Otitis Media With Effusion (OME) / Glue Ear
NICE CKS Otitis media with effusion. Last revised Nov 2023.
Background Information
Definition
Collection of fluid within the middle ear space, in the absence of acute infection
Causes and Risk Factors
Most common in 6 m/o – 4 y/o
The most significant risk factors:
- Down syndrome / cleft palate (prevalence of OME in these children is 60-85%)
- Down syndrome is associated with an increased risk of cleft palate
- >50% cases follow an episode of acute otitis media
- Primary ciliary dyskinesia
- Allergic rhinitis
Other risk factors:
- Eustachian tube dysfunction
- Household smoking
- Adenoidal hypertrophy / infection
- Recurrent URTIs
Complications
- Conductive hearing loss – most common cause of hearing impairment in childhood (>50% of children will experience OME in first year of life)
- Hearing loss in early childhood → impairment in speech and language development and communication skills
- Chronic damage to the tympanic membrane (retraction pockets, cholesteatomatous changes)
Diagnosis
Clinical Examination
Otoscopic findings – changes to the tympanic membrane:
- Loss of light reflex
- Air fluid level / air bubbles
- Retracted tympanic membrane
- Opacification
A normal-looking tympanic membrane does NOT exclude OME.
The presence of a red, bulging tympanic membrane should raise suspicion of acute otitis media.
Investigations and Diagnosis
If OME is suspected based on history and clinical examination (including otoscopic findings), perform:
- Diagnostic tests
- 1st line: pneumatic otoscopy (qualitative) – showing reduced / absent movement of the tympanic membrane
- Highly sensitive/specific, however, accuracy is operator-dependent and may be limited by patient cooperation or obstructing cerumen[Ref]
- Confirmatory: tympanometry (quantitative) – showing a type B curve (flat) suggestive of middle ear effusion
- 1st line: pneumatic otoscopy (qualitative) – showing reduced / absent movement of the tympanic membrane
- Audiometry – to assess the degree of conductive hearing loss associated with OME
Pneumatic otoscopy and tympanometry are both sensitive for detecting middle ear effusion but cannot distinguish between acute otitis media and otitis media with effusion.
Both conditions can produce a middle ear effusion, yielding reduced or absent tympanic membrane mobility and a type B (flat) tympanogram.
The key differentiator of acute otitis media (vs OME) is the presence of acute inflammatory signs (especially bulging of the tympanic membrane) on otoscopy, not the results of tympanometry or pneumatic otoscopy alone.[Ref]
Management
Referral Criteria
Consider referral to ENT in the following scenarios:
- Down syndrome, cleft palate or other craniofacial anomalies
- Complicated hearing loss
- Any level of hearing loss that is associated with a significant impact on the child’s developmental, social or educational status
- Structurally abnormal tympanic membrane
- Possible cholesteatoma (e.g., presence of persistent, foul-smelling discharge)
Unilateral OME in adults is a red flag for nasopharyngeal malignancy (esp. those of Chinese or Southeast Asian descent are at highest risk).
These patients need urgent ENT referral, including flexible nasoendoscopy and possible imaging.
Management Algorithm (0 – 12 y/o)
1st line management (acute OME): 3 months of active observation
- Active observation involves regular follow-up with repeated history and examination, audiology assessment and speech and language assessment
- Advise that OME will often get better over time without treatment
- Consider recommending autoinflation (only in older children who have no ear pain)
Pharmacological treatments are not recommended for treating OME
Surgical Interventions
Indications for surgical intervention:
- Typically if there is persistent / chronic OME AND documented hearing difficulties OR other attributable symptoms [Ref]
Surgical intervention options:
- Myringotomy
- Grommet insertion
Water precautions should be considered for 2 weeks after the operation
Non-Surgical Interventions
Consider hearing aids
- Usually if there is persistent bilateral OME and hearing loss and surgery is not appropriate