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Postgrad Med, 2015; 127(4): 381385

DOI: 10.1080/00325481.2015.1028317

CLINICAL FEATURE
REVIEW

Otitis media with effusion

Helen Atkinson, Sebastian Wallis and Andrew P. Coatesworth

Department of Otolaryngology, Head and Neck Surgery, York Teaching Hospitals NHS Foundations Trust, Wigginton Road, York, YO31 8HE, UK

Abstract Keywords:
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Otitis media with effusion (OME) is a common problem facing general practitioners, pediatricians Ear, effusion, glue, otitis media, otology,
and otolaryngologists. This article reviews the etiopathogenesis, epidemiology, presentation, pediatrics
natural history and management of OME. The literature was reviewed by using the PubMed
search engine and entering a combination of terms including otitis media with effusion, History
epidemiology and management. Relevant articles were identified and examined for content.
Received 8 December 2014
What is the take home message? While OME is a very common entity in the pediatric population,
Accepted 9 March 2015
the majority of cases will resolve spontaneously. Surgery in the form of grommet insertion, with
or without adenoidectomy is the most effective treatment in persistent symptomatic cases.

Introduction predominantly of childhood. The ET in children is oriented

at ten degrees to the horizontal. As the secondary dentition
This is the first of three papers reviewing otitis media. This
For personal use only.

paper will deal with otitis media with effusion (OME). The
second paper will review acute otitis media (AOM). The third
will focus on chronic otitis media. Each review will outline
the theories of etiopathogenesis, modes of presentation, diag-
nosis and management options for middle ear disease.
OME is defined as the presence of a middle ear effusion
in the absence of infection [1]. Its synonyms include glue
ear and serous otitis media. It is a disease predominantly of
childhood with adult prevalence of around 0.6% compared
with a point prevalence in the UK of 20% in 2-year olds [2],
91% of 2-year olds having had at least one episode of
OME according to one study [3]. This paper will discuss the
childhood disease.
Fluid in the middle ear is associated most commonly with
a conductive hearing loss and an increased risk of acute
middle ear infection. It can have an impact on quality of life.
There are several areas of controversy surrounding its man-
agement; these will be discussed.
Etiology
There are several theories as to the cause of OME:
1. Due to Eustachian tube (ET) dysfunction: The middle ear
cleft is aerated via the ET. This is a 24-mm tube, two-thirds
of its length are cartilaginous and the remaining one-third
is bony. It connects the middle ear to the nasopharynx.
Dysfunction of the tube is multifactorial. OME is a disease
erupts, the mid third of the face elongates and the angle of
orientation increases to forty-five degrees to the horizontal.
The musculature, which opens the tube functions better in
this alignment. Apart from the angulation of the tube, phys-
ical obstruction also causes ET dysfunction, as in hypertro-
phied adenoids in children. Inflammation of the ET
secondary to upper respiratory tract infection has also been
suggested to cause dysfunction.
2. There are a number of conditions and syndromes, which
affect the shape of the mid third of the face and skull base.
These are associated with an increased risk of OME, for
example, Downs syndrome and cleft palate. Children with
cleft palate can have abnormal insertion of tensor veli pala-
tini in the soft palate leading to an inability to adequately
open the ET during swallowing and mouth opening.
3. As a sequelae of AOM: In those children diagnosed with
AOM, 45% were found to have a middle ear effusion at
1 month and 10% at 3 months after the initial infection
had settled [4]. It is thought that pepsin found in 60% of
middle ear effusions causes upregulation of mucin genes
leading to increased secretion of mucin and therefore a
breeding ground for common upper respiratory tract bacte-
ria. This suggests that the effusion may also be present
prior to the AOM episode.
4. Secondary to subclinical bacterial infection: As well as
pepsin causing an increase in middle ear mucin, cytokines
released secondary to bacterial infection may also lead to
OME. One-third of effusion fluid undergoing culture was
found to have positive bacterial growth in one study [5].

Correspondence: Sebastian Wallis, ENT Department, York Hospitals NHS Foundations Trust, Wigginton Road, York, YO31 8HE, UK.
E-mail: sebwallis@hotmail.com

2015 Informa UK Ltd.
 382 H. Atkinson et al.
5. In association with gastroesophageal reflux disease: the
theory is pepsin related. Pepsin found in middle ear effu-
sions is thought to arise as a result of reflux, although
given that not all effusions have pepsin, this is unlikely to
be true in all cases.
Epidemiology
There is no difference in incidence between the sexes.
Although the condition is most common below the age of 2,
it has a bimodal distribution with a further peak at 5 years
(16% point prevalence in the UK population). Although the
disease is equally common in white and Afro-Caribbean chil-
dren, higher prevalence is recorded in Native American and
Inuit populations [3,6]. Review of the risk factors (Table 1)
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would suggest it is a disease which more commonly affects
the lower social classes given that breastfeeding rates are
higher and smoking levels lower in higher social classes [12].
Presentation and diagnosis
Children with OME may be asymptomatic only being
detected on routine screening. In those where symptoms are
present, children rarely complain of hearing loss. More
commonly, there is parental concern over the childs hearing.
Speech development can be delayed or reach a plateau. There
may be deterioration in school reports. Some children become
For personal use only.
withdrawn and behavior can decline. OME is known to
impact on balance and parents may comment on a childs
clumsiness or tendency to bump into things [13]. The child
may have associated nasal obstruction with snoring and
mouth breathing.
Clinically, the child is assessed using otoscopy, tympan-
ometry and audiometry. It is also useful to assess for obstruc-
tion of the nose and nasopharynx by putting a silvered
instrument under the nose and asking the patient to close their
mouth. Otoscopy is diagnostic in around 78% of cases with
95% specificity when performed by an otolaryngologist [14].
The classic sign of bubbles behind the drum is not present if
the middle ear cleft is completely fluid filled and ventilation
with a Valsalva maneuver is not achievable (and difficult to
perform in small children). Middle ear fluid may give the ear
drum a golden coloration but signs are generally more subtle,
with retraction of the pars flaccida onto the malleus neck and
apparent shortening of the malleus handle as it is retracted
Table 1. Risk factors for otitis media with effusion.
Protective Causative
Breast feeding Parental smoking
Chewing gum Public day care with >10 children in group
Avoidance of supine Dummy/pacifier use
bottle feeding
Increased number of siblings
Positive family history
Prematurity
Recurrent upper respiratory tract infectiona
Gastroesophageal reflux diseasea
Allergensa
a
Limited evidence.
Data from [4,7-11].
Postgrad Med, 2015; 127(4):381385
medially. The appearance on otoscopy will vary with the
nature of the effusion. Prominent vessels can be seen extend-
ing radially on the tympanic membrane. Dullness of the drum
and loss of the cone of light are non-specific.
Tympanometry aids diagnosis with a sensitivity of 93%.
Although specificity for the test is reduced at 70%, combining
the two modalities gives more accurate assessment [14]. Tym-
panometry assesses compliance of the tympanic membrane by
placing a probe in the ear and sending a sound wave into the
ear canal. The response of the drum is recorded as the sound
wave travels back to a receiver. A normal drum sends the
sound back to the receiver causing a peak indicating normal
middle ear function. In OME, the sound is absorbed by the
fluid in the middle ear, resulting in a loss of the peak and a
flat tympanometry trace. This is also seen when a perforation
is present as the sound travels through the hole and not back
to the receiver. A further result of a negative peak is seen
when the middle ear pressure is negative (see Table 2 for
tympanogram results and associated meanings).
As the management of OME is largely guided by audiologi-
cal assessment, this is vital. Although parental concern may be
high, studies have shown that there is not always a clear corre-
lation between parental concern levels and audiological thresh-
olds [15]. The average hearing thresholds seen in children with
OME are 27.8 dB [16]. The losses are conductive in nature.
Natural history
OME has a fluctuant course. It is most common in those aged
2 years and under, but may present to the otolaryngologist up
to 2 years after initial parental concern is expressed [17].
A UK multicenter study looked at older children aged
3.256.75 years of age diagnosed with OME. One hundred
and fifty-one of the initial 1315 children were not selected for
randomization due to high levels of concern regarding their
clinical presentation and went on to have a surgical
Table 2. Demonstration of common tympanogram results.
Curve
type Appearance Interpretation
A Peaked Normal middle ear
ventilation
0
B Flat Normal ear canal
volume = middle ear
effusion
Raised ear canal
volume = perforated
0 eardrum
C Negative peak Negative middle ear
pressure suggestive of
Eustachian tube
dysfunction
0
 DOI: 10.1080/00325481.2015.1028317
intervention. Without intervention 50% resolved within
3 months and 92% resolved within 9 months [18]. The impact
of hearing loss on smaller children (<3 years) has been shown
to affect speech and language development, by the age of
8 years the two groups are equivalent.
Untreated OME can lead to tympanic membrane changes
like tympanosclerosis (0%10%), segmental tympanic mem-
brane atrophy (5%31%), attic retraction (29%40%) and
atelectasis (1%20%) [19]. These changes result in an
approximate 5 dB hearing loss. These rates are lower than
those complications seen in surgically treated OME.
Management
Management of OME is a combination of watchful waiting,
medical therapy and surgical intervention. Various medical
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therapies have been trialed and subjected to Cochrane
Review, with little or no benefit (Table 3).
Watchful waiting
OME is known to resolve in 50% of children after 3 months. It
was thought initially that early detection and surgical interven-
tion would alter the course of the disease [18]. However, more
recent studies have shown that early intervention has little ben-
efit as all children were found to have equivalent hearing
thresholds at 18 months after detection of OME whether surgi-
For personal use only.
cal intervention occurred or not [24]. Most significantly,
Paradise et al. carried out a study that is now in its 11th year
of follow-up. Over 6000 neonates were assessed and enrolled
resulting in 429 being enrolled with persistent effusion. These
were randomized to immediate and delayed surgical interven-
tion, the latter being up to 9 months following diagnosis. The
outcomes, which assessed various elements of development
showed no difference between the early and delayed treatment
group at 3, 6 and 9 years, respectively. It is based on the above
findings that the National Institute for Health and Clinical
Excellence guidelines suggests a period of watchful waiting of
3 months prior to surgical intervention.
Hearing aids
Hearing aids are an option in the management of OME. They
have been found to overcome the hearing loss associated
Table 3. Medical therapies trialed for the treatment of otitis media with
effusion.
Medical intervention Action Recommended
Oral/nasal steroids Reduce chronic No
inflammation
Oral/Intranasal Reducing intranasal No
antihistamines allergens
Antibiotics Reduce subclinical No
infections
Mucolytics Improve Eustachian tube No
dysfunction
Decongestants Improve Eustachian tube No
dysfunction
Auto ventilation Improve middle ear Yes limited evidence
ventilation
Data from [20-23].
Otitis media with effusion 383
with the condition. They are particularly useful in children
with Downs syndrome and cleft palate as the disease process
is likely to be protracted compared with the general pediatric
population [25-27]. Concerns surround the fluctuant nature of
the condition and hence the variation in need for amplifica-
tion. Children under the age of 7 tolerate aids well; however,
stigma is less of an issue at this age [28].
Surgical treatment
Surgery in the form of grommet insertion, for OME is one of
the most common operations performed on children in the UK.
A grommet, also known as a ventilation tube, is inserted
through the tympanic membrane and allows the middle ear
cleft to be ventilated. Grommet insertion can either be
performed as the lone procedure or in combination with
adenoidectomy. Grommet insertion alone was found to
improve hearing thresholds by 9 dB at 6 months post-
procedure in the UK multicenter study. This reduced over time
and at 12 and 24 months threshold improvement had reduced
to 6 and 4 dB, respectively [18]. In the same study, children
undergoing grommet insertion spent 32% less time with effu-
sion during the first year [18]. These changes appear modest
but may be important in the context of a childs development.
Adenoidectomy can be used as an adjunct to grommet
insertion reducing hearing loss by a further 4 dB. As well as
improving thresholds, there is a prolongation in duration of
improvement in hearing of up to 18 months. This extended
period creates a reduction in reinsertion rate of 21% [29].
Surgical management is not without its complications.
Adenoidectomy carries a 0.6% rate of hemorrhage requiring
return to surgery [29]. Grommet insertion can result in infec-
tion (226%) and permanent perforation of the tympanic
membrane (3%). There are long-term problems including
tympanosclerosis (3965%), attic retraction (21%), tympanic
membrane atelectasis (28%), segmental atrophy (1675%)
and cholesteatoma (1%) [29,30]. These rates are all higher
than those quoted earlier for those cases of OME allowed to
resolve spontaneously [19].
In the long-term, grommets do not appear to impact on
developmental outcome [24,31,32]. It is perhaps not surpris-
ing given these data that grommet insertion rates have
dropped from 43,300 operations in 19941995 to under
25,300 in 20082009 [33]. Despite this, parents report a high
level of satisfaction in outcome following the procedure
[34-36]. In three studies, parents were questioned during the
postoperative period. Parents felt children had benefited from
grommet insertion, in ways less prosaic than developmental
milestones and audiological assessment. The Dunedin study,
which is the longest documented population cohort study,
followed children into adulthood, although it showed no
detriment to the adults who had had OME as a child. It did
suggest that children with glue ear were more likely to have
behavioral problems [32].
The future of OME
The future treatment options for the OME relate largely to
the potential etiologies of the condition as previously
 384 H. Atkinson et al.
outlined. Several avenues of therapeutic intervention are
being considered. The concept of biofilms in otitis media is
being investigated. Current thinking is that in a condition
where one-third of effusions have a positive microbiological
culture, the chronicity of the condition as in other chronic
respiratory tract infections may be due to the presence of bio-
films; communities of bacteria which unlike planktonic bacte-
ria are joined together on surface by a matrix or film. These
bacteria are considerably less susceptible to antibiotic therapy
than their planktonic counterparts and studies are underway
to assess adjuvant therapies to work alongside antibiotics to
aid their effectiveness [37].
Although the link between gastroesophageal reflux disease
and OME is increasingly well documented, there is little liter-
ature regarding the treatment of reflux and possible impact on
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OME. It does not seem possible to endorse the use of
anti-reflux medication for OME at this time [38].
It has been thought for sometime that there may be a genetic
aspect to OME. Recent studies have suggested that children
with the condition have a general reduced immunity [39].
This has led to the discovery of potential genes causing suscep-
tibility to the condition [40,41]. It may be possible to use this
information in future to identify those at risk and create tailored
therapy toward individual patients.
Summary
For personal use only.
OME affects 20% of 2-year olds at any one time. There are a
number of potential theories as to its etiopathogenesis includ-
ing ET dysfunction, subclinical bacterial infection and as a
result of AOM. There are several risk factors, the most
important of which are parental smoking and breastfeeding.
Its management remains controversial, although generally
grommet insertion is recommended following a period of
watchful waiting, with or without adjuvant adenoidectomy.
The overall developmental improvement is limited but paren-
tal enthusiasm for surgical intervention remains high. The
potential of gene-targeted therapeutics as well as further
investigation of the role of biofilms and reflux is where the
future lies for the treatment of OME.
Declaration of interest
The authors have no relevant affiliations or financial involve-
ment with any organization or entity with a financial interest
in or financial conflict with the subject matter or materials
discussed in the manuscript. This includes employment,
consultancies, honoraria, stock ownership or options, expert
testimony, grants or patents received or pending or royalties.
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