Otitis media with effusion (OME) in children requires different presentation, diagnosis, and management compared to adults, with significant prevalence following acute otitis media. The condition is characterized by fluid in the middle ear, influenced by factors such as eustachian tube dysfunction and infections, leading to hearing impairments. Current treatment options include observation, ventilation tubes, and adenoidectomy, with varying success in restoring hearing and managing symptoms.

1. Otitis media
with effusion
in children
Dr. Prathyusha PG
ENT
Narayana Medical

2. Introduction
• Otitis media with effusion in a child differs
significantly from that of adults in terms of
• Presentation
• Diagnosis
• Management
• Follow up
• A more comprehensive approach and judicious
management is required in children

3. DEFINITION
• Otitis media with effusion (OME) is characterized by
a nonpurulent effusion of the middle ear that may be
either mucoid or serous
• Serous otitis media is a specific type of otitis media
with effusion caused by transudate formation due to
rapid decrease in middle ear pressure relative to the
atmospheric pressure.
• The fluid in this case is watery and clear.

4. • 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

5. PATHOPHYSIOLOGY OF OME
• Eustachian dysfunction theory
• Reflux theory
• Gene regulation theory
• Oxidative stress theory

6. ET DYSFUNCTION THEORY
• ET has 3 main functions:
• Equilibration of pressure between the middle and
external ears,
• Clearance of secretions
• Protection of the middle ear

7. ET DYSFUNCTION THEORY
• If ET dysfunction is persistent,
• A negative pressure sets in middle ear due to diffusion of
N2 and O2 into the middle ear mucosal cells
• If it persists it elicits a transudate from the mucosa, causing
serous effusion.

8. REFLUX THEORY
• Presence of reflux proven by radiography
• Presence of pepsin A in the middle ear
Bluestone CD, Beery QC, Andrus WS. Mechanics of the eustachian tube as it
influences susceptibility to and persistence of middle ear effusions in
children. Ann Otol Rhinol Laryngol. 1974 Mar-Apr. 83:Suppl 11:27-34.
Crapko M, Kerschner JE, Syring M, Johnston N. Role of extra-esophageal
reflux in chronic otitis media with effusion. Laryngoscope. 2007 Jun 20.

9. GENE REGULATION THEORY
• Upregulation of mucin genes secondary to bacterial
antigen challenge.
• Production of a mucin-rich effusion

10. OXIDATIVE STRESS THEORY
• Significant changes in oxidative stress in patients with
otitis media with effusion
• Significantly improved but not normalized level of
oxidants following the placement of ventilation tubes.
• However, the role of antioxidants in the treatment of
OME has yet to be fully investigated.
Yilmaz T, Koçan EG, Besler HT, Yilmaz G, Gürsel B. The role of
oxidants and antioxidants in otitis media with effusion in
children. Otolaryngol Head Neck Surg. 2004 Dec. 131(6):797-

11. PREDISPOSING FACTORS

12. • Infections
• Age
• Eustachian tube dysfunction
• Craniofacial abnormalities
• Diet
• Racial and sex differences
• Seasonal variations
• Others

13. ETIOLOGY AND PREDISPOSING
FACTORS FOR OME
• The same flora found in ASOM can be isolated in OME
• In OME the inflammatory process is less and volume of
bacteria is less
• S pneumoniae is found in 35%
• H influenzae is found in 20%
• M catarrhalis is found in 4-13%
• Streptococcus pyogenes, Staphylococcus aureus, gram-
negative enteric bacteria, and anaerobes.
• Pseudomonas species predominate.( long standing)

14. 35
206
3
2
4
30
INFECTIOUS AGENTS IN ASOM
pneumococcus
H. Influenzae
moraxella
strep.pyogenes,stah
aureus
pseudomonas
RSV, Influenza
Sterile
Kubba H, Pearson JP, Birchall JP. The aetiology of otitis media with effusion: a
review. Clin Otolaryngol. 2000 Jun. 25(3):181-94

15. 8
3
7 1
15
66
INFECTIOUS AGENTS IN OME
pneumococcus
H influenzae
Branhamella
Strep. Pyogenes
others
Negative Culture
Jero J, Karma P. Bacteriological findings and persistence of middle ear effusion in
otitis media with effusion. Acta Otolaryngologica. 1997; 529: 22-6.

16. AGE
• In infants, the eustachian tube has a nearly horizontal
orientation
• Develops the 45° angle (as in adults) after several
years.
• Size and shape of the eustachian tube at birth, unlike
adults, are unfavourable for ventilation

18. ET DYSFUNCTION
• Respiratory tract has ciliated, pseudostratified columnar
epithelium
• Extends up to ET and anterior part of the middle ear
• Along with goblet cells they produce mucus
• In OME inflammation of this epithelium in the Eustachian
tube and hypotympanum.
• Flat cuboidal middle ear and mastoid mucosa is patchily

19. ET DYSFUNCTION
• The ciliary lining would appear to be less efficient
• The submucosa is oedematous and inflamed with
dilated blood vessels and an increased number of
• Macrophages
• Plasma cells
• Lymphocytes

20. CRANIOFACIAL ABNORMALITIES
• Cleft palate (even if repaired) have deficient palatine
muscles and resultant poor ET function
• Down syndrome
• Turner syndrome more likely to have OME,
• Bifid uvula do not appear to have a higher incidence
of OME

21. DIET
• high-fat diet proven risk factor
• Body mass index category
• Protein
• Water
• Sodium intake
• distribution of carbohydrate intake
Choi HG, Sim S, Kim SY, Lee HJ. A high-fat diet is associated with otitis
media with effusion. Int J Pediatr Otorhinolaryngol. 2015 Dec. 79
(12):2327-31
NOT

22. RACIAL AND SEX DIFFERENCE
• OME is higher in Native Americans
• NO difference in prevalence rates between white and
black populations exists.
• Males may have a slightly higher preponderence (not
statistically significant)

23. EFFECT OF SEASONAL VARIATION
• Twice an amount of children were diagnosed in
winter with OME when compared with summer.
• Probable reason could be due to increased URTIs in
winter
Tos M, Holm-Jensen S, Sorensen CH, Mogensen C. Spontaneous course
and frequency of secretory otitis in 4-year-old children. Archives of
Otolaryngology. 1982; 108: 4-10

24. OTHER PREDISPOSING FACTORS
• bottle feeding,
• feeding while supine,
• having a sibling with otitis media,
• attending day care,
• having allergies to common environmental entities,
• having a lower socioeconomic status,
• living in a home in which people smoke,
• having a parental history of otitis media with effusion.
Erdivanli OC, Coskun ZO, Kazikdas KC, Demirci M. Prevalence of
Otitis Media with Effusion among Primary School Children in
Eastern Black Sea, in Turkey
The Effect of Smoking in the Development of Otitis Media with

25. Prevalence and Management of Otitis Media with Effusion Amongst the School Going
Children of a Rural Area in Puducherry
Sharath Babu et alBengal Journal of Otolaryngology and Head Neck Surgery Vol. 24 No. 1

26. HISTORY
• very unreliable and cannot be a pointer to OME
• decreased hearing
• history of ear problems
• recurrent upper respiratory infections
• mouth breathing and snoring,
• Stewart MG, Friedman EM, Sulek 1t1, Duncan 110, Fernandez AD,
Bautista MH. Is parental perception an accurate predictor of childhood
hearing loss? A prospective study. Otolaryngology and Head and Neck
Surgery. 1999; 120: 340-4
ALL THESE TO BE
EXAMINED

27. OTOSCOPY
• Unfortunately the otoscopic appearances of OME are
extremely varied.
• The otoscopic findings in OME are mainly different
combinations of retraction of the pars tensa and
variations in its colour.
• Retractions may be evident by indrawing of the handle
of the malleus

37. OTHER FEATURES
• Tonsillar hypertrophy
• Adenoid hypertrophy
• Turbinate bogginess
• Postnasal drip,
• Rhinorrhea
• Watery or erythematous eyes consistent with a concurrent URTI

38. PNEUMATIC OTOSCOPY AND VIDEO
OTOSCOPY
• American Clinical Practice Guidelines have
strongly advocated the use of pneumatic otoscopy
as the primary diagnostic method for OME
• Video recordings of otoscopy ( video otoscopy),
used to monitor changes with time.
Clinical Practice Guideline: Otitis Media with Effusion (Update)
Otolaryngology–Head and Neck Surgery 2016, Vol. 154(1S) S1–S41

40. TYMPANOMETRY
Type B tympanogram is most of the times associated
with OME
Type A is infrequently associated with OME
T type C falls in between

41. Sensitivity (Sens), specificity (Spec). positive (PPV) and negative
predictive values (NPV) of a Type B tympanogram

42. Sensitivity, specificity , of a Type B+ C2 tympanogram versus
Type A + C in the detection of OME with surgical findings as the
reference standard

43. ACOUSTIC REFLECTOMETRY
• Hand-held acoustic otoscope that does not require a
seal
• Unfortunately, the sensitivity and specificity of the
test is poorer than tympanometry

44. AUDIOMETRY
• Audiometry is mandatory in all children with a
suspected hearing impairment
• Irrespective as to whether OME is diagnosed at the
time.
• Routine audiometric testing of the hearing of every
child with OME seen at secondary care is
recommended
• Hearing impairment can vary enormously from

45. COMPREHENSIVE ASSESMENT OF
CHILD
• Needs to be skilfully done with the assistance of
• ENT Surgeon
• Audiologist
• Pediatrician
• Pediatric psychiatrist/psychologist
• Nursing staff/personel trained in developmental
pediatrics

46. COMPREHENSIVE ASSESMENT
• SPEECH AND LANGUAGE
• COGNITION
• BALANCE
• BEHAVIOUR

47. SPEECH AND LANGUAGE
• Including speech reception
• Speech and sound production
• Expressive language and cognitive understanding.
• Compare with standard mile stones
• Example: Thus, at 18 months they would be expected to have a
vocabulary of ten words with meaning.

48. BALANCE
• 30% of children with OME are report by parents
that they are
• Clumsy,
• imbalanced and can fall.
• May be due to vestibular dysfunction that settles with
time

49. BEHAVIOR
• Rutter score (antisocial, neurotic, hyperactive and
inattentive behaviour)
• The MRC Behaviour Questionnaire (aggressive, social
immaturity)
• Behaviour scores in children Of 3 to 7 yrs with B/L
deafness of 20dB HL are poorer
• At 15 yrs still have poorer behaviour than non-OME
children, (inattentive and hyperactive aspects)

50. MANAGEMENT
• Medical
• Surgical

51. NASAL TOPICAL STEROIDS
• Systematic reviews of the RCT s have found NO ROLE
of topical nasal steroids versus placebo
• Another study which gave antibiotics in addition to
nasal steroids also found NO difference.
Butler CC, van der Voort JH, Oral or topical nasal steroids for hearing loss
associated with otitis media with effusion. Cochrane Database of Systematic
Reviews. 2002:
Tracy.lM, Demain JG, Hoffman KM, Goetz OW. Intranasal beclomethasone as an

52. SYSTEMIC STEROIDS
• NO evidence to suggest that oral steroids are effective
for longer or short term with 0r without antibiotics.
• Systemic steroids CANNOT be recommended at
present for childhood OME.
Mandel EM, Casselbrant Ml, Rockette HE, Fireman P, KursLasky
M, Bluestone CD. Sytemic steroid for chronic otitis media with
effusion in children. Pediatrics. 2002; 110: 1071-80.
Thomas Cl, Simpson S, Butler CC, van der Voort .IH. Oral or

53. ANTIBIOTICS
• Multiple RCT s have shown NO role of antibiotics
beyond 2 weeks of antibiotics
• 6 weeks of antibiotics have NO benefit
Rosenfeld RM, Post JC. Meta-analysis of antibiotics for the treatment of
otitis media with effusion. Otolaryngology and Head and Neck Surgery.
1992; 106: 378-86
Williams Rl, Chalmers TC, Stange KC, Chalmers FT, Bowlin SJ. Use of
antibiotics in preventing recurrent .

54. NASAL DECONGESTANTS
• meta-analysis of four trials found that
antihistamine/decongestants had NO effect on
OME
• Nasal decongestants are NOT recommended for
use in childhood OME.
Griffin GH, Flynn C, Bailey RE, Schultz .IK. Antihistamines

55. MUCOLYTICS
• Systematic review of six RCT s of S-
Carboxyrnethylcysteine published before 1993 had NO
effect.
• Later trials added NO significant effect.
Pignataro 0, Pignataro lD, Gallus G, Calori G, Cordaro CI. Otitis media with
effusion and S-carboxymethylcysteine and/or its lysine salt: a critical overview.

56. AUTO INFLATION
• Metanalysis of the three studies indicated that children with
autoinflation were 3.5 times more likely to improve
• Ability to autoinflate with the balloon is a particular
problem in younger children (hence NOT recommended)
• During a period of watchful waiting, it has strongest
evidence of efficacy for older children.
Williamson I. Otitis media with effusion. Clinical Evidence Concise. 2006; 16:
245-7

57. HOMEOPATHY
• NO randomized controlled trials have been identified.
• A small, non blinded study DID NOT show
homeopathy to be of benefit.

58. MYRINGOTOMY AND ASPIRATION
• From three trials, myringotomy with aspiration has
NOT been shown to be effective in restoring the
hearing levels in children with OME.
• Freemantle N, Sheldon TA, Song F, long A. The treatment of
persistent glue ear in children. Effective Health Care Bulletin
No.4. York: University of York, NHS Centre for Reviews and

59. VENTILATION TUBES
• Introduced in 1954 by Armstrong
• Pressure equalization tubes (grommets)are available
in a variety of sizes, shapes,
• Teflon,silicone, titanium, gold and be coated with
materials such as silver oxide.
• 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.

61. HOW LONG
• Ventilation tubes are classified as short, or long term,
• Data are lacking on 'duration of tube function'
• Relied upon less relevant 'duration till extrusion
• Self extrude from 6 to 12 months

62. 0
5
10
15
20
25
30
35
40
45
Shepard Armstrong T tube
45
40
10
% OF EXTRUSION IN 6 MONTHS

63. INSERTION SITE
• Anterosuperior or anteroinferior outcomes are SIMILAR
• Posterosuperiorly is NOT done as it can damage the
ossicular chain.
• Radial or circumferential, extrusion rates are SIMILAR
Heaton .1M, Bingham BJG, Osbourne J. A comparison of performance of
Shepard and Sheehy collar button ventilation tubes. Journal of Laryngology and
Otology. 1991; 105: 896-8
Guttenplan MD, Tom WC, DeVito MA, Handler SO, Radial versus

66. PERCENTAGE IN SITU
0
20
40
60
80
100
120
Antero
inferior
Postero
inferior
80
45
30
15 12 Months In Situ
6 Months In Situ

67. ASSOCIATED ASPIRATION
• Common practice to aspirate fluid before inserting a
ventilation tube
• NO evidence that this is required.
• The hearing levels three months following insertion of a
ventilation tube was NO DIFFERENT in ears that were
aspirated compared with those that were not aspirated

68. HEARING FOLLOWING VT
INSERTION
• Ventilation tubes alone will improve the hearing level by
9dB at 6 months,
6dB at 12 months
4 dB at 24 months. (persistent decrease in improvement is
due to non functioning VT over a period of time)
• Children randomized to have VT had a marked
improvement three months following surgery of 12 dB
compared with the nonsurgical group.
• The younger children at day care those with binaural
hearing thresholds poorer than 25 dB HL and persistent over
at least 12 weeks will benefit most
Rovers MM, Black N, Browning GG, Maw R, Zielhius GA, Haggard MP.

69. MEAN IMPROVEMENT IN HEARING WITH TUBE
METAANALYSIS

70. SPEECH AND LANGUAGE
• 3 RCTs assesed speech abd language post VT at
different intervals
• VT are not indicated to aid speech and language
development in children three years and younger.

71. COMPLICATIONS OF VT TUBE
• Dislodgement
• Blockage ( 9% without antibiotics and 1% with
antibiotics)
• Otorrohoea
• acute otorrhoea 9%
• Recurrent otorhoea 7%
• Chronic otorrhoea 3%

72. COMPLICATIONS OF VT
CONTINUED……….
• Perforation
• Short term incidence 2%
• Long term incidence 17%

73. TYMPANOSCLEROSIS, PARS TENSA
ATROPHY
• Localized white patches or plaques of
tympanosclerosis occur with OME
• With VT it increases dramatically
• Short term 3 dB
• Long term ( 18 yrs) 5 to 10 dB
• More tubes, more impairment
• Pars tensa atrophy occurs with OME and increases
with VT
• NOT significant

74. ADENOIDECTOMY
• Mechanism unclear (? source of infection ?? Physical
obstruction to ET )
• Prior to VT Adenoidectomy alone was the surgical
management for many years
• Metanalysis showed e overall effect at 6 months on the
hearing of adenoidectomy was 8 dB and 12 dB for VT.
• Current practice is to do adenoidectomy as an adjunct to

75. ADENOIDECTOMY
• Blind curettage. ( risk of bleeding)
• Suction diathermy ablation (less risk)
• Selective removal of adenoid tissue and avoiding
palatopharyngeal incompetence by leaving an inferior pad
of tissue. (preferred)
• Microdebriders have also been advocated as allowing more
selective removal of tissue.

76. ADJUVANT EFFECT OF ADENOIDECTOMY
WITH VT

77. Additional benefit of adenoidectomy during the
second year of TARGET trial

78. HEARING AIDS
• Their use as the preferred initial management has not been
extensively reported
• Improvement is at least in the same range as expected of
ventilation tubes.
• Main concern is potential noise trauma if the aid continues
to be worn after the OME has resolved
• BAHA® (bone anchored hearing aid) offers advantage
over hearing aid in a head-band as it avoids noise trauma

79. RECOMMEND
ATIONS

80. Slide Title
Clinical Practice Guideline: Otitis Media with Effusion (Update) Otolaryngology–Head and Neck S
American Academy of Otolaryngology—Head and Neck Surgery Foundation 2016

81. Slide Title
•
Clinical Practice Guideline: Otitis Media with Effusion (Update) Otolaryngology–Head and Neck S
American Academy of Otolaryngology—Head and Neck Surgery Foundation 2016

82. Slide Title
•
Clinical Practice Guideline: Otitis Media with Effusion (Update) Otolaryngology–Head and Neck S
American Academy of Otolaryngology—Head and Neck Surgery Foundation 2016

83. BIBILIOGRAPHY
• Clinical Practice Guideline: Otitis Media with Effusion
(Update) Otolaryngology–Head and Neck Surgery 2016,
Vol. 154(1S) S1–S41 American Academy of
Otolaryngology—Head and Neck Surgery Foundation 2016
• Scott-Brown's Otorhinolaryngology, Head and Neck
Surgery 8th edition 2008 Edward Arnold (Publishers) Ltd
• Ila Upadhya J. Datar Treatment Options in Otitis Media
with Effusion Indian J Otolaryngol Head Neck Surg
January 2014 66(Suppl 1):S191–S197

84. Slide Title
•