Otitis Media with Effusion Clinical Overview
Otitis Media with Effusion (OME)
I. The "On-Call" Snapshot
Clinical Significance in Malaysia: OME is the most common cause of acquired hearing impairment in our paediatric population. You will be actively screening for this in every child with speech delay or learning difficulties.
High-Yield Definition: As per the Malaysian CPG, OME is a condition characterised by a collection of fluid within the middle ear without signs or symptoms of acute inflammation.
Clinical One-Liner: Basically, it's "glue ear." The middle ear is blocked and filled with fluid, muffling the child's hearing, but there's no acute infection.
II. Etiology & Risk Factors
Etiology: Primarily caused by Eustachian tube dysfunction. Following an upper respiratory tract infection (URTI) or a resolving acute otitis media (AOM), the tube fails to ventilate the middle ear, leading to negative pressure and accumulation of a serous or mucoid effusion.
Risk Factors (Malaysian Context):
Non-modifiable:
Age (Peak incidence 2-5 years old)
Craniofacial anomalies (e.g., Down syndrome, Cleft Palate)
Sibling history of OME
Modifiable:
Recurrent episodes of Acute Otitis Media (AOM)
Attending daycare (taska)
Passive smoking
Bottle feeding (especially when supine)
Concurrent allergic rhinitis and adenoid hypertrophy
III. Quick Pathophysiology
The Eustachian tube in a child is shorter, more horizontal, and floppier than in an adult. When it gets blocked—usually by inflammation from a URTI or enlarged adenoids—it can't equalise pressure. This creates a vacuum in the middle ear, sucking fluid out from the mucosal lining. This fluid, which is initially thin, becomes thick and glue-like over time, impairing the movement of the tympanic membrane and ossicles. The result is a conductive hearing loss.
IV. Clinical Assessment
Red Flags & Immediate Actions:
Suspected Cholesteatoma (Pearly white mass behind TM, chronic foul-smelling otorrhoea, bony erosion on otoscopy): This is a red flag. Do not poke it. Make an urgent referral to the ENT team.
Unilateral OME in an adult: Always perform a nasoendoscopy to rule out a nasopharyngeal carcinoma (NPC) obstructing the Eustachian tube. This is a "can't miss" diagnosis in our population.
Significant speech and language delay: Refer to both ENT and the Speech Therapy department concurrently.
History:
Common (>50%):
Parental concern about hearing ("dia macam tak dengar," "kena panggil banyak kali")
Inattentiveness or poor performance at school
Speech and language developmental delay
Less Common (10-50%):
Recurrent, mild earache (otalgia)
Feeling of "fullness" or "popping" in the ear
Clumsiness or balance issues
Pertinent Negatives: Ask specifically about the absence of fever, severe pain, or purulent discharge to differentiate from AOM.
Physical Examination:
Otoscopy is key. You are looking for:
Colour: Dull, opaque, yellowish, or amber tympanic membrane (TM). Loss of the light reflex.
Position: Retracted TM, making the handle of the malleus look more prominent and horizontal.
Fluid: Air-fluid levels or bubbles may be visible behind the TM.
Mobility: Use a pneumatic otoscope. A key sign of OME is reduced or absent mobility of the TM. A normal TM moves briskly.
General: Look for "adenoid facies" (prolonged mouth-breathing, flattened mid-face). Check for cleft palate.
Clinical Pearl: Don't just glance at the TM. If you suspect OME, you must assess mobility with a pneumatic otoscope. If your clinic doesn't have one that seals well, your suspicion from history and a dull, retracted TM is enough to refer for formal audiology.
V. Diagnostic Workflow
Differential Diagnosis:
Acute Otitis Media (AOM):
Points For: Ear pain, fever, red and bulging TM.
Points Against: OME lacks acute inflammatory signs.
How to Differentiate: AOM is an acute, painful event. OME is a chronic, low-grade issue. Otoscopy in AOM shows a bulging, erythematous TM, not just a retracted and dull one.
Congenital Hearing Loss:
Points For: Hearing impairment from birth.
Points Against: OME is acquired, often after a series of URTIs.
How to Differentiate: Newborn hearing screening results. An Auditory Brainstem Response (ABR) test can confirm sensorineural vs. conductive loss.
Investigations Plan:
Bedside / Initial (In Clinic):
Pneumatic Otoscopy: The single most useful clinical test to assess TM mobility.
First-Line (Referral to Audiology/ENT Clinic):
Pure Tone Audiometry (PTA): For cooperative children (>4-5 years old). It will show a mild to moderate conductive hearing loss, typically 25-40 dB.
Tympanometry: This is the objective test of choice. The classic finding in OME is a Type B (flat) tympanogram, indicating fluid in the middle ear with poor TM mobility. A Type C curve (negative pressure) suggests Eustachian tube dysfunction.
Confirmatory / Gold Standard:
Myringotomy (a small incision in the TM) with visualization of middle ear fluid is the definitive confirmation, but this is a surgical procedure, not a routine diagnostic one.
VI. Staging & Severity Assessment
Severity is primarily based on duration and the impact on hearing and development.
Newly Diagnosed OME: An episode present for less than 3 months.
Persistent OME: Effusion that has been present for 3 months or longer.
Impact on Hearing (based on PTA):
Mild hearing loss (<25-30 dB): May not significantly impact development.
Moderate hearing loss (>30 dB): High risk for speech, language, and learning problems.
Management Impact: The 3-month mark is critical. According to the Malaysian CPG, this is the point where we move from "active observation" to considering surgical intervention if the condition persists with significant hearing loss.
VII. Management Plan
Immediate Stabilisation: OME is not an emergency. The focus is on diagnosis and planning.
Definitive Treatment (The Ward Round Plan):
First-Line: Active Observation (Watchful Waiting)
For all newly diagnosed cases of OME.
Observe for 3 months. Many cases resolve spontaneously.
Provide advice to parents/teachers on communication strategies (e.g., face the child, reduce background noise, speak clearly).
Non-Surgical Interventions (During Observation):
Intranasal Steroids: A short course (<6 weeks) can be considered ONLY if there is concurrent allergic rhinitis or significant adenoid hypertrophy.
What NOT to use: The CPG is clear. There is NO ROLE for oral steroids, antihistamines, decongestants, or routine antibiotics in treating OME.
Second-Line / Surgical Intervention (Referral to ENT):
Indication: Persistent bilateral OME for >3 months with a documented conductive hearing loss >25-30 dB, OR structural changes to the TM (e.g., severe retraction pockets).
Procedure of Choice: Myringotomy with Ventilation Tube (Grommet) Insertion. This equalises pressure and allows the middle ear to drain and ventilate.
Adjunctive Procedure: Adenoidectomy is considered concurrently if the child has significant nasal obstruction symptoms or hypertrophied adenoids.
Long-Term & Discharge Plan:
Post-VT Insertion: Keep the ear dry. Advise parents on using earplugs during bathing/swimming. Follow up in the ENT clinic in 1 month, then 6-monthly.
Hearing Aids: May be considered as an alternative to surgery in children unfit for GA or those with persistent hearing loss despite VT insertion.
Follow-up: Regular audiological assessment is crucial until the OME resolves and hearing returns to normal.
VIII. Complications
From the Disease (If untreated):
Short-Term:
Hearing Loss: Conductive type, leading to...
Speech & Language Delay: The most significant consequence in young children.
Long-Term:
Adhesive Otitis Media: TM becomes severely retracted and stuck to the ossicles.
TM Perforation & Ossicular Chain Disruption: Chronic negative pressure can erode the ossicles.
Cholesteatoma: A destructive skin cyst in the middle ear, a serious complication requiring surgery.
From Management (VT Insertion):
Otorrhoea (Discharge): Commonest complication, usually managed with topical antibiotic drops.
Tympanosclerosis: Benign whitish plaques on the TM.
Persistent TM Perforation: The hole may not heal after the tube extrudes (falls out).
IX. Prognosis
Excellent. The vast majority (around 50%) of OME cases resolve spontaneously within 3 months without any intervention.
With surgical intervention (VT insertion), hearing is almost immediately restored.
Top 3 Prognostic Factors:
Duration of effusion: The longer it persists, the more likely intervention is needed.
Severity of hearing loss: Greater hearing loss is associated with poorer developmental outcomes if not addressed.
Presence of craniofacial anomalies: These children often have persistent and recurrent OME requiring long-term management.
X. How to Present to Your Senior
"Dr., for review please. This is [Child's Name], a 4-year-old boy, referred from the KK for speech delay. Parents report he seems inattentive and needs the TV volume turned up high. There is no history of fever or acute ear pain. On otoscopy, the right TM is dull and retracted with visible air bubbles. My main differential is bilateral Otitis Media with Effusion. I would like to refer him to the Audiology clinic for a formal hearing test and tympanometry to confirm, and then review in 3 months as per our CPG."
XI. Summary & Further Reading
Top 3 Takeaways:
OME is fluid in the middle ear without acute infection. Suspect it in any child with hearing concerns or speech delay.
Management is "active observation" for the first 3 months. Do not give antibiotics or antihistamines.
Refer to ENT for surgery consideration if OME persists >3 months with hearing loss >25-30 dB. The objective confirmation is a Type B tympanogram.
Key Resources:
Primary Guideline: Ministry of Health Malaysia. Clinical Practice Guidelines: Management of Otitis Media with Effusion in Children. (2012).
UpToDate: Search for "Otitis media with effusion (serous otitis media) in children: Management".
StatPearls: Search for "Otitis Media With Effusion".
