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Otitis Media With Effusion
Introduction
Otitis media encompasses various otologic conditions, including acute otitis media, recurrent acute otitis media, OME, and chronic otitis media.[1] OME is a specific clinical condition characterized only by fluid accumulation in the middle ear without acute infection. The fluid may be either mucoid or serous. Elevated levels of prostaglandins and leukotrienes may be present in middle ear effusions.[2] As fluid accumulates in the middle ear and the Eustachian tube, it exerts pressure on the tympanic membrane. This pressure hinders the tympanic membrane's ability to vibrate correctly, reducing sound conduction and thereby diminishing the patient's hearing.
Most individuals experience no symptoms besides a sensation of fullness in the ear and mild hearing loss. Serous otitis media likely occurs due to the formation of transudate resulting from a rapid decrease in middle ear pressure compared to atmospheric pressure.[3] Mucoid otitis media refers to "glue ear" because of the thick accumulation of mucins, including MUC4, MUC5AC, MUC5B, and MUC6–8.[4] Chronic OME refers to OME that lasts 3 months or longer upon examination or tympanometry. However, some clinicians suggest using the term "chronic otitis media" exclusively for patients who experience complications, including tympanic membrane perforation, mastoiditis, or cholesteatoma.[5]
Audiometry and tympanometry are the most effective diagnostic tools for OME. Weber and Rinne tests play a minimal role and tend to be subjective. Patient management is customized based on individual needs, particularly in relation to speech and language development risks. Pharmacologic treatments are constrained by both their effectiveness and cost. Myringotomy, with or without the placement of ear ventilation tubes and adenoidectomy, has been effective, whereas tonsillectomy has not proven beneficial. Expectant management is advocated for many patients.[6]
Etiology
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Etiology
OME can arise from several underlying causative factors, including host characteristics, inflammation, infections, allergies, and environmental influences, all of which impact the Eustachian tube and middle ear. The Eustachian tube plays a vital role in balancing air pressure between the middle ear and the external environment, removing secretions, enhancing sound transmission in the middle ear, and protecting both the middle and inner ear. The dominant theory posits that OME develops when negative pressure forms in the middle ear space.[7] This negative pressure triggers a transudate from the mucosa, resulting in a sterile effusion. This fluid may create an environment conducive to infection. However, this theory may have limitations, as identical pathogenic bacteria have been identified in acute OME.[8]
Host Factors
Contributing host factors to the evolution of OME include:
- Physiological dysfunction of the Eustachian tube [9]
- Anatomic blockage
- Inflammation
- Allergies
- Upper respiratory tract infection
- Trauma
- Immune system
- Immature
- Impaired with congenital immune deficiencies, HIV, diabetes, or other developmental anomalies [10]
- Genetic predisposition
- Mucins
- Anatomic abnormalities including cleft palate, Crouzon or Apert syndrome, and Treacher Collins syndrome [11]
- Children with developmental anomalies affecting the palate, palate muscles, and muscle tone, or variations in bone development, are at a higher risk of developing OME, eg, cleft palate and Down syndrome.[12]
- Patients with Down syndrome may experience disorders of mucociliary function that further increase the risk of developing OME.[13][14]
- Age
- The eustachian tube is positioned more horizontally in younger children than at a 45-degree angle in adults. As the child develops into an adult, the tube elongates and angles caudally.
- The size and shape of the Eustachian tube at birth are unfavorable for the ventilation of the middle ear.
- The peak incidence of OME occurs in children aged 2 to 4 years.[15]
- Adults with unilateral OME must be evaluated for a nasopharyngeal mass.[16]
Environmental Factors
Environmental factors that increase the risk of developing OME include:
- Having a sibling with otitis media
- Attending daycare [13]
- Having allergies to common environmental substances
- Lower socioeconomic status [17]
- Second-hand or third-hand smoke [18]
- Parental history of OME
- Dietary factors
- Ethnicity
- Children of Asian ethnicity may show a lower incidence of OME [21]
- Gastroesophageal reflux (adults) [22][23]
Both children and adults may develop OME, though the underlying causes differ between these groups. In younger children, the Eustachian tube lies in a more horizontal orientation. As the child develops into an adult, the tube elongates and shifts to a more caudal angle. This anatomical progression explains the higher incidence of OME in children. Additionally, head positioning during early childhood plays a significant role in the development of the condition.[12]
Epidemiology
OME ranks as the most common disease affecting children.[24] As the leading cause of acquired hearing loss in childhood, OME often develops early in life.[25] By age 4, up to 80% of children experience at least 1 episode, though prevalence typically declines after the age of 6 years.[26] Most children recover within 3 months without intervention; however, recurrence occurs in approximately 30% to 40% of cases.[27]
OME can adversely affect developmental milestones, particularly during the first year of life, and may significantly impact the quality of life for both children and their parents, contributing to physical, emotional, and financial stress.[28][29][28] The highest prevalence is observed in children younger than 2, followed by a marked decline after the age of 5 years.[30] Incidence rates rise during the winter months, correlating with an increase in upper respiratory infections, especially among children from lower socioeconomic backgrounds.[31]
Pathophysiology
OME, or "glue ear," involves fluid accumulation in the middle ear, with viscosity ranging from thin and serous to thick and mucoid. The primary theories explaining its pathophysiology include inflammatory mechanisms, biofilms, gastroesophageal reflux, and the structure of the eustachian tube (see Image. Acute Otitis Media Pathophysiology).
Inflammatory Hypothesis
Inflammation and immune responses to rhinopharyngeal infections contribute to OME. Although previously believed to involve sterile effusion, polymerase chain reaction (PCR) assays have identified bacterial RNA and DNA in middle ear fluid.[32] Pathogens such as Streptococcus pneumoniae, Haemophilus influenzae, and Moraxella catarrhalis have been visualized using confocal microscopy.[33]
Biofilms
Biofilms, consisting of adherent bacterial communities embedded in a matrix of polysaccharides, nucleic acids, and proteins, have been detected in over half of culture-negative OME cases.[34] These bacteria, often metabolically active, survive in low-oxygen environments and show resistance to systemic antibiotics.[35][36][35]
Gastroesophageal Reflux and Allergy
Pepsins and Helicobacter pylori have been identified in middle ear effusions, suggesting a link to Gastroesophageal reflux.[37][38] Children with chronic rhinitis, turbinate hypertrophy, asthma, or allergies may face an elevated risk.[39] Mucin gene activation may also contribute, with membrane-bound proteins, eg, MUC1, MUC3, and MUC4 facilitating microbial attachment, while MUC5AC and MUC5B promote mucus accumulation in the middle ear.[40][41]
Eustachian Tube Structure
In children, the Eustachian tube's shorter, more horizontal orientation and limited closure capacity reduce its ability to regulate pressure and prevent contamination of the middle ear space. Enlarged adenoids may further obstruct the Eustachian tube, exacerbating the condition.[42]
Histopathology
Researchers believe the mucociliary defense system in the Eustachian tube is the first line of defense in the middle ear. This system relies on immunoglobulins produced by the mucosa. Since these immunoglobulins are significantly elevated in effusions, the defense system may be overactive in OME.[43] Additionally, hyperplasia of the middle ear is a key part of OME and may be linked to the expression of the heparin-binding epidermal growth factor (HB-EGF).[44] Histopathology of the temporal bone in OME reveals mucosal inflammation and metaplasia, accompanied by edema, vascular dilation, hyperplasia, and infiltration by mononuclear cells, similar to that seen in acute otitis media.[45]
Toxicokinetics
In addition to bacterial pathogens, OME may also be caused by inflammation driven by viruses or allergies. While allergy is a significant risk factor for otitis media, clinical practice guidelines (2004) concluded that there was little evidence to support specific management strategies for allergy-induced OME.[46] However, treatment of allergic rhinitis may assist patients who develop OME in conjunction with allergies.[47] Some recommend screening children with allergies or asthma for OME.[39] Other experts recommend screening for allergies only when OME is paired with asthma or chronic rhinitis.[48]
History and Physical
Clinical Features
Hearing loss, though not always readily apparent, represents the most frequently reported symptom of OME by patients, families, or caregivers. OME commonly results in communication difficulties, delayed language development, academic struggles, behavioral or sleep disturbances, social withdrawal, and reduced concentration during activities, eg, conversations, listening to music, or watching television.
Many children present with a history of prior ear infections or hearing changes. Complaints may include a sensation of blocked ears, popping sounds, ear pain, or frequent ear tugging. Most children experience an episode of acute otitis media—characterized by fever, pain, and upper respiratory symptoms—before developing OME. In adults, OME typically presents unilaterally and often follows upper respiratory symptoms. Adult patients may report hearing loss, tinnitus, or a sensation of fullness or obstruction in the ear canal. Middle ear fluid accumulation in adults often occurs after pressure changes, such as during flying or diving.
A thorough medical history should include previous ear infections, hearing loss, tinnitus, vertigo, ear drainage, or prior procedures such as tympanostomy tube placement, tonsillectomy, or adenoidectomy. Pneumatic otoscopy remains essential for evaluating the ear canal and eardrum, including assessment of tympanic membrane mobility and light reflex (see Image. Acute Otitis Media on Otoscopy). When available, binocular microscopes or video-otoscopes provide additional diagnostic support. In some cases, air bubbles, a liquid film, cloudiness, or bluish or yellowish discoloration of the tympanic membrane may be visible.
Evaluation
Audiometry and Tympanometry Evaluation
Age-appropriate pure-tone audiometry and tympanometry should be performed to assess hearing. A "flat" tympanogram will support a diagnosis of OME.[49] Testing hearing in infants can be done using auditory brainstem responses (ABR) or brainstem auditory evoked potentials (BAEP). These tests assess the functioning of the auditory pathway, from the auditory nerve to the brainstem. ABR is considered the gold standard for confirming hearing loss in infants who fail newborn screenings; however, it doesn't specifically detect conductive hearing loss resulting from middle ear effusion. Another option is otoacoustic emissions (OAE), which can be used for hearing screening. However, OAE is not very specific and may be inaccurate if background sounds are present.
The 3 types of hearing loss are sensorineural (SNHL), conductive, and mixed hearing loss.[50] OME can lead to conductive hearing loss by impacting the transmission of sound from the air through the middle ear structures. This condition may create an air-bone gap >15 dB HL. In some children, mixed hearing loss may be present, as SNHL is known to occur in otitis media, although the etiology is not yet understood. Children with suspected OME should undergo language testing to assess for language delay.
Additional Diagnostic Studies
Other tests that have been used include:
- Erythrocyte sedimentation rate (ESR) to rule out bone destruction (rarely used)
- Complete blood count (CBC) for ruling out acute infection
- Computed tomography scan to rule out middle ear disease, eg, cholesteatoma, extracranial or intracranial abnormalities, or congenital anomalies
- Magnetic resonance imaging scan for soft tissue masses or intracranial abnormalities
Tympanocentesis has been recommended in certain clinical contexts. This procedure, typically conducted in an office setting, may serve both diagnostic (culture) and therapeutic purposes.[51] However, most otolaryngologists prefer myringotomy for improved visualization, middle ear drainage, and placement of ear ventilation tubes in uncomplicated OME patients.
Treatment / Management
Expectant Management
OME may resolve on its own, or the hearing loss may be minor, making watchful waiting an option. Modification of risk factors during ongoing expectant management may be beneficial, including:
- Avoidance of known allergens
- Avoidance of feeding, either breast or bottle, while the child is supine
- Breastfeeding when possible
- Avoidance of secondhand or thirdhand smoke
- Avoidance of daycare settings or places where children may have upper respiratory infections
- Chewing gum at least once a week (a study showed a 40% reduction in OME) [52]
Autoinsufflation
Autoinsufflation involves forcing air from the nose and throat into the middle ear to equalize pressure and promote drainage. This technique proves especially helpful for adults capable of performing the maneuver independently. Children who understand and can execute autoinsufflation may also benefit, as the practice can help clear middle ear effusions, enhance hearing, and improve overall quality of life.[53](A1)
Pharmacological Management
Pharmacologic management of OME includes:
- Antibiotics (eg, erythromycin, sulfisoxazole, amoxicillin, amoxicillin-clavulanate, and trimethoprim-sulfamethoxazole)
- Steroids with or without antibiotics
- No statistically significant impact on hearing improvement from the use of oral steroids after OME persists for 3 to 9 months. However, a slight improvement is noted at 12 months of OME persistence with the use of oral steroids.[56]
- Topical intranasal steroids, alone or in combination with oral antibiotics, have no statistically significant benefit [57][58]
- Antihistamines, decongestants, or mucolytics (A1)
Surgical Management
Surical therapies are widely accepted and effective, but the indications remain controversial. Interventions include:
Myringotomy with tympanostomy tube insertion
Myringotomy with tympanostomy tube insertion serves as an effective treatment for OME.[61] Ventilation tubes enable air entry into the middle ear, reducing the likelihood of fluid reaccumulation. Following the procedure, many patients require no further therapy, as the natural growth and angulation of the Eustachian tube support improved drainage. Extended middle ear ventilation helps reverse mucosal hyperplasia and metaplasia. Pressure equalization tubes come in various configurations, materials, and designs.
Complications occur in approximately 10% of cases and may include persistent otorrhea, tympanosclerosis, or tympanic membrane perforation. Less common complications include granulation tissue formation, cholesteatoma, and sensorineural hearing loss.[62] A hearing loss threshold of 40 dB or greater often prompts surgical consideration, although decisions also depend on factors, eg, speech and language development.
In children, most procedures are performed under general anesthesia without the need for intubation. Newer techniques, including single-pass devices, are being evaluated for use in office-based settings. In adults, unilateral procedures are more common and typically conducted in-office with local anesthesia.[63] While most adults tolerate the procedure well, some may experience intermittent or chronic ear discharge.[64]
Myringotomy and aspiration of fluid without tympanostomy tube placement
Myringotomy with fluid aspiration alone generally offers less benefit without tympanostomy tube insertion, though select adult patients may experience immediate relief.
Adenoidectomy and tonsillectomy
Tonsillectomy does not improve outcomes for patients with OME. In contrast, adenoidectomy—with or without concurrent tympanostomy tube placement—plays a key role in managing persistent or recurrent OME.[65] Many otolaryngologists recommend both procedures when ventilation tubes alone fail to prevent recurrence. Adenoid size alone does not reliably predict surgical success. Adenoidectomy may help by reducing nasopharyngeal pressure during swallowing, limiting Eustachian tube reflux, relieving functional obstruction at the Eustachian tube orifice, and eliminating a potential source of chronic inflammation or infection.[66][67][68]
Hearing Aids or other assistive hearing devices (limited use in OME)
Hearing aids and other assistive listening devices have limited use in the management of OME. Childhood hearing loss can negatively influence language development.[69] Hearing aids offer a noninvasive treatment option for OME; yet, most children with this condition do not receive referrals to audiology for hearing aids or assistive devices.[70] While hearing aids may provide significant benefits, some children experience adverse effects such as self-consciousness or teasing, which can reduce device usage and limit effectiveness.[71] Among those referred for hearing aids due to OME-related hearing loss, only about half are eventually fitted with a device.[70](B2)
An individualized, patient-focused approach should be adopted.[72][73][74] How the child is coping socially and at school may be more important than the results of audiometry investigations when deciding whether to proceed with surgery.[75][76][77] However, certain otologic findings may prompt surgical intervention, eg, the formation of a posterior superior retraction pocket, ossicular abnormalities or erosions, adhesive atelectasis, and keratin debris in the ear canal. (A1)
Differential Diagnosis
Adults
Differential diagnoses that should be considered when evaluating OME in adults include:
- Benign nasopharyngeal masses
- Acute otitis media
- Myringitis
- Patulous Eustachian tube
- Malignant tumors of the nasal cavity
- Malignant tumors of the temporal bone
- Nasopharyngeal carcinoma [16]
Children
Differential diagnoses that should be considered when evaluating OME in children include:
- Acute otitis media [46]
- Myringitis
- Adenoid hypertrophy
- Congenital craniofacial anomalies
- Down syndrome
- Cleft palate
- Achondroplasia
- Treacher Collins syndrome
- Hemifacial microsomia
- CHARGE syndrome
- Klippel-Feil syndrome
- Ciliary dyskinesia
- Cystic fibrosis
- Immunoglobulin G (IgG) subclass deficiencies
Prognosis
In 2016, the American Academy of Otolaryngology-Head and Neck Surgery Foundation (AAO-HNS), with the endorsement of the American Academy of Family Physicians (AAFP), updated its clinical practice guidelines for the diagnosis and management of OME.[78] For OME, the prognosis is generally good. Treatment is tailored to each patient, focusing on their individual needs. In most cases, children with OME will recover from hearing loss and speech and language delays, with no lasting effects. Adults with OME also tend to have a positive outlook, depending on the underlying condition. Malignancies related to OME remain rare.
Complications
The vast majority of patients with OME see a resolution of their signs and symptoms with appropriate management and follow-up. Complications are generally rare, but may depend on an underlying condition or comorbidity.
Minor complications associated with OME include:
- Hearing loss (conductive, sensorineural, or mixed) [79]
- Tympanic membrane perforation [80]
- Tympanosclerosis [81]
- Acute or chronic suppurative otitis media [82]
- Speech and language delay [83]
Major complications of OME, which are rarer, include:
- Cholesteatoma
- Postauricular abscess
- Mastoiditis
- Labyrinthitis
- Facial nerve paresis or paralysis
- Temporal bone abscess
- Petrositis
- Intracranial abscess
- Meningitis
- Otitic hydrocephalus
- Sigmoid sinus thrombosis
- Encephalocele
- Cerebrospinal fluid leak
- Nasal or nasopharyngeal complications related to the underlying condition
Postoperative and Rehabilitation Care
Most children who undergo myringotomy and ear ventilation tube placement or adenoidectomy to treat OME require minimal postoperative care. These procedures are performed on an outpatient basis with few complications or long-term sequelae. Rehabilitation may include speech and language training once the child's hearing has improved. Repeat pure tone audiometry may be necessary for monitoring.
Adults who undergo myringotomy and ear ventilation tube placement typically experience immediate improvement. This procedure is conducted in an office setting under binocular microscopy, resulting in minimal discomfort. Follow-up and management depend on diagnosing and treating any underlying medical conditions.
Most otolaryngologists recommend using otic drops after a myringotomy and ear tube placement to prevent infections and ensure the tube's proper function and patency. These ear drops can also help manage postoperative otorrhea. However, some ambiguity regarding which type of antibiotic drops surgeons use exists due to concerns about potential ototoxicity.[84] Many surgeons avoid drops containing aminoglycosides, eg, gentamicin or neomycin, but the choice of medication often relies on the surgeon's experience and personal preference.
Consultations
Consultations may involve a wide range of medical professionals, including pediatricians, neonatal specialists, geneticists, family doctors, internal medicine specialists, neurologists, pulmonologists, cardiologists, audiologists, allergists, speech therapists, and otolaryngologists.
Deterrence and Patient Education
Evaluating, diagnosing, and managing OME should involve a collaborative effort among patients, families, educators, and healthcare professionals. Hearing difficulties can lead to behavioral issues, reduced educational or training opportunities, balance problems, and various other medical complications. Patient education must be tailored to individual needs, with thorough follow-up that includes pneumatic otoscopy, tympanometry, and pure-tone audiometry.
Children with suspected craniofacial anomalies or congenital disorders require careful attention and evaluation. Adults with unilateral OME should undergo a comprehensive evaluation, including nasopharyngoscopy, to identify underlying causes, eg, nasal or nasopharyngeal lesions and infections. Clinicians should have a low threshold for obtaining imaging in patients suspected of having upper airway abnormalities, which may underlie OME. The use of antibiotics, steroids, antihistamines, leukotriene receptor antagonists, mucolytics, proton pump inhibitors, anti-reflux medications, and decongestants in treating OME should be avoided.[85]
Pearls and Other Issues
The following factors should be kept in mind when managing OME:
- Pneumatic otoscopy should be used to document the presence of middle ear effusion in patients with otalgia, hearing loss, or tinnitus.
- Pure-tone audiometry and tympanometry should be obtained, if available, and the patient is cooperative.
- Weber and Rinne tests tend to be subjective and of less value than pure-tone audiometry and tympanometry.
- For most children diagnosed with OME, conservative treatment with watchful waiting is recommended within the first 3 months of diagnosis.
- Hearing aids or other assistive devices play a limited role in OME management. They should be discouraged in adults with unilateral OME who have not undergone a thorough evaluation by an otolaryngologist and audiologist.
- Antibiotics, steroids, or other medications should be avoided in most patients, particularly without comorbidities.
- Management should focus on elective myringotomy, ear ventilation tube placement, or adenoidectomy.
- Adults with unilateral OME should undergo a thorough head and neck examination, including nasopharyngoscopy, and imaging as appropriate to rule out malignancy or other abnormalities, such as nasal polyps and chronic sinusitis.
- Children with persistent OME should be evaluated for craniofacial anomalies, congenital disorders, or other systemic etiologies.
- Caution should be used in patients with a suspicion on otoscopy of posterior superior retraction pockets, cholesteatoma, or other otologic abnormalities.
Enhancing Healthcare Team Outcomes
Delivering patient-centered care for individuals with OME depends on the coordinated efforts of an interprofessional healthcare team. Physicians, advanced practice practitioners, audiologists, speech therapists, and other specialists must apply clinical expertise to ensure accurate diagnosis and effective management. A high level of skill is required to distinguish OME from other middle ear conditions and to avoid unnecessary pharmacologic interventions. Particular attention must be paid to the developmental impact of hearing loss in young children, including the risks it poses to speech and language acquisition. Adult patients also require thorough evaluation to rule out nasopharyngeal masses or other structural abnormalities. A strategic, evidence-based approach should guide decision-making, incorporating each patient’s medical history, developmental stage, family context, and social environment. Individualized care plans must address not only clinical needs but also educational and psychosocial factors, especially when evaluating surgical interventions such as tympanostomy tube placement or adenoidectomy.
Interprofessional collaboration plays a vital role in improving outcomes and ensuring patient safety. Clearly defined responsibilities among team members allow each professional to contribute effectively—physicians lead diagnostic and treatment efforts, nurses support patient education and monitoring, audiologists assess hearing function, and speech therapists address communication delays. Pharmacists contribute by evaluating medication use and preventing the use of ineffective treatments. Open, respectful communication among disciplines fosters timely information exchange, encourages clinical inquiry, and enhances shared decision-making. Coordinated care pathways, from initial evaluation through treatment and follow-up, reduce fragmentation, prevent delays in care, and minimize diagnostic and therapeutic errors. These efforts not only support optimal hearing and developmental outcomes but also improve patient satisfaction, reduce the burden on families, and strengthen the overall performance of the healthcare team.
Media
(Click Image to Enlarge)
Acute Otitis Media on Otoscopy. This otoscopic image shows tympanic membrane erythema and bulging, consistent with acute otitis media.
Contributed by Wikimedia Commons, B. Welleschik (CC by 2.0) https://creativecommons.org/licenses/by/2.0/
(Click Image to Enlarge)
Acute Otitis Media Pathophysiology. This illustration shows the common etiologies and pathophysiology of acute otitis media.
Purchased from Shutterstock
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