Otitis Media with Effusion (OME), often called Secretory Otitis Media (SOM) or “Glue Ear,” is an insidious condition, defined by the collection of nearly sterile, non-purulent effusion in the middle ear cleft behind an intact tympanic membrane without signs and symptoms of an acute infection.

Definition and Terminology

• Definition: Chronic accumulation (>3 months) of serous or mucoid fluid in the middle ear without signs or symptoms of acute ear infection, causing conductive hearing loss.
• Glue Ear: The term “glue ear” is used when the effusion is thick and glue-like, also called mucoid otitis media.
• Chronic OME: The term “chronic OME” is used when the effusion persists for 3 months or longer.

Epidemiology

1. OME is the most common cause of acquired hearing impairment in children, subsequently impacting speech, language development, learning, and behaviour.
2. It usually occurs following respiratory tract infection and otalgia with an episode of acute otitis media.
3. Approximately 90% of children will experience at least one episode of OME by the age of 4 years.
4. The most commonly affected age group is 1–8 years, although it can also affect adults.
5. It is more common in winter than in summer.

Predisposing Factors

1. Young age
2. Family history of otitis media
3. Bottle feeding.
4. Day care attendance
5. Exposure to tobacco smoke
6. Low socioeconomic level

Pathogenesis

Three main mechanisms are thought to be responsible.

1. Impaired ET Function: The ET fails to properly aerate the middle ear, therefore leading to the absorption of middle ear air by the mucosa. This results in negative pressure in the middle ear and accumulation of fluid.
2. Inflammation and Metaplasia (Excessive Secretion): Inflammation of middle ear due to URI/ allergens, the middle ear’s normal flat cuboidal mucosa undergoes metaplasia to a thicker, pseudostratified columnar respiratory epithelium, which contains an increased number of goblet cells and mucus-secreting glands, therefore leading to excessive production of serous or mucoid effusion.
3. Infection/Biofilms: Although the effusion is often described as sterile, respiratory bacteria (S. pneumoniae, H. influenzae, M. catarrhalis) have been isolated using sensitive techniques like PCR. Biofilms are also recognized as probable organisms in OME formation, thus suggesting a persistent, low-grade inflammatory stimulus.

 

Effects of Acute and Chronic Tubal Blockage (Flowchart for Viva)

Acute	Chronic
Eustachian tube blockage ↓ Resorption of air from the middle ear ↓ Development of negative pressure in the middle ear ↓ Retraction of the tympanic membrane ↓ Transudate in ME/haemorrhage (acute OME)	Eustachian tube blockage/dysfunction ↓ OME (thin watery or mucoid discharge) ↓ Atelectatic ear/perforation ↓ Retraction pocket/cholesteatoma ↓ Erosion of the incudostapedial joint

AETIOLOGY.

1. Malfunctioning of eustachian tube. The causes are:

• • Hypertrophy of adenoids.
  • Chronic rhinitis and sinusitis.
  • Chronic tonsillitis. Enlarged tonsils mechanically obstruct the movements of soft palate and interfere with the physiological opening of eustachian tube.
  • Benign and malignant tumours of nasopharynx. This cause should always be excluded in unilateral serous otitis media in an adult.
  • Disorders of tubal kinetics, particularly incompetence of the muscles opening the tube in cleft palate or palatal paralysis.

2. Allergy. Seasonal or perennial allergy to inhalants or foodstuff is common in children. This not only obstructs eustachian tube by oedema but may also lead to increased secretory activity as middle ear mucosa acts as a shock organ in such cases. Allergic rhinitis reduces the immune competencies of the mucosal immune system of the upper respiratory tract and makes the middle ear more prone to infection. In addition, mucosal oedema present in allergic rhinitis, impairs the function of the ET.
3. Unresolved otitis media. Inadequate antibiotic therapy in acute suppurative otitis media may inactivate infection but fail to resolve it completely. Low-grade infection lingers on. This acts as stimulus for mucosa to secrete more fluid. The number of goblet cells and mucous glands also increase. Recent increase in the incidence of this disease seems to be due to this factor.
4. Viral infections. Various adeno and rhinoviruses of upper respiratory tract may invade middle ear mucosa and stimulate it to increased secretory activity.

History (Clinical Features)

A. Symptoms

1. Hearing Loss (Most Common): Conductive hearing loss occurs when there is fluid in the middle ear, while sensorineural hearing loss can also occur due to the passage of inflammatory mediators present in exudate into the inner ear through the round window membrane. Hearing loss rarely exceeds 35-40 dB.
2. Speech and Language Delay: Prolonged middle ear effusion can lead to defective speech, learning, cognitive abilities and behavioural problems.
3. Mild Earache/Aural Fullness.
4. Balance Problems: A Few children may experience subtle balance difficulties, which usually resolve after successful OME treatment.

B. Examination (Otoscopic Findings)

1. Tympanic Membrane (TM) is often retracted, dull and opaque with loss of light reflex. It may appear yellow, grey or bluish in colour (the so-called “blue drum”). A thin leash of blood vessels may be seen along the handle of the malleus or at the periphery of the tympanic membrane and differs from the marked congestion of acute suppurative otitis media. Sometimes, it may appear full or with localised bulging in its posterior part due to effusion.
2. Fluid in the middle ear. Blackish coloured air fluid level may be seen when fluid is thin, and tympanic membrane is transparent or air bubbles may be seen
3. TM Mobility is restricted on pneumatic otoscopy (Siegelization).
4. Handle of Malleus (HM). Often and due to the retraction of the eardrum, the handle of malleus looks shorter and horizontal with a prominent short process.

Differential Diagnosis (Viva Question Tip):

1. Hemotympanum (the dark-brown exudate behind the tympanic membrane on occasion lends this a bluish tinge)
2. Chronic otitis media, evidenced by perforation, cholesteatoma flakes, and purulent exudate.

Investigations

1. Impedance Audiometry (Tympanometry): This is the most useful, cost-effective, and objective test for diagnosing OME in infants and children. A flat curve (Type B) indicates reduced compliance due to fluid in the middle ear. Sometimes, a Type C curve (negative pressure) is seen, thus suggesting ET dysfunction without frank fluid.
2. Acoustic Reflex: The reflex is either absent or elicited at a higher threshold due to the conductive hearing loss.
3. Pure Tone Audiometry (PTA): Reveals a conductive hearing loss with an air-bone gap (ABG), typically 10–40 dB. The associated sensorineural component, if present, disappears after fluid evacuation.
4. Tuning Fork Tests: Shows a conductive hearing loss (e.g., Rinne Negative, Weber lateralizes to the affected ear). However, these are often unreliable in young children.

Other tests

• X-ray Mastoids (Schuller’s View): Shows clouding of air cells due to the fluid, but it is rarely indicated.
• Radiological Investigations (CT/MRI): Not generally desired for routine OME, but they are essential if a nasopharyngeal mass (e.g., tumor) is suspected in an adult with unilateral OME.

Principles of Management of OME

Current guidelines (e.g., American Academy of Otolaryngology–Head and Neck Surgery) emphasise watchful waiting before surgical intervention, particularly in low-risk children

Medical Management (The New Paradigm)

• Watchful Waiting: The current cornerstone of management. For a child who is not at risk (e.g., no Down Syndrome, no permanent hearing loss), the recommended approach is watchful waiting for 3 months from the diagnosis date. Re-evaluate the child at 3–6 month intervals until the effusion resolves.
• Ineffective Therapies (MCQ Alert): Recent studies have not proven beneficial for systemic antibiotics, systemic/intranasal steroids, antihistamines, mucolytics, or decongestants, therefore they are not recommended for routine OME treatment.
• Auto-inflation (Valsalva Manoeuvre): This is the best non-surgical approach to aerate the middle ear and promote drainage, therefore patients should be encouraged to perform it repeatedly. Give children chewing gum to encourage repeated swallowing, which opens the ET.

Surgical Management

Surgery is indicated when OME persists with significant sequelae or hearing loss.

1. Myringotomy and Grommet Insertion (Ventilation Tube). First-line surgery if OME persists with: 1) Significant hearing loss more than 30–40 dB or 2) Structural abnormalities (e.g., retraction pockets).
2. Adenoidectomy with or without Grommet Insertion. Age more than 4 years with OME persisting despite two or more episodes of OME. Adenoidectomy addresses the primary cause (obstruction, infection reservoir). Perform it regardless of adenoid size if indicated for OME.
3. Prompt Myringotomy (Without 3-Month Wait). High-Risk Children: Children with permanent hearing loss, autism/developmental disorders, syndromes (e.g., Down), or craniofacial disorders. These children require immediate attention to prevent further developmental delay.
4. Tympanotomy and cortical mastoidectomy for loculated, thick fluid or cholesterol granuloma. Rarely required, only for complex/resistant cases.

Myringotomy

Indications of Myringotomy:

1. Acute suppurative otitis media – (i) Severe earache with bulging drum about to perforate, (ii) Persistent retraction of the tympanic membrane causing conductive deafness, (iii) Complications of acute otitis media, e.g. facial nerve paralysis, labyrinthitis or meningitis with the bulging tympanic membrane. (iv) Recurrent acute otitis media.
2. Otitis media with effusion.
3. Aero-otitis media (to drain fluid and “unlock” the eustachian tube).
4. Patulous eustachian tube.
5. Atelectatic ear (grommet is often inserted for long-term aeration).
6. Hemotympanum

Anaesthesia of Myringotomy: General anaesthesia is routinely used in children and geriatric patients. Otherwise, myringotomy can be done under local anaesthesia or no anaesthesia at all.

Steps of operation of Myringotomy:

1. First, beware of this illusion that it is the most common and simple operation.
2. Clean wax and debris from the ear canal.
3. Inspect for any perforations, retraction and retraction pockets, myringosclerosis, dehiscent jugular bulb and only then proceed with the operation.
4. Always perform under the operating microscope.
5. The preferred insertion site of the ventilation tube is anteroinferior quadrant (right ear at 5 o’clock, left ear at 7 o’clock) through a circumferential or radial incision. Insertion of the ventilation tube posterosuperiorly is not recommended because of the risk of damaging the ossicular chain. The ventilation tube is preferably placed in the anterosuperior quadrant for longer retention. Radial or circumferential incision does not influence the extrusion rate.
6. The incision should cut through the entire thickness of tympanic membrane avoiding injury to ossicular chain, posterior meatal wall, jugular bulb or any other abnormal vascular anomalies (e.g. high jugular bulb, aberrant carotid artery or glomus tympanicum).
7. Aspiration of middle ear fluid through the incision site before placing grommet should be avoided. It may encourage biofilm infection and tympanosclerosis (secondary to trauma and bleeding of the tympanic membrane).

 Incision for Myringotomy:

• Incision for drainage only – In acute infection wide circumferential incision in posteroinferior quadrant is preferred since drainage alone is the purpose. and prompt closure is desired. Circumferential incisions accumulates more epithelial debris leading to prompt closure of incision.
• Incision for grommet insertion – Radial incision in anteroinferior quadrant is preferred since it sections fewer fibres, runs parallel to most of the blood vessels irrigating the membrane and causes less scarring.

Incisions should not be made in the posterosuperior quadrant because epithelial migration is slowest in this quadrant leading to incidence of persistent perforation and can also can cause injury to incudostapedial joint and stapes.  Incisions should not be made close to the umbo because of its close proximity to the promontory. Incision close to the annulus favours early extrusion of the tube.

Postoperative care of Myringotomy:

1. Use of ear drops at the time of placement of grommet reduces the risk of its blockage with blood and mucus. It also reduces the chances of local infection during the early postoperative period.
2. Avoid swimming and entry of water in the canal as long as grommet is in position.
3. Daily cleaning of ear discharge from the canal in cases of acute suppurative otitis media. In serous otitis media, just leave a wad of cotton wool for 24–48 h.

Complications of Myringotomy include:

1. The most common operative complication is the displacement of the ventilation tube into the middle ear (Attempts should be made to retrieve the tube, but failure to remove it seldom causes problems due to inert nature of grommet).
2. Infection around the grommet leads to middle ear infection.
3. Otorrhea may follow an acute upper respiratory tract infection.
4. Granulation tissue may develop secondary to infection.
5. Residual tympanic membrane perforation
6. Pars tensa atrophy and retraction
7. Blockage due to blood or secretions.
8. Tympanosclerosis is the most common structural complication.

Biofilm.

Bacteria form biofilm in order to protect their cells from the action of the immune system of the host, antibodies and antibiotics. They secrete complex polysaccharides and form a layer that permits the diffusion of nutrients into the bacterial cells and exit of bacterial excretory products. Biofilms are responsible for bacterial resistance and persistence of infection. Biofilms are implicated in chronic otitis media with effusion, chronic rhinosinusitis, and tonsil and adenoid infections. They also form on grommets, stents and catheters kept for a long time. Biofilm formation can be prevented by antibiotic-coated tubes and stents and an early removal of tubes and stents, if no longer required.

Sequelae of Chronic Secretory Otitis Media

1. Atrophic tympanic membrane and atelectasis of the middle ear. In prolonged effusions, there is dissolution of the fibrous layer of the tympanic membrane. It becomes thin and atrophic and retracts into the middle ear.
2. Ossicular necrosis. Most commonly, the long process of incus gets necrosed. Sometimes, stapes superstructure also gets necrosed. This increases the conductive hearing loss to more than 50 dB.
3. Tympanosclerosis. Hyalinized collagen with chalky deposits may be seen in the tympanic membrane, around the ossicles or their joints, leading to their fixation.
4. Retraction pockets and cholesteatoma. The thin atrophic part of the pars tensa may get invaginated to form retraction pockets or cholesteatoma. Similar pockets may be seen in the attic region.
5. Cholesterol granuloma. The term describes a foreign body, a giant cell reaction to cholesterol crystals, and hemosiderin derived from ruptured erythrocytes. The tympanic membrane appears blue in colour due to hemosiderin crystals. Cholesterol granuloma arises due to stasis of secretions in the middle ear and mastoid from obstructed drainage and insufficient aeration of the middle ear cleft. It causes conductive hearing loss. Treatment is mastoidectomy. A ventilation tube can be placed in the early stages. A cholesterol granuloma should be differentiated from glomus tumour (causes bone erosion) and heamotympanum (history of trauma).

———— End of the chapter ————

High-Yield Points for Revision

1. OME is defined by fluid for >3 months with an intact TM.
2. It is the most common cause of hearing loss in children.
3. The key diagnostic test is Tympanometry (Type B curve).
4. The primary risk factor is Eustachian Tube Dysfunction.
5. Watchful waiting for >3 months is the standard management for low-risk children.
6. Antibiotics/Steroids are NOT recommended for routine management.
7. Surgical treatment for persistent OME is Grommet Insertion.
8. Adenoidectomy is indicated in children aged more than 4 years with recurrent OME.
9. Unilateral OME in an adult always warrants a nasopharyngeal mass exclusion (e.g., tumour).

NEET PG-Style MCQs

1. The hallmark finding on Impedance Audiometry (Tympanometry) in Otitis Media with Effusion (OME) is: A. Type A curve B. Type Ad curve C. Type As curve D. Type B curve
2. Which of the following is the most common cause of acquired hearing impairment in children? A. Otosclerosis B. Otitis Media with Effusion (OME) C. Noise-induced hearing loss D. Acute Otitis Media (AOM)
3. The management of a 3-year-old child with an intact tympanic membrane, bilateral OME, and a 20 dB conductive hearing loss, with no other risk factors, should initially be: A. Immediate Myringotomy and Grommet Insertion B. Systemic Amoxicillin for 10 days C. Watchful Waiting for 3 months D. Valsalva Manoeuvre twice daily only
4. In which group of children is a prompt surgical intervention (Tympanostomy Tube Insertion) indicated, potentially bypassing the 3-month watchful waiting period? A. Children with a family history of Otitis Media B. Children with allergic rhinitis C. Children with Down syndrome D. Children whose parents smoke 5 cigarettes/day
5. Unilateral Otitis Media with Effusion in an adult patient mandates the exclusion of which serious underlying condition? A. Chronic Suppurative Otitis Media B. Laryngeal Carcinoma C. Nasopharyngeal Carcinoma D. Maxillary Sinusitis
6. The primary mechanism leading to the development of Otitis Media with Effusion is: A. Labyrinthitis leading to fluid transudation B. Metaplasia of the external ear canal skin C. Eustachian Tube Dysfunction and ventilation failure D. Direct spread of infection from the mastoid
7. The presence of pepsinogen in OME effusions is associated with which risk factor? A. Exposure to tobacco smoke B. Gastro-oesophageal reflux C. Day care attendance D. Family history of otitis media
8. Which long-term sequela of chronic OME involves the loss of the fibrous layer of the Tympanic Membrane? A. Tympanosclerosis B. Atrophic Tympanic Membrane C. Cholesteatoma D. Ossicular Necrosis
9. Adenoidectomy is generally recommended along with Grommet insertion when OME persists, and the child is: A. Less than 1 year old B. Aged 1 to 3 years C. Aged 4 years or older D. Adolescents only
10. The hearing loss in OME rarely exceeds which level? A. 10 dB B. 20 dB C. 40 dB D. 60 dB

MCQ Answers and Explanations

1. D. Type B curve. A flat curve (Type B) indicates reduced compliance due to fluid in the middle ear space, which is the pathognomonic finding for OME.
2. B. Otitis Media with Effusion (OME). OME is universally recognised as the single most common cause of acquired hearing loss in childhood.
3. C. Watchful Waiting for 3 months. Current guidelines recommend initial watchful waiting for low-risk children for 3 months, as many cases resolve spontaneously.
4. C. Children with Down syndrome. Children with syndromes (like Down’s) or other developmental disorders are considered high-risk due to pre-existing ETD and the need to preserve development, thus requiring prompt intervention.
5. C. Nasopharyngeal Carcinoma. Unilateral OME in an adult is a red flag for a nasopharyngeal mass (benign or malignant), which can obstruct the ET orifice.
6. C. Eustachian Tube Dysfunction and Ventilation Failure. The inability of the ET to aerate the middle ear results in negative pressure, inflammation, and subsequent fluid accumulation, which is the primary driver of OME.
7. B. Gastro-oesophageal reflux. Pepsinogen is a marker for reflux, thus linking GOR to middle ear inflammation and OME.
8. B. Atrophic Tympanic Membrane. Atrophy specifically refers to the weakening and loss of the central fibrous layer of the TM.
9. C. Aged 4 years or older. Adenoidectomy combined with Grommet insertion is generally recommended for children $\ge$ 4 years with recurrent/persistent OME.
10. C. 40 dB. The maximum hearing loss in a simple conductive loss due to fluid is limited to around 40 dB, as the bone conduction remains unaffected.

Clinical Case Scenario

Case 1: The Distracted Student

A 6-year-old male child is brought to the ENT OPD by his parents and class teacher. The teacher reports he is “distracted and inattentive” in class, often asking for instructions to be repeated. The parents deny any history of ear pain or discharge. On otoscopy, both TMs are dull, retracted, and a faint air-fluid level is suspected on the right side. Tympanometry shows bilateral Type B curves.

• Q1. Provisional Diagnosis: Bilateral Otitis Media with Effusion (OME).
• Q2. Immediate Management: Since he is a low-risk child, the initial step is Watchful Waiting for $\mathbf{3}$ months with parent counselling regarding the need for follow-up and monitoring for speech/developmental issues. Encourage auto-inflation (e.g., chewing gum).
• Q3. Next Step if OME Persists at 3 Months: Myringotomy and Grommet Insertion (since he is more than 4 years, consider adenoidectomy if there is a history of chronic nasal obstruction or two prior OME episodes).

Case 2: The High-Risk Toddler

A 2-year-old child with Down syndrome and a history of speech delay presents for a routine check-up. Otoscopy reveals an intact, dull, and retracted TM on the left side. Tympanometry confirms a left-sided Type B curve and a right-sided Type C curve.

• Q1. Special Concern: The patient is high-risk (Down syndrome) and already has a developmental delay (speech delay).
• Q2. Management Strategy: Do NOT wait for 3 months. The guideline recommends prompt surgical intervention.
• Q3. Procedure of Choice: Left Myringotomy with Tympanostomy Tube Insertion (Grommet). Adenoidectomy is generally reserved for those more than 4 years old unless a significant indication is present.

Case 3: The Adult with Unilateral Ear Fullness

A 55-year-old man, a long-term smoker, complains of a persistent fullness, occasional tinnitus, and mild hearing loss in his left ear for 4 months. He has no history of URIs or ear infections. Left otoscopy shows a retracted TM with a yellowish tinge. Right otoscopy is normal. Left Tympanometry is Type B.

• Q1. Provisional Diagnosis: Left Unilateral OME.
• Q2. Mandatory Exclusion: Nasopharyngeal Carcinoma. Unilateral OME in an adult is a red flag.
• Q3. Immediate Investigation: Nasal Endoscopy and Imaging (CT/MRI) of the nasopharynx to rule out a mass obstructing the left Eustachian tube orifice.

Frequently Asked Questions (FAQ) in Viva

1. How long must fluid persist for OME to be considered chronic? Chronic OME is diagnosed when the middle ear effusion persists for 3 months or longer.
2. What is the best initial treatment for OME in a low-risk child? The best initial treatment is watchful waiting for 3 months, as many effusions resolve spontaneously.
3. Which imaging test is mandatory for unilateral OME in an adult? Nasal Endoscopy and CT/MRI of the nasopharynx are mandatory to exclude Nasopharyngeal Carcinoma.
4. What is the specific finding for OME on tympanometry? The specific finding for OME on tympanometry is a flat curve, known as a Type B curve.
5. Why are antibiotics not recommended for routine OME treatment? Antibiotics are not recommended because OME is generally a sterile or low-grade inflammatory process, not an acute bacterial infection, and studies show no consistent benefit.
6. At what age should adenoidectomy be considered for OME management? Adenoidectomy is generally recommended along with Grommet insertion for children aged 4 years or older with recurrent or persistent OME.

———— End ————

Download full PDF Link:
Otitis Media with Effusion Best Lecture Notes Dr Rahul Bagla ENT Textbook

Reference Textbooks.

• Scott-Brown, Textbook of Otorhinolaryngology-Head and Neck Surgery.
• Glasscock-Shambaugh, Textbook of Surgery of the Ear.
• P L Dhingra, Textbook of Diseases of Ear, Nose and Throat.
• Hazarika P, Textbook of Ear Nose Throat And Head Neck Surgery Clinical Practical.
• Mohan Bansal, Textbook of Diseases of Ear, Nose and Throat Head and Neck Surgery
• Hans Behrbohm, Textbook of Ear, Nose, and Throat Diseases With Head and Neck Surgery.
• Salah Mansour, Middle Ear Diseases – Advances in Diagnosis and Management.
• Logan Turner, Textbook of Diseases of The Nose, Throat and Ear Head And Neck Surgery.
• Rob and smith, Textbook of Operative surgery.
• Anirban Biswas, Textbook of Clinical Audio-vestibulometry.
• Arnold, U. Ganzer, Textbook of  Otorhinolaryngology, Head and Neck Surgery.

Author:

Dr. Rahul Bagla
MBBS (MAMC, Delhi) MS ENT (UCMS, Delhi)
Fellow Rhinoplasty & Facial Plastic Surgery.
Renowned Teaching Faculty
Mail: msrahulbagla@gmail.com
India

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