BASICS
Description
- Also known as serous otitis media, secretory otitis media, nonsuppurative otitis media, "ear fluid," or "glue ear"
- Definition: Presence of fluid in the middle ear without acute infection signs or symptoms
- Mostly a pediatric disease
- May occur spontaneously (poor eustachian tube function) or after acute otitis media (AOM)
EPIDEMIOLOGY
- Children: ~90% have OME before school age (mainly 6 months–4 years)
- ~2.2 million new cases annually in the US
- Adults: Less common; usually secondary to underlying disorder
ETIOLOGY & PATHOPHYSIOLOGY
- Chronic inflammation → increased mucin production → functional eustachian tube blockage & mucin-rich effusion
- Young children: shorter, more horizontal eustachian tubes
- Common stimuli: Biofilms, anatomic variants, post-AOM, viral/bacterial infection
- Adults: Often linked to sinus disease (66%), smoking/adenoidal hypertrophy (19%), or tumors (4.8%)
RISK FACTORS
- Family history of OME
- Early daycare attendance
- Cigarette smoke exposure
- Bottle-feeding
- Low socioeconomic status
- Eustachian tube dysfunction
- Gastroesophageal reflux
GENERAL PREVENTION
- No definitive prevention, but reduced smoke exposure, breastfeeding, and avoiding daycare may decrease risk
DIAGNOSIS
History
- Often asymptomatic/transient in kids
- Main symptom: Hearing loss
- May have: Mild discomfort, fullness, popping, irritability, sleep issues, ear rubbing (infants), speech/language delay, poor attention/balance, clumsiness
- Often follows AOM or recent URI
Physical Exam
- Cloudy TM with impaired mobility
- Air-fluid level or bubble may be seen
- TM color: yellow, amber, blue; may be retracted/concave
- Redness in ~5% of cases
- No acute illness signs
Differential Diagnosis
- AOM
- Bullous myringitis
- Tympanosclerosis
- Sensorineural hearing loss
Diagnostic Tests
- Pneumatic otoscopy: Reduced/absent TM mobility (sensitivity 94%, specificity 80%)
- Tympanometry: Helpful if diagnosis unclear (especially infants >4mo)
- Acoustic reflectometry: Alternative tool
- Audiogram: Mild conductive hearing loss possible
- Hearing test: Recommended if OME >3 months
- Language testing: For abnormal hearing tests
- Myringotomy: Gold standard (not practical routinely)
TREATMENT
- Resolves in most within 3 months, especially if post-AOM
- Guidelines: 3 months of observation with optional serial exams, tympanometry, and language assessment
- Adults: Search for/treat underlying causes
Medication
- NOT recommended routinely:
- Antibiotics (Cochrane: small short-term benefit, but adverse events possible)
- Antihistamines and decongestants (no benefit, possible harm)
- Oral or intranasal corticosteroids (no long-term benefit, possible adverse effects)
- Adults: Role of decongestants/antihistamines/nasal steroids is unclear
Referral
- Indications for tympanostomy tube referral:
- Chronic bilateral OME (≥3 months) with hearing difficulty
- Chronic OME with symptoms (vestibular problems, poor performance, ear discomfort, ↓QoL)
- At-risk children (speech, language, or learning problems)
- Hearing aids: Acceptable alternative if surgery not feasible
Surgery/Procedures
- Tympanostomy tubes: Initial surgery of choice
- Risks: otorrhea, myringosclerosis, retraction pockets, persistent TM perforations
- Adenoidectomy: Similar efficacy to tubes in children >4 years; only with another indication or repeat surgery
- Tonsillectomy or myringotomy alone: Not recommended
Complementary/Alternative
- Autoinflation: May help (forced exhalation against closed mouth/nose)
ONGOING CARE
- Monitor at-risk children for OME at diagnosis and again at 12–18 months
- Follow-up: Repeat hearing tests every 3–6 months until effusion resolves or surgery is needed
PROGNOSIS
- ~50% resolve within 3 months in children >3 years
COMPLICATIONS
- Permanent hearing loss: Risk for speech/language/developmental delay
- Cholesteatoma: Possible with underventilated middle ear
ICD-10 Codes
- H65.90 Unspecified nonsuppurative otitis media, unspecified ear
- H65.00 Acute serous otitis media, unspecified ear
- H65.20 Chronic serous otitis media, unspecified ear
Clinical Pearls
- OME = middle ear effusion without infection
- Usually follows AOM in kids; eustachian tube dysfunction in adults
- Pneumatic otoscopy is diagnostic standard
- No benefit: antihistamines, decongestants, corticosteroids in children
- Watchful waiting and surgery (when indicated) are primary management options, chosen by risk of associated delays and hearing loss severity