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ENT (Ear, Nose, Throat Conditions)

Otitis Media with Effusion (OME)

Presence of non-purulent fluid (effusion) in the middle ear space behind an intact tympanic membrane, without signs or symptoms of acute infection. Common cause of hearing impairment in children.

Also known as: Glue Ear, Serous Otitis Media

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Referral and warning signs

When to refer

Refer to ENT Specialist if: OME persists >3 months with significant hearing loss or symptoms. Suspected underlying cause requiring investigation (e.g., cleft palate). Need for consideration of grommet insertion +/- adenoidectomy. Unilateral OME in an adult (needs exclusion of nasopharyngeal mass).

Red flags

  • Significant hearing loss impacting development/learning.
  • Structural TM abnormalities (deep retraction pocket).
  • Unilateral OME in an adult.
  • Associated craniofacial abnormalities.

Signs and symptoms

  • Hearing impairment: Main symptom. Often mild-moderate, conductive type. May fluctuate.
  • Speech and language delay (in young children with persistent bilateral OME).
  • Feeling of fullness or 'popping' in the ear.
  • Balance problems (less common).
  • Poor school performance.
  • Behavioural problems (due to hearing difficulty).
  • Usually no ear pain or fever (unlike AOM).
  • Otoscopy: Dull, retracted, or bulging TM (due to fluid pressure), impaired mobility on pneumatic otoscopy, visible air-fluid level or bubbles behind TM, yellowish or blueish TM colour.

Risk factors

  • Recent Acute Otitis Media (OME often follows AOM).
  • Upper respiratory tract infections / Viral infections.
  • Eustachian tube dysfunction (common in young children due to anatomy).
  • Adenoid hypertrophy.
  • Allergic rhinitis.
  • Craniofacial abnormalities (e.g., Cleft palate, Down syndrome).
  • Passive smoking.
  • Daycare attendance.

Diagnosis

Clinical assessment

Suspicion based on hearing concerns, speech delay, or history of recurrent AOM. Otoscopy findings are key.

Investigations

  • Pneumatic Otoscopy: Assess TM mobility (reduced mobility is characteristic).
  • Tympanometry: Measures middle ear pressure and compliance (Type B flat tympanogram characteristic of effusion).
  • Audiometry: Confirms conductive hearing loss.
  • Otoscopy: Visualize TM appearance (dull, retracted, bubbles, fluid level).

Diagnostic criteria

Presence of middle ear effusion (visualized on otoscopy or confirmed by tympanometry) WITHOUT signs of acute infection.

Management

Non-pharmacological management

  • Watchful Waiting / Active Observation: Recommended initial approach for most cases, as OME often resolves spontaneously within 3 months.
  • Monitor hearing and language development.
  • Address risk factors (e.g., treat allergies, adenoidectomy if indicated).
  • Autoinflation techniques (e.g., Otovent balloon) may help some older children.
  • Environmental modifications (preferential seating in class).

Pharmacological treatment

  • Antibiotics, Steroids (Oral/Nasal), Antihistamines, Decongestants: Generally NOT recommended for routine treatment of OME due to lack of proven long-term benefit and potential side effects.
  • Short course of antibiotics MAY be considered if OME persists >3 months AND associated with significant hearing loss or other symptoms (controversial).
  • (UCG recommendation: Chlorphenamine + Nasal decongestant drops + Exercises - Chewing/blowing against closed nose). (LOC: HC4)

Monitoring

Follow-up visits every 3-6 months to monitor effusion resolution, hearing status, and language development during watchful waiting. Monitor grommets post-insertion.

Complications

  • Conductive hearing loss.
  • Speech and language delay.
  • Learning difficulties / Poor school performance.
  • Behavioural problems.
  • Recurrent Acute Otitis Media.
  • Tympanic membrane changes (retraction pockets, atelectasis, tympanosclerosis).
  • Cholesteatoma (rare, from severe retraction).

Prevention

  • Pneumococcal vaccination.
  • Breastfeeding.
  • Avoidance of passive smoke exposure.
  • Prompt treatment of AOM (may not prevent OME).

Patient education

  • Explanation of OME ('fluid behind eardrum').
  • Natural history (often resolves spontaneously).
  • Impact on hearing and potential impact on speech/learning.
  • Rationale for watchful waiting.
  • When surgery (grommets) might be considered.
  • Importance of follow-up hearing tests.
  • Avoidance of unnecessary antibiotics/decongestants.

Uganda-specific notes

OME is common but often underdiagnosed due to limited access to pneumatic otoscopy, tympanometry, and audiometry. Hearing loss may be attributed to other causes. Surgical options (grommets, adenoidectomy) limited to specialized centres.

Surgical Management

  • Myringotomy with Grommet (Ventilation Tube) Insertion: Considered if OME persists >3 months (bilateral) or >6 months (unilateral) WITH significant hearing loss (e.g., >25-30 dB) OR associated speech/language/learning problems OR structural TM changes. (LOC: ENT Specialist)
  • Adenoidectomy: Often performed concurrently with grommet insertion, especially if adenoid hypertrophy present or recurrent OME.

References

  • Uganda Clinical Guidelines (UCG) 2023

    Chapter 21, Section 21.1.5

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