http://informahealthcare.com/pgm ISSN: 0032-5481 (print), 1941-9260 (electronic) Postgrad Med, 2015; 127(4): 381–385 DOI: 10.1080/00325481.2015.1028317
CLINICAL FEATURE REVIEW
Otitis media with effusion Helen Atkinson, Sebastian Wallis and Andrew P. Coatesworth
Postgraduate Medicine Downloaded from informahealthcare.com by Nyu Medical Center on 07/15/15 For personal use only.
Department of Otolaryngology, Head and Neck Surgery, York Teaching Hospitals NHS Foundations Trust, Wigginton Road, York, YO31 8HE, UK
Abstract
Keywords:
Otitis media with effusion (OME) is a common problem facing general practitioners, pediatricians and otolaryngologists. This article reviews the etiopathogenesis, epidemiology, presentation, natural history and management of OME. The literature was reviewed by using the PubMed search engine and entering a combination of terms including ‘otitis media with effusion’, ‘epidemiology’ and ‘management’. Relevant articles were identified and examined for content. What is the take home message? While OME is a very common entity in the pediatric population, the majority of cases will resolve spontaneously. Surgery in the form of grommet insertion, with or without adenoidectomy is the most effective treatment in persistent symptomatic cases.
Ear, effusion, glue, otitis media, otology, pediatrics
Introduction This is the first of three papers reviewing otitis media. This paper will deal with otitis media with effusion (OME). The second paper will review acute otitis media (AOM). The third will focus on chronic otitis media. Each review will outline the theories of etiopathogenesis, modes of presentation, diagnosis and management options for middle ear disease. OME is defined as the presence of a middle ear effusion in the absence of infection [1]. Its synonyms include ‘glue ear’ and serous otitis media. It is a disease predominantly of childhood with adult prevalence of around 0.6% compared with a point prevalence in the UK of 20% in 2-year olds [2], 91% of 2-year olds having had at least one episode of OME according to one study [3]. This paper will discuss the childhood disease. Fluid in the middle ear is associated most commonly with a conductive hearing loss and an increased risk of acute middle ear infection. It can have an impact on quality of life. There are several areas of controversy surrounding its management; these will be discussed.
Etiology There are several theories as to the cause of OME: 1. Due to Eustachian tube (ET) dysfunction: The middle ear cleft is aerated via the ET. This is a 24-mm tube, two-thirds of its length are cartilaginous and the remaining one-third is bony. It connects the middle ear to the nasopharynx. Dysfunction of the tube is multifactorial. OME is a disease
History Received 8 December 2014 Accepted 9 March 2015
predominantly of childhood. The ET in children is oriented at ten degrees to the horizontal. As the secondary dentition erupts, the mid third of the face elongates and the angle of orientation increases to forty-five degrees to the horizontal. The musculature, which opens the tube functions better in this alignment. Apart from the angulation of the tube, physical obstruction also causes ET dysfunction, as in hypertrophied adenoids in children. Inflammation of the ET secondary to upper respiratory tract infection has also been suggested to cause dysfunction. 2. There are a number of conditions and syndromes, which affect the shape of the mid third of the face and skull base. These are associated with an increased risk of OME, for example, Down’s syndrome and cleft palate. Children with cleft palate can have abnormal insertion of tensor veli palatini in the soft palate leading to an inability to adequately open the ET during swallowing and mouth opening. 3. As a sequelae of AOM: In those children diagnosed with AOM, 45% were found to have a middle ear effusion at 1 month and 10% at 3 months after the initial infection had settled [4]. It is thought that pepsin found in 60% of middle ear effusions causes upregulation of mucin genes leading to increased secretion of mucin and therefore a breeding ground for common upper respiratory tract bacteria. This suggests that the effusion may also be present prior to the AOM episode. 4. Secondary to subclinical bacterial infection: As well as pepsin causing an increase in middle ear mucin, cytokines released secondary to bacterial infection may also lead to OME. One-third of effusion fluid undergoing culture was found to have positive bacterial growth in one study [5].
Correspondence: Sebastian Wallis, ENT Department, York Hospitals NHS Foundations Trust, Wigginton Road, York, YO31 8HE, UK. E-mail: [email protected] 2015 Informa UK Ltd.
382
H. Atkinson et al.
Postgrad Med, 2015; 127(4):381–385
5. In association with gastroesophageal reflux disease: the theory is pepsin related. Pepsin found in middle ear effusions is thought to arise as a result of reflux, although given that not all effusions have pepsin, this is unlikely to be true in all cases.
Postgraduate Medicine Downloaded from informahealthcare.com by Nyu Medical Center on 07/15/15 For personal use only.
Epidemiology There is no difference in incidence between the sexes. Although the condition is most common below the age of 2, it has a bimodal distribution with a further peak at 5 years (16% point prevalence in the UK population). Although the disease is equally common in white and Afro-Caribbean children, higher prevalence is recorded in Native American and Inuit populations [3,6]. Review of the risk factors (Table 1) would suggest it is a disease which more commonly affects the lower social classes given that breastfeeding rates are higher and smoking levels lower in higher social classes [12].
Presentation and diagnosis Children with OME may be asymptomatic only being detected on routine screening. In those where symptoms are present, children rarely complain of hearing loss. More commonly, there is parental concern over the child’s hearing. Speech development can be delayed or reach a plateau. There may be deterioration in school reports. Some children become withdrawn and behavior can decline. OME is known to impact on balance and parents may comment on a child’s clumsiness or tendency to bump into things [13]. The child may have associated nasal obstruction with snoring and mouth breathing. Clinically, the child is assessed using otoscopy, tympanometry and audiometry. It is also useful to assess for obstruction of the nose and nasopharynx by putting a silvered instrument under the nose and asking the patient to close their mouth. Otoscopy is diagnostic in around 78% of cases with 95% specificity when performed by an otolaryngologist [14]. The classic sign of bubbles behind the drum is not present if the middle ear cleft is completely fluid filled and ventilation with a Valsalva maneuver is not achievable (and difficult to perform in small children). Middle ear fluid may give the ear drum a golden coloration but signs are generally more subtle, with retraction of the pars flaccida onto the malleus neck and apparent shortening of the malleus handle as it is retracted
medially. The appearance on otoscopy will vary with the nature of the effusion. Prominent vessels can be seen extending radially on the tympanic membrane. Dullness of the drum and loss of the cone of light are non-specific. Tympanometry aids diagnosis with a sensitivity of 93%. Although specificity for the test is reduced at 70%, combining the two modalities gives more accurate assessment [14]. Tympanometry assesses compliance of the tympanic membrane by placing a probe in the ear and sending a sound wave into the ear canal. The response of the drum is recorded as the sound wave travels back to a receiver. A normal drum sends the sound back to the receiver causing a peak indicating normal middle ear function. In OME, the sound is absorbed by the fluid in the middle ear, resulting in a loss of the peak and a flat tympanometry trace. This is also seen when a perforation is present as the sound travels through the hole and not back to the receiver. A further result of a negative peak is seen when the middle ear pressure is negative (see Table 2 for tympanogram results and associated meanings). As the management of OME is largely guided by audiological assessment, this is vital. Although parental concern may be high, studies have shown that there is not always a clear correlation between parental concern levels and audiological thresholds [15]. The average hearing thresholds seen in children with OME are 27.8 dB [16]. The losses are conductive in nature.
Natural history OME has a fluctuant course. It is most common in those aged 2 years and under, but may present to the otolaryngologist up to 2 years after initial parental concern is expressed [17]. A UK multicenter study looked at older children aged 3.25–6.75 years of age diagnosed with OME. One hundred and fifty-one of the initial 1315 children were not selected for randomization due to high levels of concern regarding their clinical presentation and went on to have a surgical Table 2. Demonstration of common tympanogram results. Curve type
Appearance
A
Peaked
B
Flat
C
Negative peak
Interpretation Normal middle ear ventilation
Table 1. Risk factors for otitis media with effusion. Protective
Causative
Breast feeding Chewing gum Avoidance of supine bottle feeding
Parental smoking Public day care with >10 children in group Dummy/pacifier use Increased number of siblings Positive family history Prematurity Recurrent upper respiratory tract infectiona Gastroesophageal reflux diseasea Allergensa
0
0
a
Limited evidence. Data from [4,7-11].
0
Normal ear canal volume = middle ear effusion Raised ear canal volume = perforated eardrum Negative middle ear pressure suggestive of Eustachian tube dysfunction
Otitis media with effusion
DOI: 10.1080/00325481.2015.1028317
intervention. Without intervention 50% resolved within 3 months and 92% resolved within 9 months [18]. The impact of hearing loss on smaller children (
CLINICAL FEATURE REVIEW
Otitis media with effusion Helen Atkinson, Sebastian Wallis and Andrew P. Coatesworth
Postgraduate Medicine Downloaded from informahealthcare.com by Nyu Medical Center on 07/15/15 For personal use only.
Department of Otolaryngology, Head and Neck Surgery, York Teaching Hospitals NHS Foundations Trust, Wigginton Road, York, YO31 8HE, UK
Abstract
Keywords:
Otitis media with effusion (OME) is a common problem facing general practitioners, pediatricians and otolaryngologists. This article reviews the etiopathogenesis, epidemiology, presentation, natural history and management of OME. The literature was reviewed by using the PubMed search engine and entering a combination of terms including ‘otitis media with effusion’, ‘epidemiology’ and ‘management’. Relevant articles were identified and examined for content. What is the take home message? While OME is a very common entity in the pediatric population, the majority of cases will resolve spontaneously. Surgery in the form of grommet insertion, with or without adenoidectomy is the most effective treatment in persistent symptomatic cases.
Ear, effusion, glue, otitis media, otology, pediatrics
Introduction This is the first of three papers reviewing otitis media. This paper will deal with otitis media with effusion (OME). The second paper will review acute otitis media (AOM). The third will focus on chronic otitis media. Each review will outline the theories of etiopathogenesis, modes of presentation, diagnosis and management options for middle ear disease. OME is defined as the presence of a middle ear effusion in the absence of infection [1]. Its synonyms include ‘glue ear’ and serous otitis media. It is a disease predominantly of childhood with adult prevalence of around 0.6% compared with a point prevalence in the UK of 20% in 2-year olds [2], 91% of 2-year olds having had at least one episode of OME according to one study [3]. This paper will discuss the childhood disease. Fluid in the middle ear is associated most commonly with a conductive hearing loss and an increased risk of acute middle ear infection. It can have an impact on quality of life. There are several areas of controversy surrounding its management; these will be discussed.
Etiology There are several theories as to the cause of OME: 1. Due to Eustachian tube (ET) dysfunction: The middle ear cleft is aerated via the ET. This is a 24-mm tube, two-thirds of its length are cartilaginous and the remaining one-third is bony. It connects the middle ear to the nasopharynx. Dysfunction of the tube is multifactorial. OME is a disease
History Received 8 December 2014 Accepted 9 March 2015
predominantly of childhood. The ET in children is oriented at ten degrees to the horizontal. As the secondary dentition erupts, the mid third of the face elongates and the angle of orientation increases to forty-five degrees to the horizontal. The musculature, which opens the tube functions better in this alignment. Apart from the angulation of the tube, physical obstruction also causes ET dysfunction, as in hypertrophied adenoids in children. Inflammation of the ET secondary to upper respiratory tract infection has also been suggested to cause dysfunction. 2. There are a number of conditions and syndromes, which affect the shape of the mid third of the face and skull base. These are associated with an increased risk of OME, for example, Down’s syndrome and cleft palate. Children with cleft palate can have abnormal insertion of tensor veli palatini in the soft palate leading to an inability to adequately open the ET during swallowing and mouth opening. 3. As a sequelae of AOM: In those children diagnosed with AOM, 45% were found to have a middle ear effusion at 1 month and 10% at 3 months after the initial infection had settled [4]. It is thought that pepsin found in 60% of middle ear effusions causes upregulation of mucin genes leading to increased secretion of mucin and therefore a breeding ground for common upper respiratory tract bacteria. This suggests that the effusion may also be present prior to the AOM episode. 4. Secondary to subclinical bacterial infection: As well as pepsin causing an increase in middle ear mucin, cytokines released secondary to bacterial infection may also lead to OME. One-third of effusion fluid undergoing culture was found to have positive bacterial growth in one study [5].
Correspondence: Sebastian Wallis, ENT Department, York Hospitals NHS Foundations Trust, Wigginton Road, York, YO31 8HE, UK. E-mail: [email protected] 2015 Informa UK Ltd.
382
H. Atkinson et al.
Postgrad Med, 2015; 127(4):381–385
5. In association with gastroesophageal reflux disease: the theory is pepsin related. Pepsin found in middle ear effusions is thought to arise as a result of reflux, although given that not all effusions have pepsin, this is unlikely to be true in all cases.
Postgraduate Medicine Downloaded from informahealthcare.com by Nyu Medical Center on 07/15/15 For personal use only.
Epidemiology There is no difference in incidence between the sexes. Although the condition is most common below the age of 2, it has a bimodal distribution with a further peak at 5 years (16% point prevalence in the UK population). Although the disease is equally common in white and Afro-Caribbean children, higher prevalence is recorded in Native American and Inuit populations [3,6]. Review of the risk factors (Table 1) would suggest it is a disease which more commonly affects the lower social classes given that breastfeeding rates are higher and smoking levels lower in higher social classes [12].
Presentation and diagnosis Children with OME may be asymptomatic only being detected on routine screening. In those where symptoms are present, children rarely complain of hearing loss. More commonly, there is parental concern over the child’s hearing. Speech development can be delayed or reach a plateau. There may be deterioration in school reports. Some children become withdrawn and behavior can decline. OME is known to impact on balance and parents may comment on a child’s clumsiness or tendency to bump into things [13]. The child may have associated nasal obstruction with snoring and mouth breathing. Clinically, the child is assessed using otoscopy, tympanometry and audiometry. It is also useful to assess for obstruction of the nose and nasopharynx by putting a silvered instrument under the nose and asking the patient to close their mouth. Otoscopy is diagnostic in around 78% of cases with 95% specificity when performed by an otolaryngologist [14]. The classic sign of bubbles behind the drum is not present if the middle ear cleft is completely fluid filled and ventilation with a Valsalva maneuver is not achievable (and difficult to perform in small children). Middle ear fluid may give the ear drum a golden coloration but signs are generally more subtle, with retraction of the pars flaccida onto the malleus neck and apparent shortening of the malleus handle as it is retracted
medially. The appearance on otoscopy will vary with the nature of the effusion. Prominent vessels can be seen extending radially on the tympanic membrane. Dullness of the drum and loss of the cone of light are non-specific. Tympanometry aids diagnosis with a sensitivity of 93%. Although specificity for the test is reduced at 70%, combining the two modalities gives more accurate assessment [14]. Tympanometry assesses compliance of the tympanic membrane by placing a probe in the ear and sending a sound wave into the ear canal. The response of the drum is recorded as the sound wave travels back to a receiver. A normal drum sends the sound back to the receiver causing a peak indicating normal middle ear function. In OME, the sound is absorbed by the fluid in the middle ear, resulting in a loss of the peak and a flat tympanometry trace. This is also seen when a perforation is present as the sound travels through the hole and not back to the receiver. A further result of a negative peak is seen when the middle ear pressure is negative (see Table 2 for tympanogram results and associated meanings). As the management of OME is largely guided by audiological assessment, this is vital. Although parental concern may be high, studies have shown that there is not always a clear correlation between parental concern levels and audiological thresholds [15]. The average hearing thresholds seen in children with OME are 27.8 dB [16]. The losses are conductive in nature.
Natural history OME has a fluctuant course. It is most common in those aged 2 years and under, but may present to the otolaryngologist up to 2 years after initial parental concern is expressed [17]. A UK multicenter study looked at older children aged 3.25–6.75 years of age diagnosed with OME. One hundred and fifty-one of the initial 1315 children were not selected for randomization due to high levels of concern regarding their clinical presentation and went on to have a surgical Table 2. Demonstration of common tympanogram results. Curve type
Appearance
A
Peaked
B
Flat
C
Negative peak
Interpretation Normal middle ear ventilation
Table 1. Risk factors for otitis media with effusion. Protective
Causative
Breast feeding Chewing gum Avoidance of supine bottle feeding
Parental smoking Public day care with >10 children in group Dummy/pacifier use Increased number of siblings Positive family history Prematurity Recurrent upper respiratory tract infectiona Gastroesophageal reflux diseasea Allergensa
0
0
a
Limited evidence. Data from [4,7-11].
0
Normal ear canal volume = middle ear effusion Raised ear canal volume = perforated eardrum Negative middle ear pressure suggestive of Eustachian tube dysfunction
Otitis media with effusion
DOI: 10.1080/00325481.2015.1028317
intervention. Without intervention 50% resolved within 3 months and 92% resolved within 9 months [18]. The impact of hearing loss on smaller children (
