myringotomy and aspiration of effusion

When performed alone without the placement of pressure equalization tubes, this
procedure has proved disappointing in long-term follow-up in children. Gates and
others have shown that when myringotomy is performed with placement of pressure
equalization tubes, there was improvement hearing, duration of middle ear effusion
(MEE), time to recurrence, and need for repeated procedures.
Myringotomy and aspiration may be more a reasonable treatment in adults who can
undergo the procedure in the office. The benefit is that immediate improvement in
hearing and symptoms of aural fullness and pressure are possible. The drawback is
that the incision usually heals within 1 week, whereas the underlying problem of
eustachian tube dysfunction takes longer to resolve (6 wk on average); therefore,
recurrences are common.

Myringotomy and aspiration is useful to treat patients with moderate to severe

hearing loss as they recover normal middle ear function. A 20-25 dB conductive
hearing loss added to their underlying loss may render hearing aids or other coping
devices or strategies inadequate.

Myringotomy with PET insertion

Introduced in 1954 by Armstrong, this intervention has become the criterion standard
and most common therapy for chronic otitis media with effusion (COME). Improved
hearing and decreased rates of acute otitis media (AOM) are absolute benefits of
myringotomy with placement of pressure equalization tubes; these have been
documented multiple times. Typically, the tubes self-extrude 9-12 months after
placement.

Pressure equalization tubes are available in a variety of sizes, shapes, and

materials. All are designed to permit ventilation of the middle ear and mastoid
system. Prolonged aeration of the middle ear has been shown to reverse the
mucosal hyperplasia and metaplasia that accompany otitis media with effusion.

Complications

The overall complication rate after placement of pressure equalization tubes is about
11%. Persistent otorrhea is the most common complication, occurring in 15% of
patients and persisting as long as 1 year in 5%. Second in frequency is
tympanosclerosis, which is not likely to be clinically significant unless it is extensive.

Persistent perforation is the third most common complication. Although its exact
frequency is unknown (estimates approximate 2%), persistent perforation increases
markedly if the pressure equalization tubes remain in place longer than 18 months.
This complication is also known to increase with the placement of tympanostomy
tubes (T-tubes) that are designed to stay in the tympanic membrane longer than the
typical grommet tube.[25, 26, 27] They can stay in place for years and are more
commonly used for the patient with recurrent or chronic otitis media that has failed to
improve after the placement of grommet tubes.

Other potential complications include granulation tissue formation, cholesteatoma,

and sensorineural hearing loss.

Clinical guidelines summarize a number of studies and state that tympanostomy

tubes are recommended for initial surgery, because randomized trials show a mean
62% relative decrease in effusion prevalence and an absolute decrease of 128
effusion days per child during the next year. Hearing levels improve by a mean of 6-
12 dB while the tubes remain patent.
A report on 248 pediatric patients who received tympanostomy tubes and
postoperative otic drop therapy found that tube occlusion occurred most frequently in
patients with middle ear fluid and in those with longer time to postsurgical follow-up.
In the study, a retrospective medical record review, Conrad et al determined that at
first follow-up, one or both tubes were occluded in 10.6% of patients. Children with
no serous fluid were found to be 3 times more likely to have unobstructed tubes than
were children with fluid. It was also found that the chance of occlusion increased in
relation to the amount of time that existed between surgery and follow-up.[28, 29]

In December 2015, an otic suspension of ciprofloxacin was approved by the US

Food and Drug Administration (FDA) for pediatric patients with bilateral otitis media
with effusion undergoing tympanostomy tube placement. In a double-blind,
randomized, controlled clinical trial, 83 children (mean age 2.8 y) were administered
intraprocedural otic ciprofloxacin drops or placebo or sham treatment, with
significantly fewer treatment failures associated with ciprofloxacin than with either the
placebo or sham therapies.[30, 31]

Adenoidectomy
Although adenoidectomy was once the principal treatment for otitis media with
effusion (OME), easy and low-risk placement of pressure equalization tubes (PETs)
is now favored.

Three rationales exist for the removal of the adenoids in the treatment of otitis media
with effusion and are discussed below. Whatever the rationale used, adenoidectomy
alone was found to be nearly as effective as placement of pressure equalization
tubes for treatment of otitis media with effusion. When adenoidectomy is performed
with placement of pressure equalization tubes, the frequency of recurrent disease,
disease-free interval, and duration of disease all improved, compared with the use of
either procedure alone.

Complications of adenoidectomy include bleeding (0.4%), velopalatal insufficiency

(usually temporary), and a patulous eustachian tube.

Removal because of enlargement

This theory states that large adenoids occlude the nasopharynx and choanae and
lead to excessive nasopharyngeal pressure during swallowing. This potentiates
eustachian tube reflux. However, multiple studies have revealed that the result of
adenoidectomy is independent of adenoid size. This finding suggests that processes
other than simple adenoid mass are involved.

Removal for improvement of eustachian tube function

Improvement in the equilibration of positive middle ear pressure after adenoidectomy

has been documented. In addition, extremely large adenoids may physically occlude
the eustachian tube orifice, although Bluestone and others have shown that this is
rare. The obstruction is nearly always functional.[3]

Removal of a potential source of inflammation and infection at the

eustachian tube orifice

The third and most recent rationale for adenoidectomy is to remove a potential
inflammatory source and the presence of infection at the orifice of the eustachian
tube. When performed correctly, adenoidectomy can be used to create a smooth
nasopharyngeal mucosa, which decreases the colonization of bacteria that can
occur in the crypts of adenoid tissue.

Long-Term Monitoring
No standard of care for the follow-up of patients with otitis media with effusion (OME)
has been established.

The author follows up with the patient 3 weeks after the placement of the tubes and
then every 6 months thereafter, until the tubes extrude or are removed. Additional
appointments are made as needed.

Patients are instructed that if more than 2 episodes of otorrhea occur before the 6-
month follow-up is scheduled, they should see their otolaryngologist (ENT) instead of
or in addition to their primary care physician (PCP). The author recommends the
removal of pressure equalization tubes (PETs) that have not spontaneously extruded
between 18-24 months after placement due to the increasing risk of persistent
tympanic membrane perforation. That rule generally applies to the first set of
grommet-style tubes.

Patients should see their primary care physician, at the physician's discretion, during
times of active disease, at regular intervals for well visits, and on an as-needed basis
for further problems or questions.

The otolaryngologist should monitor patients until the conditions resolves with
medical or surgical intervention. Thereafter, if the patient's hearing is normal, the
primary physician can provide care. If a documented hearing loss is present, it
should be reevaluated as the severity and type dictate.

A multidisciplinary team should rigorously follow and aggressively treat language-

related developmental delays. Interventions should include the use of hearing aids, if
justified.

Guidelines
Guidelines Summary
Guidelines for the diagnosis and management of otitis media with effusion (OME)
have been issued by the following organizations:

 American Academy of Otolaryngology-Head and Neck Surgery Foundation

(AAO-HNSF) (2016)
 University of Michigan Health System (UMHS) (2013)
 National Institute for Health and Care Excellence (NICE) (2008)

In 2016, the AAO-HNSF released updated practice guidelines for the management
of OME which have been endorsed by the American Academy of Family Physicians
(AAFP).[32] The UMHS published an update to its 2007 guidelines in 2013.[33] The
guidelines from the NICE, published in 2008 and reaffirmed in 2011, are primarily
focused on surgical interventions.[34]

Screening and diagnosis

The 2016 AAO-HNSF recommendations for the diagnosis of OME include the
following[32] :

 Document the presence of middle ear effusion with pneumatic otoscopy

 Pneumatic otoscopy should be used to assess for OME in a child with otalgia
and/or hearing loss
 If the diagnosis is uncertain after performing pneumatic otoscopy,
tympanometry should be obtained
 Counsel parents of infants with OME who fail a newborn hearing screen
regarding the importance of follow-up to ensure that hearing is normal when
OME resolves and to exclude an underlying sensorineural hearing loss
(SNHL)
 Determine if the child is at increased risk for speech, language, or learning
problems because of baseline sensory, physical, cognitive, or behavioral
factors
 Children at high risk for developing otitis media with effusion—ie, those with
an increased likelihood due to developmental issues or a syndrome or
condition—should be screened for OME when the risk factor is diagnosed and
again between age 12 and 18 months
 Routine screening of children for OME who are not at risk and do not have
symptoms that may be attributable to OME, such as hearing difficulties,
balance (vestibular) problems, poor school performance, behavioral problems,
or ear discomfort, is not recommended

The 2013 UMHS guidelines recommend the combined use of otoscopy, pneumatic
otoscopy, and tympanometry when necessary to determine the presence of middle
ear effusion.[33]

The NICE guidelines note that concerns from parents, caregivers, or professionals
about features suggestive of OME should precipitate an initial assessment. In
addition, all children with Down syndrome or cleft palate should be assessed
regularly for OME. Features suggestive of OME include the following[34] :

 Hearing difficulty (for example, mishearing when not looking at the speaker,
difficulty in a group, asking for things to be repeated)
 Indistinct speech or delayed language development
 Repeated ear infections or earache
 History of recurrent upper respiratory tract infections or frequent nasal
obstruction
 Behavioral problems, particularly lack of concentration or attention, or being
withdrawn
 Poor educational progress
 Less frequently, balance difficulties (for example, clumsiness), tinnitus, and
intolerance of loud sounds

Treatment

The 2016 AAO-HNSF recommendations for treatment of OME include the

following[32] :

 Watchful waiting for 3 months from the date of effusion onset or, if the onset
date is unknown, 3 months from the date of diagnosis for children who are not
at risk for speech, language, or learning problems
 Medical therapy for OME—including systemic antibiotics, systemic steroids,
intranasal steroids, antihistamines, and decongestants—should be employed
only in exceptional circumstances
 An age-appropriate hearing test should be given if OME persists for more
than 3 months or should be administered to any at-risk child with OME
regardless of duration
 At 3- to 6-month intervals, reevaluate children with chronic OME until the
effusion is no longer present, significant hearing loss is identified, or structural
abnormalities of the eardrum or middle ear are suspected
 Tympanostomy tube insertion when surgery is performed in a child under age
4 years; adenoidectomy should not be performed unless an indication for
adenoid removal, such as nasal obstruction or chronic adenoiditis, is present
 Tympanostomy tube insertion, adenoidectomy, or both when surgery is
performed in a child aged 4 years or older

Children who, as mentioned above, may be at risk for speech, language, or learning
problems, according to the AAO-HNSF, include the following:

 Children with permanent hearing loss independent of OME

 Those with suspected or diagnosed speech and language delay or disorder
 Those with autism spectrum disorder or other pervasive developmental
disorders
 Children with syndromes (eg, Down syndrome) or craniofacial disorders that
include cognitive, speech, and language delays
 Those who are blind or have uncorrectable visual impairment
 Children with cleft palate, with or without an associated syndrome
 Children with developmental delay
In 2013, the AAO-HNSF released specific guidelines on use tympanostomy tube
insertion for children with otitis media that included the following
recommendations[35] :

 Tympanostomy tube insertion should not be performed in children with a

single episode of OME of less than 3 months' duration
 Bilateral tympanostomy tube insertion should be offered to children with
bilateral OME of more than 3 months' duration and documented hearing
difficulties
 Tympanostomy tube insertion may be considered in children with unilateral or
bilateral OME of more than 3 months' duration and symptoms that include
balance problems, poor school performance, behavioral problems, ear
discomfort, or reduced quality of life
 Children with chronic OME who do not receive tympanostomy tubes should
be reevaluated at 3- to 6-month intervals until the effusion is no longer
present, significant hearing loss is detected, or structural abnormalities of the
tympanic membrane or middle ear are suspected
 Tympanostomy tube insertion may be offered to at-risk children with unilateral
or bilateral OME that is unlikely to resolve quickly, as reflected by a type B
(flat) tympanogram or persistence of effusion for more than 3 months
 Educate caregivers of children with tympanostomy tubes regarding the
expected duration of tube function, recommended follow-up schedule, and
detection of complications
 Clinicians should prescribe topical antibiotic eardrops only, without oral
antibiotics, for children with uncomplicated acute tympanostomy tube otorrhea
 Encourage routine, prophylactic water precautions (use of earplugs or
headbands; avoidance of swimming or water sports) for children with
tympanostomy tubes

The NICE guidelines include the following recommendations[34] :

 Consider surgical intervention after bilateral OME and hearing loss have been
confirmed over a 3-month period and the impact of the hearing loss on a
child's developmental, social, or educational status is judged to be significant
 Insertion of ventilation tubes is recommended
 Adenoidectomy is not recommended in the absence of persistent and/or
frequent upper respiratory tract symptoms
 Autoinflation may be considered during the active observation period for
children with OME who are likely to cooperate with the procedure
 Hearing aids should be offered to children with persistent bilateral OME and
hearing loss as an alternative to surgical intervention if surgery is
contraindicated or not acceptable

The following treatments are not recommended for the management of OME,
according to the NICE guidelines:

 Antibiotics
 Topical or systemic antihistamines
 Topical or systemic decongestants
 Topical or systemic steroids
  Homeopathy
 Cranial osteopathy
 Acupuncture
 Dietary modification, including probiotics
 Immunostimulants
 Massage

Medication
Medication Summary
A consensus statement published in August 2000 defined an appropriate logarithm
for the medical treatment of acute otitis media (AOM) and recurrent acute otitis
media (RAOM).[36] Antimicrobials are the only medications that have been shown to
increase the rate of clearance of otitis media with effusion (OME) in randomized
controlled trials. However, these benefits are temporary at best.

Topical Nasal Steroids

Class Summary
Results of small trials have shown that nasal steroids speed the clearance of otitis
media with effusion (OME) and prevent its recurrence. A 2011 meta-analysis
confirmed these findings.[20] However, to the author's knowledge, no large
randomized trials have been performed to confirm this finding.

Fluticasone (Flonase)
Fluticasone is a topical corticosteroid spray that has anti-inflammatory effects on the
nasal mucosa and, presumably, on the nasopharynx, where the eustachian tube
orifice is located.

Antibiotics, Otic
Class Summary
An otic suspension may be used intraoperatively.

Ciprofloxacin otic (Otiprio)

Ciprofloxacin is an ototopical fluoroquinolone. This class of antimicrobial has a broad
spectrum of activity. Additionally, fluoroquinolones do not cause vestibular or
cochlear toxicity, recognized with aminoglycosides. The sustained-exposure
ciprofloxacin suspension (Otiprio) is indicated for pediatric patients with bilateral otitis
media with effusion undergoing tympanostomy tube placement. It is administered as
a single intratympanic dose of 0.1 mL (6 mg) into each affected ear, following
suctioning of the middle ear effusion.

Questions & Answers

Overview

What is otitis media with effusion (OME)?

What is the approach to treatment of otitis media with effusion (OME)?

How is otitis media with effusion (OME) distinguished from other forms of middle ear
infections?

What is the approach to workup and diagnosis of otitis media with effusion (OME)?

How frequently does otitis media with effusion (OME) occur following resolution of
acute otitis media (AOM)?

What is the classic theory of acute otitis media (AOM) pathogenesis?

What are alternative theories of acute otitis media (AOM) pathogenesis?

What is the possible pathogenesis of middle ear effusion (MEE) in otitis media with
effusion (OME)?

Why is otitis media with effusion (OME) ubiquitous in children with a cleft palate?

What are is the role of bacterial flora in the etiology of otitis media with effusion
(OME)?

What is the prevalence of bacterial pathogens in acute otitis media (AOM)?

How frequently are pathogenic agents found in tympanocentesis specimens of acute

otitis media (AOM)?
What is the relationship between viral and bacterial infection in the etiology of acute
otitis media (AOM)?

What is the difference in pathogens between otitis media with effusion (OME) and
acute otitis media (AOM)?

What factors are associated with increased risk for otitis media with effusion (OME)?

Which environmental factors increase the risk of developing otitis media with effusion
(OME)?

How does the prevalence of otitis media with effusion (OME) vary by age?

How does eustachian tube disruption affect the risk for otitis media with effusion
(OME)?

What role does diet play in the development of otitis media with effusion (OME)?

What are risk factors for otitis media with effusion (OME)?

What is the prevalence of middle ear infections among children in the US?

What is the incidence of middle ear effusion (MEE), acute otitis media (AOM), and
otitis media with effusion (OME) among children in the US?

How does the prevalence of otitis media with effusion (OME) vary by race?

How does the prevalence of otitis media with effusion (OME) vary by sex?

What are possible complications of otitis media with effusion (OME)?

What is the prognosis of otitis media with effusion (OME)?

How frequently does otitis media with effusion (OME) recur?

What are the most important reasons for treatment of otitis media with effusion
(OME)?

What information about otitis media with effusion (OME) should primary care
providers (PCPs) and parents receive?

What can decrease the frequency of otitis media with effusion (OME)?

What is the risk for otitis media with effusion (OME) among breastfed infants?

Presentation

What is the relationship between otitis media with effusion (OME), acute otitis media
(AOM), and middle ear effusion (MEE)?
What are the signs and symptoms of otitis media with effusion (OME)?

How can otoscopic findings differentiate acute otitis media (AOM) from otitis media
with effusion (OME)?

Which physical findings suggest otitis media with effusion (OME)?

DDX

How is unilateral otitis media with effusion (OME) diagnosed in adults?

What should be evaluated in children with otitis media with effusion (OME)?

Which conditions should be included in the differential diagnosis of otitis media with
effusion (OME)?

What are the differential diagnoses for Otitis Media With Effusion?

Workup

What is the role of lab testing in the diagnosis of otitis media with effusion (OME)?

What is the role of radiography in the evaluation of otitis media with effusion (OME)?

What is the role of CT scanning in the diagnosis of otitis media with effusion (OME)?

What is the role of MRI in the diagnosis of otitis media with effusion (OME)?

What is the role of tympanometry in the diagnosis of otitis media with effusion
(OME)?

At what age is tympanometry reliable for diagnosis of otitis media with effusion
(OME)?

What are the advantages to tympanometry for diagnosing otitis media with effusion
(OME)?

What is the role of language testing in the workup of otitis media with effusion
(OME)?

What is the role of tympanocentesis in the diagnosis and management of otitis media
with effusion (OME)?

What is the role of myringotomy in the workup of otitis media with effusion (OME)?

Treatment

When is inpatient care for otitis media with effusion (OME) indicated?
What is the role of medical interventions in the treatment of otitis media with effusion
(OME)?

What is the role of autoinflation in the treatment of otitis media with effusion (OME)?

What specialist consultations are needed in the treatment of otitis media with
effusion (OME)?

What is the role of risk modification in the management of otitis media with effusion
(OME)?

Which risk factor modifications are used to decrease the prevalence of otitis media
with effusion (OME)?

What is the efficacy of risk factor modification in decreasing otitis media with effusion
(OME) prevalence?

What are the pharmacologic treatment options for otitis media with effusion (OME)?

What is the role of antimicrobial agents in the treatment of otitis media with effusion
(OME)?

What is the role of steroids in the treatment of otitis media with effusion (OME)?

What is the role of antihistamines and decongestants in the treatment of otitis media
with effusion (OME)?

What is the role of mucolytics in the treatment of otitis media with effusion (OME)?

What are the surgical options for otitis media with effusion (OME)?

What are indications for surgical treatment of otitis media with effusion (OME)?

How frequently does otitis media with effusion (OME) have spontaneous resolution?

What conditions associated with otitis media with effusion (OME) require surgical
intervention?

When is pressure equalization tube insertion indicated for the treatment of otitis
media with effusion (OME)?

What is the role of myringotomy and aspiration of effusion in the treatment of otitis
media with effusion (OME)?

What is the role of myringotomy with pressure equalization tube (PET) insertion in
the treatment of otitis media with effusion (OME)?

What are complications of myringotomy with pressure equalization tube (PET)

insertion for the treatment of otitis media with effusion (OME)?
What is the efficacy of tympanostomy tubes for treatment of otitis media with effusion
(OME)?

What is the role of adenoidectomy in the treatment of otitis media with effusion
(OME)?

What are complications of adenoidectomy as a treatment for otitis media with

effusion (OME)?

What is the rationale for adenoidectomy as treatment for otitis media with effusion
(OME)?

What improves following adenoidectomy for otitis media with effusion (OME)?

How does adenoidectomy result in decreased colonization of bacteria in the

treatment of otitis media with effusion (OME)?

How frequently should patients be monitored following treatment of otitis media with
effusion (OME)?

What specific follow-up care is recommended for patients with otitis media with
effusion (OME)?

What is the role of the otolaryngologist in the follow-up of patients with otitis media
with effusion (OME)?

Guidelines

What are the American Academy of Otolaryngology-Head and Neck Surgery

Foundation (AAO-HNSF) recommendations for the diagnosis of otitis media with
effusion (OME)?

What are the National Institute for Health and Care Excellence (NICE) guidelines for
assessment of otitis media with effusion (OME)?

What are the American Academy of Otolaryngology-Head and Neck Surgery

Foundation (AAO-HNSF) recommendations for treatment of otitis media with effusion
(OME)?

What are the National Institute for Health and Care Excellence (NICE) treatment
guidelines for otitis media with effusion (OME)?

Which organizations have issued guidelines for the diagnosis and management of
otitis media with effusion (OME)?

What do the 2013 University of Michigan Health System (UMHS) guidelines

recommend for the diagnosis of middle ear effusion (MEE)?
According to the American Academy of Otolaryngology-Head and Neck Surgery
Foundation (AAO-HNSF) guidelines, which children may be at risk for speech,
language, and learning problems with otitis media with effusion (OME)?

What are the American Academy of Otolaryngology-Head and Neck Surgery

Foundation (AAO-HNSF) recommendations for tympanostomy tube insertion to treat
otitis media with effusion (OME)?

What treatments for otitis media with effusion (OME) are specifically not
recommended by the National Institute for Health and Care Excellence (NICE)
guidelines?

Medications

What is the efficacy of antibiotic therapy in the treatment of otitis media with effusion
(OME)?

Which medications in the drug class Antibiotics, Otic are used in the treatment of
Otitis Media With Effusion?

Which medications in the drug class Topical Nasal Steroids are used in the
treatment of Otitis Media With Effusion?

Contributor Information and Disclosures

Author

Thomas S Higgins, Jr, MD, MSPH Rhinologist and Associate in Otolaryngology-

Head and Neck Surgery, Kentuckiana Ear, Nose and Throat, PSC

Disclosure: Serve(d) as a speaker or a member of a speakers bureau for: Acclarent;

IntersectENT.

Specialty Editor Board

Francisco Talavera, PharmD, PhD Adjunct Assistant Professor, University of

Nebraska Medical Center College of Pharmacy; Editor-in-Chief, Medscape Drug
Reference

Disclosure: Received salary from Medscape for employment. for: Medscape.

Chief Editor

Arlen D Meyers, MD, MBA Professor of Otolaryngology, Dentistry, and Engineering,

University of Colorado School of Medicine

Arlen D Meyers, MD, MBA is a member of the following medical societies: American
Academy of Facial Plastic and Reconstructive Surgery, American Academy of
Otolaryngology-Head and Neck Surgery, American Head and Neck Society

Disclosure: Serve(d) as a director, officer, partner, employee, advisor, consultant or

trustee for: Cerescan;RxRevu;Cliexa;The Physicians Edge;Sync-n-
Scale;mCharts<br/>Received income in an amount equal to or greater than $250
from: The Physicians Edge, Cliexa<br/> Received stock from RxRevu; Received
ownership interest from Cerescan for consulting; .

Acknowledgements

Gregory C Allen, MD Assistant Professor, Department of Otolaryngology-Head and

Neck Surgery, University of Colorado School of Medicine

Disclosure: Nothing to disclose.

Richard D Thrasher III, MD Private Practice, McKinney, Texas

Richard D Thrasher III, MD is a member of the following medical societies: American

Academy of Otolaryngology-Head and Neck Surgery, American Medical Association,
and American Rhinologic Society

Disclosure: Nothing to disclose.

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