Otitis Media with Effusion
Otitis media with effusion (OME), also known as glue ear, is the presence of fluid in the middle ear without signs of acute infection. It is most common in young children and usually results from Eustachian tube dysfunction, causing negative middle ear pressure and fluid accumulation.
This updated UKMLA guide to otitis media with effusion (OME) is based on NICE NG233 and NICE CKS, which covers causes, risk factors, clinical features, complications, diagnosis and management.
Pathophysiology
The key underlying pathophysiological mechanism is Eutachain tube dysfunction
- → -ve Middle ear pressure
- → Accumulation of fluid
Causes and Risk Factors
OME is most common in young children (6 m/o – 4 y/o)
OME is more common in children with:
- Cleft palate (60-85% prevalence in these patients) – causes Eustachian tube dysfunction
- Down syndrome (associated with increased risk of cleft palate)
- Primary ciliary dyskinesia
- Allergic rhinitis
Other risk factors:
- Acute otitis media (>50% cases occur after an episode of acute otitis media)
- Household smoking
- Adenoidal hypertrophy / infection
- Recurrent URTIs
- Winter months
Clinical Features
| Symptoms | Most common presentation: hearing loss
Other possible features:
|
| Signs | Otoscopic findings:
The presence of a red, bulging tympanic membrane should raise suspicion of acute otitis media, instead of OME. |
Complications
Key complications in children:
- Conductive hearing loss – OME is the most common cause of hearing impairment in childhood
- >50% of children with OME will have some degree of hearing loss (usually mild)
- Hearing loss in early childhood can impair speech and language development, communication skills, and education
- Behavioural problems (esp. lack of concentration or attention), irritability, withdrawn
- Balance difficulties (e.g. clumsiness)
- Chronic damage to the tympanic membrane may predispose one to cholesteatoma (see the Cholesteatoma article for more information)
Investigations and Diagnosis
If OME is suspected and hearing loss is present, refer for the following tests:
| Hearing testing | Perform audiometry to assess the degree of hearing loss
OME causes conductive hearing loss |
| Objective testing [Ref] | 1st line: pneumatic otoscopy
Confirmatory test (if pneumatic otoscopy is inconclusive): tympanometry
|
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 would cause a middle ear effusion, resulting in a reduced or absent tympanic membrane mobility and a type B (flat) tympanogram.
- The key differentiator of acute otitis media (vs otitis media with effusion) is the presence of acute inflammatory signs (especially bulging of the tympanic membrane) on otoscopy and clinical features like acute otalgia and fever. [Ref]
Management
Referral Criteria
Refer to ENT specialist if ANY of the following:
- Down syndrome, cleft palate or other craniofacial anomalies
- Hearing loss that is significant enough to impact the child’s developmental, social or educational status
- Structurally abnormal tympanic membrane
Possible cholesteatoma (e.g. presence of persistent, foul-smelling ear discharge) requires semi-urgent referral.
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
Initial management diagnosed OME:
- No hearing loss → reassure that no treatment is necessary, as it will often improve over time
- Hearing loss present → active observation for 3 months and reassess
For OME with hearing loss, subsequent management depends on the 3-month audiology reassessment:
- No hearing loss → discharge the patient
- Hearing loss is still present
- Bilateral hearing loss → consider active management of hearing loss (see below)
- Unilateral hearing loss → consider a further 3 months of active observation OR active management if hearing is impacting daily living or communication
Active management options for hearing loss:
| Category | Description |
|---|---|
| Non-surgical management | Consider air conduction hearing aids or bone conduction devices
Consider autoinflation in those who are likely to cooperate, usually older children with no ear pain |
| Surgical management | Most common: myringotomy + grommets insertion
Patient education post-procedure:
Possible complications:
|
Do NOT offer the following pharmacological management to treat OME:
- Antibiotics
- Corticosteroids (oral or nasal), decongestants
- Antihistamines, LTRAs, mucolytics, PPIs, anti-reflux medications