Otitis media with effusion, also known as serous otitis media or glue ear, is defined as the chronic accumulation of fluid in the middle ear caused by Eustachian tube dysfunction. It is a common reason for pediatric visits and the most frequent cause of hearing loss in children. Risk factors include young age, male gender, attendance at daycare, and winter season. Diagnosis involves tympanometry showing a flat tympanic membrane and treatment options include watchful waiting, antibiotics, myringotomy with tube insertion, or adenoidectomy. Complications can include permanent hearing loss if left untreated.

1. OTITIS MEDIA WITH
EFFUSION
1

2. • Definition
• Introduction
• Epidemiology
• Aetio pathogenesis
• Clinical presentation
• Diagnosis
• Treatment
• Sequelae
2

3. Otitis media with effusion (OME)
Defined as Chronic accumulation of mucus
within middle ear and sometimes mastoid air
cell system.
Time for fluid to be present – 12 weeks
3

4. Synonyms
•Otitis media catarrhal
•Sub acute catarrh of middle ear
•Mucous aural catarrh
•Exudative catarrh
•Adhesive catarrh
•Chronic middle ear exudate catarrh
•Secretory otitis media
•Chronic non suppurative otitis
media
4
Introduction
•Serous otitis media
•Otitis media with effusion
•The hypersecretory ear
•Tympanic hydrops
•Glue ear
•Otitis media ex vacuo
•Exudative otitis media
•Indolent otitis media
•Sero mucinous otitis media
•Mucoid otitis media

5. • $3.5 billion in expenditures in USA
• Most common reason for visit to pediatrician
• In the developed world AOM is the most common cause
for prescribing antibiotics in children and accounts for over
90% of all antimicrobial consumption during the first 2
years of life (Dagan, 1995).
• Tympanostomy tube placement is 2nd most common
surgical procedure in children
• Development of multidrug-resistant bacteria
• Most common cause of acquired HL in pediatric age
Introduction : the burden of otitis media
5

6. • Egyptian mummies have perforations of TM and mastoid
destruction
• 450 BC: Hippocrates described the disease
• 1704: Valsalva maneuver and Toynbee – ET dysfunction
with negative ME pressure
• 1869: Politzer described OM catarrahalis & its treatment
as insufflation of air & paracentesis of middle ear
• Jean Riolan: Inadvertant puncture of TM-
tympanocentesis. Fell into disrepute for decades.
• 20th century: Schwartz reintroduces tympanocentesis
• 20th century: Armstrong – use of tympanostomy tubes
• Post World war II- Nasopharyngeal radium irradiation.
Given up for potential for malignancies
Introduction : History of otitis media
6

7. Epidemiology : risk factors
I. Host-Related factors (intrinsic or genetic)
• Age
• Gender : males more prone to persistent OME
• Race : American natives and Eskimos > whites >
blacks
• Cleft palate/craniofacial abnormality/Down Syndrome
• genetic
• Allergy (no support to prove)
7

8. 2. Environmental or aetiological factors
(extrinsic)
• season and upper respiratory infection
• day care / home care
• siblings
• passive smoking (negligible risk.)
• breast feeding / bottle feeding
• socio-economic status
8

9. Aetio pathogenesis
No single cause for OME in children
• Viral URI
• Eustachian tube dysfunction
• Middle ear gas composition
• Nasopharyngeal disproportion
9

10. Developmental Differences between Infants
and Adults in Anatomy of the Eustachian Tube*
• Adults
– ant 2/3-
cartilaginous
– post 1/3- bony
– 45 degree angle
– nasopharyngeal
orifice 8-9 mm
• Children
– longer bony portion
– 10 degree angle
– nasopharyngeal
orifice 4-5 mm in
infants
10

11. Eustachian tube
• Usually closed
• Opens during swallowing, yawning, and
sneezing for 2 sec
• Opening involves cartilaginous portion
• Tensor veli palatini responsible for active
tubal opening
• No constrictor function
11

12. Role of the Eustachian Tube
1. Pressure regulation of
middle ear
2. Clearance ‘Drainage’ of
middle ear secretions
mucociliary
muscular
3. Protection from sound and
secretion
anatomic
immunologic and mucociliairy
12

13. Eustachian Tube Dysfunction
• Palatal abnormalities
• Cleft palate
• Sub mucous cleft palate
• Altered mucociliary system
• Infection
• Allergy
• Immunological factors
• Surfactant deficiency
• Cilial abnormalities
• Hormonal factors 13
Aetio pathogenesis

14. Aetio pathogenesis
• Middle ear gas composition
– Acts as gas pocket
– Spectrometry shows middle ear gas partial
pressures
• PN2 – 82.4 percent
• PO2 – 7.6 percent
• PCO2 – 10.0 percent
– Closely resemble mixed venous blood and not
atmospheric air
– Theories of middle ear gas deficiency
14

15. Theories of middle ear gas deficiencies
• Hydrops ex vacuo theory
• Ventilation deficiency theory
• Sniff theory
• Excess diffusion theory
15

16. Anatomic obstruction
Intrinsic
Inflammation
Extrinsic
adenoid
Tumor
ObstructionWeak TVP
Open
Functional obstruction
Ventilation deficiency theory
16

17. Theories of middle ear gas deficiencies
• Hydrops ex vacuo theory
• Ventilation deficiency theory
• Sniff theory
• Excess diffusion theory
17

18. Aetio pathogenesis
• Nasopharyngeal disproportion
• Cranio facial abnormalities
• Adenoids and nasopharynx
– Mechanical blockage of ET
– Focus of infection
18

19. Related Clinical Conditions
• Barotrauma
• Diving / flying / HBO therapy - OM even in normal ET
function
• NP tumors
• Radiation therapy
• Inadequate antibiotic therapy
• Gross DNS
• Neoplasms
• Syndromic diseases
19
Aetio pathogenesis

20. Pathology
• Normal flat cuboidal middle ear and
mastoid epithelium – thickened
pseudostratified mucus secreting epithelium
• Goblet cells , mucus secreting glands
• Ciliary lining less efficient
• Defective mucociliary clearance
• Submucosa – oedematous – with dilated
blood vessels and increase in no. of
macrophages and lymphocytes
20

21. Resolution of acute inflammation and bacterial
infection -- a failure of the middle ear clearance
mechanism allows OME to persist.
Factors implicated in the failure of the clearance
mechanism:
•ciliary dysfunction
•mucosal edema
•hyperviscosity of the effusion
•possibly, an unfavorable pressure gradient.
23

22. Composition of fluid
• Fluid in middle ear – mixture of epithelial cells,
goblet cells, mucous glands alongwith
inflammatory exudate/ transudate – intercellular
spaces from the inflamed submucosa
• Bacteria isolated in 1/3rd of cases
• Biochemical: increase protein concentration.
• OME: sclerotic mastoids
– Children – smaller mastoids
– Pneumatization less with recurrent episodes
24

23. Pathogenesis of OM
Infection ET dysfunction
Host response
Liberation of inflammatory mediators
Increase of vascular permeability
Increase of glandular secretion
Inflammation Mucosal proliferation
26

24. • Quiescent phase – Asymptomatic
• Covert or overt hearing loss
• Impaired speech and language development
• Behavioral changes
• Indirect symptoms of hearing loss
• Otalgia – due to secondary infection
• Features of associated URI, Nasal pathologies
• Symptoms of palatal abnormality or syndromic
conditions with cranio facial abnormalities
27
Clinical features

25. • History
• Otoscopy
• Tympanometry
• Pure tone audiometry
• Myringotomy and aspiration of fluid (Gold
standard)
28
Diagnosis

26. Medical history
Hearing loss
Otalgia : ear pulling, irritability
Otorrhoea
Fever
Preceding upper respiratory tract infection
Purulent conjunctivitis (Haemophilus influenzae)
Vertigo : not common as a complaint, unilateral disease,
clumsiness
Nystagmus : labyrinthitis
Tinnitus
Swelling about the ear : DD mastoiditis, external otitis, adenitis
Facial paralysis 29

27. Examination
• Tympanic Membrane – otoscopy
• Nasopharynx / nose –especially in adults
• Adequate examination of the head and neck
30

28. • Audiological evaluation-
– TFT
– Tympanometry
– PTA-Conductive Loss of 10-40dB
• Radiology -Mastoids
-Adenoids
31
Examination

29. TYPE B TYMPANOGRAM: FLAT OR NO
PEAK, SEEN IN OTITIS MEDIA WITH
EFFUSION 32

30. • Audiological evaluation-
– TFT
– Tympanometry
– PTA-Conductive Loss of 10-40dB
• Myringotomy and aspiration of fluid (Gold
standard)
• Radiology -Mastoids
-Adenoids
33
Examination

31. I. Counselling and hearing tactics
• Parents of children of OME often misinformed-both
overpessimistic and overoptimistic.
• Counsel about benign nature and high spontaneous
resolution rates as well as natural history of disease.
• Concern about hearing – Impairement associated with
OME variable and mild or moderate at most.
• Minimise disability by Hearing tactics
TREATMENT
34

32. II. Medical therapy
• Antibiotic therapy - modest impact on short-term and
impact on long-term resolution is smaller.
• Steroid therapy and antihistamine-decongestant therapy
- no proven effect
• Ventilate the ET- No URTI
• Valsalva
• Chewing gums
• Politzerization
• Auto inflation using otovent balloons-older children
• Mucolytic agents – no long term effect.
• Management of associated nasal condition / allergy
• Homeopathy – not shown to be of benefit
TREATMENT
35

33. III. Surgical therapy
• (a) Myringotomy and aspiration
• (b) Ventilation tubes
• (c) Adenoidectomy
• (d) Rarely explorative tympanotomy with/without mastoidectomy
• No improvement > 90 days of treatment
• Persistent OME with hearing loss in children
• Chronic effusion
• Reassessment at pre admission clinic for
persistence
36

34. (b). Myringotomy with ventilation tubes
• Diagnostic
• OME –therapeutic
• Types of ventilation tubes
• Procedure –
• Outcomes
37

35. Tympanostomy Tubes
• Silicone rubber
• Teflon
• Plastic
• Precautions-flange
– Not too near the annulus
38

36. Tube Choice
• Standard grommets (Armstrong, Shepard, collar button)
– Persistent perforation rates 3-5%
– Persist 6-18 months
• Goode T-tubes
– Persistent perforation rates 10 of 64 in best study
– Persist 2-4 yrs
• Bioabsorbable/bacteriostatic grommets
– New choice in future
– Made of bacteriostatic polylactic acid
– Similar material to resorbable miniplates
– Mix can be customized to persist a given amount of time
39

37. Myringotomy with ventilation tubes
• Diagnostic
• OME –therapeutic
• Types of ventilation tubes
• Procedure –
• Outcomes
40
• Complications -

38. (c). Adenoidectomy
• Rationale
• Recommendation
• Effect on hearing improvement
41
IV. Hearing Aids

39. 100
90
80
70
60
50
40
30
20
10
0
0 1 2 3 4 5 6 7 8 9 10
Proportion(%)withfluidremaining
Survival
functions
for time to
fluid Clearance
as Confirmed
by otoscopy
• No surgery (n=77)
• Ventilation tube only
(n=77)
• Adenoidectomy only
• Adenoidectomy
and tube (n=136)
Years
Maw et al, 1994
42

40. Treatment Recurrent Otitis media
• Chemoprophylaxis
– Sulfisoxazole, amoxicillin, ampicillin
– less efficacy for intermittent propylaxis
• Myringotomy and tube insertion
– Decreased frequency and severity of AOM
– otorrhoea and other complications
– may require prophylaxis if severe
• Adenoidectomy
– 28% and 35% fewer episodes of AOM at first and
second years
43

41. Sequelae Of OME
• Scarring
• Atelectasis
• Attic retraction
• Tympanosclerosis
• Otorrhoea
• Perforation
• COM / cholesteatoma
• SNHL
• Behavioural/ developmental 44

42. Follow-up
• Child should demonstrate symptomatic benefit
within 72 hours of antibiotic
• Failure to show improvement - re-evaluation.
• A follow-up examination - one month after the
diagnosis and should include:
- Inspection of the tympanic membrane
- Assessment of hearing
• The purpose of the follow-up - identify persistent
otitis media or persistent middle ear effusion
• Children with persistent otitis media or persistent
middle ear effusion - seen on a monthly basis
until their exam is normal 45

43. Future solution
• Immunisation with Haemophilus influenzae
type B vaccine
• Heptavalent pneumococcal conjugate
vaccine PCV7
• Attempt to produce vaccine for nontypable
H. influenzae and M. catarrhalis
• Surfactants
46

44. Bibliography
47
• Scott Brown Otorhinolaryngology, Head
and Neck surgery, 6th and 7th edition
• Ballenger’s Otorhinolaryngology, Head and
Neck surgery, 17th edition
• Ludman and Wright diseases of the ear, 6th
edition

45. Thank You
48