Summary
Otitis media with effusion (OME) is the presence of mucoid or serous effusion in the tympanic cavity with no signs of acute infection. OME that persists for ≥ 3 months is classified as chronic. OME occurs most commonly in young children and causes include eustachian tube dysfunction or underdevelopment, acute otitis media (AOM), and upper respiratory tract infection. Patients with OME are often asymptomatic but may present with ear pressure, hearing loss, and/or a delay in speech and language development. Diagnosis is confirmed if pneumatic otoscopy shows reduced tympanic membrane (TM) mobility. Additional diagnostic testing may include tympanometry if there is diagnostic uncertainty, or hearing tests in patients presenting with hearing loss. OME is usually managed conservatively. Surgical management with tympanostomy tubes and/or adenoidectomy are indicated in some patients (e.g., patients with TM damage seen on otoscopy, chronic OME with hearing loss, or risk factors for developmental disorders in children with OME). For adults with OME, nasopharyngeal cancer should be considered as a possible underlying cause and diagnostic evaluation may include nasopharyngoscopy.
See also “Chronic suppurative otitis media” and “Acute otitis media.”
Epidemiology
- Up to 90% of children experience OME before the age of 5 years, often after a viral infection or episode of AOM. [1]
- OME is the leading cause of childhood hearing loss in resource-rich countries. [1]
Epidemiological data refers to the US, unless otherwise specified.
Etiology
- AOM (may be recurrent AOM) [1]
- Upper respiratory tract infections [1]
- Eustachian tube dysfunction or underdevelopment [1]
- Allergic rhinitis and GERD have been associated with OME, however, the relationship is unclear. [1][2]
- See also “Risk factors for AOM.”
Pathophysiology
- Eustachian tube dysfunction causes negative middle ear pressure → triggers formation of transudate → dysfunctional eustachian tube prevents adequate drainage → accumulation of fluid
- More common in children as the eustachian tube is shorter, more horizontal, and less effective at closing compared to adults and therefore less effective at aerating the middle ear and protecting it from pathogens. [1]
Clinical features
Symptoms [1][3]
- Often asymptomatic
- Sensation of pressure in the affected ear (may be painless or manifest with mild otalgia)
- Sleep disturbances
- Balance problems
-
Conductive hearing loss, which may cause developmental disorders
- Includes speech and language impairment, behavioral difficulties, poor school performance
- More common if there are risk factors for developmental disorders in children with OME, e.g.:
- Craniofacial disorders, Down syndrome, cleft palate
- Neurodevelopmental disorders, autism spectrum disorders
- Permanent hearing loss unrelated to OME
- Developmental delay
- See also “Child development and milestones” for more information on expected development according to age.
Examination findings [1]
- Examination, including otoscopy, may be completely normal.
- Underlying structural abnormalities of the TM or middle ear may be detected.
- Fluid behind the TM can be seen in both OME and AOM; additional clinical features help differentiate the conditions.
| Otoscopic findings in OME vs. AOM [1][4] | ||
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| Tympanic membrane characteristics | Otitis media with effusion | Acute otitis media |
| Position |
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| Translucency |
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| Color |
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| Possible other findings |
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Otoscopy may be normal in patients with OME; pneumatic otoscopy should be performed for diagnostic confirmation. [1]
Diagnosis
General principles [3]
- The diagnosis of OME is based on clinical features and pneumatic otoscopy findings of reduced TM mobility.
- Further tests (tympanometry, hearing tests) are usually reserved for diagnostic uncertainty or suspected complications.
- In adults, nasopharyngoscopy may also be required (see “OME in adults”). [3]
Pneumatic otoscopy [1]
-
Indications
- All patients with suspected OME
- Otalgia
- Hearing loss
- Findings: reduced TM mobility secondary to effusion
Tympanometry [1]
-
Indications
- Diagnostic uncertainty
- Risk factors for developmental disorders in children with OME
- Preoperative assessment for tympanostomy tubes
-
Pneumatic otoscopy cannot be performed because:
- The TM cannot be visualized
- Intolerance of procedure
- Findings: a flat curve indicating reduced TM mobility [5]
Hearing tests [1][2]
- Indications
-
Modalities [1]
- ≥ 4 years of age: Obtain subjective audiometry.
- < 4 years of age or hearing loss detected on subjective audiometry: Refer to audiology for further evaluation.
- Findings: Audiogram may show conductive hearing loss of 21–55 dB. [1][2]
Hearing loss associated with OME is usually in the range of 21–55 dB; children with higher levels of hearing loss should undergo additional evaluation. [1][2]
Differential diagnoses
- Acute otitis media: Consider in children with fever and/or moderate to severe otalgia. [1]
- Nasopharyngeal tumor: Consider in all patients with nasal obstruction and adults with chronic OME. [3]
- Chronic suppurative otitis media: can cause similar symptoms to OME but the TM will not be intact
The differential diagnoses listed here are not exhaustive.
Treatment
Management of OME is largely conservative; patients are referred to ENT for consideration of surgery if there is hearing loss or an increased risk of developmental delay.
Approach [1]
- Screen patients for the following risk factors for complications and refer to ENT if present:
- TM damage seen on otoscopy
- Risk factors for developmental disorders in children with OME
- All other patients: follow-up in 3 months
- Effusion resolves at 3 months: No follow-up is necessary.
- Effusion persists at 3 months: Perform a hearing test (see “Diagnostics of OME”).
- No hearing loss: conservative management of OME
- Hearing loss: Refer to ENT for consideration of surgery.
In children, hearing loss due to OME may impair speech and language development. Therefore, early initiation of treatment is important. [1]
Conservative management of OME [1][2]
- Perform pneumatic otoscopy and hearing tests every 3–6 months.
- Discontinue follow-up if OME resolves.
- Refer to ENT if any of the following occur:
- TM damage
- Hearing loss
- Consider use of an autoinflation device; increasing nasal pressure can help keep the eustachian tube open. [6]
- If hearing is impaired, strategies to facilitate the child's understanding and learning should be implemented. [1]
- Steroids, antibiotics, antihistamines, anti-reflux therapies, and decongestants are not routinely indicated for the treatment of OME. [1][2][7]
Watchful waiting is recommended for most patients; medications (e.g., steroids, antibiotics) are not effective in managing OME. [1][2]
Surgical management [1][8]
- Indications: Chronic OME with any of the following characteristics. [1][8][9]
-
Methods [1][1]
- Patients < 4 years of age: tympanostomy tube placement
- Patients ≥ 4 years of age: tympanostomy tube placement and/or adenoidectomy
- Follow-up: Repeat hearing test to confirm hearing loss has improved. [1]
Use shared decision-making when considering surgery for the management of OME. [1]
Surgery should not be performed for OME of < 3 months' duration. [8]
Prevention
Primary prevention
- Encourage breastfeeding. [1]
- Educate patients and caregivers on prevention of AOM.
- Provide prompt treatment of AOM.
Breastfeeding is associated with a reduced risk of OME. [1]
Screening
- Routine screening for OME in healthy children is not recommended.
- For patients with risk factors for developmental disorders in children with OME: [1]
- Evaluate for OME at the time risk factors are identified (see “Diagnostics of OME”).
- Repeat evaluation for OME at 12–18 months of age (if risk factors were identified prior to this age).
Special patient groups
OME in adults
General principles
- Additional etiologies of OME in adults include: [10][11]
- Sinonasal inflammation (e.g., sinusitis, rhinitis)
- Adenoidal enlargement
- Malignancy (e.g., nasopharyngeal carcinoma)
- Clinical features of OME in adults are generally similar to those in children.
Diagnostics
- Diagnostics of OME are largely the same as in children.
- Obtain nasopharyngoscopy in patients with additional features that are concerning for nasopharyngeal cancer. [11][12][13]
Incidence of nasopharyngeal cancer varies significantly; in adults from high prevalence areas (East and South East Asia), consider a more aggressive initial workup of OME. [11][14]
Management [15]
- There is a lack of guidelines on the management of OME in adults.
- Treatment is broadly similar to children with the following modifications:
- Refer to ENT if OME lasts for > 6 weeks. [15]
- Treatment of underlying sinus disease may be appropriate (e.g., treatment of sinusitis). [16]
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