Describe otitis media with effusion with its management.

Nature and Aetiology

• Otitis media with effusion (OME, "glue ear", serous or secretory otitis media) is the presence of fluid in the middle ear without signs of acute infection, behind an intact tympanic membrane.
• It is the commonest cause of acquired hearing loss in children.
• The peak incidence is at 2 and again at 5 years, and it is characteristically seasonal, being commoner in winter

Management

• The foundation OF management IS that most resolve spontaneously: 50% within 3 months and 90% within a year. This is why watchful waiting for 3 months with two audiological assessments is the correct first step, and why early surgery is inappropriate
• What does not work, and should not be prescribed — antibiotics (no lasting benefit); antihistamines and decongestants (no benefit, with side effects); mucolytics; and topical or systemic steroids, whose effect is transient. These are among the most over-prescribed drugs in paediatric practice
• Autoinflation (Otovent balloon, Valsalva) has modest evidence and is harmless, and is worth teaching to a cooperative child
• Treat the associated conditions — allergic rhinitis, sinusitis and adenoid disease; and eliminate passive smoking
• Indications for surgery — persistence beyond 3 months bilaterally with a hearing loss of 25 to 30 dB or worse in the better ear; speech, language or developmental delay; significant behavioural or educational problems; structural change in the drum — a retraction pocket, atelectasis or ossicular erosion.
• The threshold is lower in a child with down syndrome, cleft palate, visual impairment, existing developmental delay or autism, in whom the hearing loss compounds an existing disadvantage
• Grommet (ventilation tube) insertion is the standard operation, restoring hearing immediately
• Adenoidectomy should be added where there is nasal obstruction or recurrent disease, and particularly at a second set of grommets, since it reduces the recurrence rate independently of adenoid size — which is a point regularly examined and reflects its role as a reservoir of infection rather than a mechanical obstruction alone
• Hearing AIDS are a legitimate alternative to grommets, particularly where surgery is refused, anaesthesia is risky, or in a child with cleft palate or Down syndrome in whom grommets do less well
• Alongside any treatment — inform the school, seat the child at the front, speak face to face, and reduce background noise. These simple measures address the actual disability while the effusion is being managed
• It is painless, which is why it presents late and is noticed first by a teacher rather than a doctor
• Half resolve in three months and ninety per cent in a year.
• Antibiotics, antihistamines and decongestants do not work, and prescribing them delays proper assessment
• Bacterial biofilms explain antibiotic failure, and are found in a substantial proportion of effusions
• A flat type B trace with normal canal volume means effusion, whereas a large volume means a perforation or patent grommet
• Air bubbles or a fluid level are diagnostic, and are worth looking for specifically before relying on colour alone
• Test hearing twice over three months before offering surgery, since the effusion and the loss both fluctuate
• Adenoidectomy reduces recurrence independently of adenoid size, acting as a reservoir of infection rather than a mechanical block
• Add adenoidectomy at a second set of grommets, which is where the evidence for it is strongest