Diagnosis and Management of Glue Ear for Healthcare Professionals
Otitis media with effusion (OME), also known as “Glue ear,” is the most common cause of hearing impairment in children, with children under five years most affected.
OME can cause temporary hearing loss and delayed speech development, and may impact on behaviour and educational progress. OME occurs when fluid builds up in the middle ear cavity. This is often, but not always, linked to ear infections. Fluid build-up can occur as a result of Eustachian tube inflammation which can prevent air getting to the middle ear. With no ventilation, the lining of the middle ear starts to produce fluid, and in-turn OME. In children the Eustachian tube is not as wide or as vertical as in adults, so they are more prone to blockage.
Diagnosis and when to refer
Patients with OME will normally present in the clinic as a result of parental or school concern. On taking a history, parents may complain that their child misunderstands instructions, asks for things to be repeated, or is not developing speech as expected. Parents may sometimes be unaware of a problem, and school may have highlighted hearing as an issue in class, or the child may have failed a school hearing screening test. OME can present with symptoms similar to those seen in other conditions, such as behaviour problems, poor progress at school or speech and language problems. It is therefore important that OME is not overlooked and that Otoscopy is carried out.
When performing Otoscopy identification of abnormalities in the shape of the tympanic membrane (TM) is a good indicator of OME. The drum may be bulging or retracted inwards. The colour is also important; the normal drum is quite translucent and a “light reflex” can be observed. If OME is present the drum can look yellow or darker than normal with no light reflex, also fluid bubbles can sometimes be seen behind the drum. It is important to note that in some cases OME can be very difficult to identify through Otoscopy due to only slight changes in the TM appearance. If OME is suspected further tests should be carried out with an Audiologist to confirm diagnosis and assess impact on hearing levels. Audiological tests will include Pure Tone Audiometry (PTA) to assess the extent of hearing loss, and Tympanometry to measure middle ear function. The following case study gives an example of how both these tests are used to identify OME, and how these tests should be interpreted.
Parents of patient “EE” (aged 2.5 years) were concerned as his speech was not developing as quickly as his older brother’s. EE also speaks loudly and has recently shown signs of frustration and anxiety at nursery. Otoscopy indicated slightly reddening of the eardrum, with a retraction of the TM. EE was thought to have possible Glue ear and referred for Audiological testing.
Audiological testing consisted of Pure tone Audiometry and Tympanometry. PTA indicated a bilateral mild conductive hearing loss (Fig 3) and Tympanometry showed a type B flat tympanogram (Fig 4). (Please see FIG1 and FIG2 for comparison against normal results). The conductive nature of the hearing impairment and the flat tympanogram would confirm the diagnosis of OME. PTA results suggest that the glue ear has reduced hearing to a level sufficient to affect speech development, therefore management options need to be considered for patient EE.
FIG 1 – Example of a normal Audiogram (Red: right ear, Blue: Left ear) thresholds for the main speech frequencies (500Hz, 1KHz, 2KH, and 4KHz) are between 0-15dB.
FIG 2 – Example of a normal Tympanogram (Red: right ear, Blue: Left ear) the line showing compliance is curved and peaks at around 0 daPa.
EE test results
FIG 3 – Bilateral mild conductive hearing loss, Thresholds for the main speech frequencies (500Hz, 1KHz, 2KH, and 4KHz) are lower than the normal range for children of 0-15dB. Bone conduction (triangles) results are normal indicating that this is a conductive hearing loss
FIG 4 – Flat type B Tympanogram – the line showing compliance is flat and does not peak.
In most cases OME will resolve of its own accord within the first three months of diagnosis, therefore a policy of “active observation” is recommended (NICE guidelines), and the child will receive no immediate treatment. After three months another Audiological examination is advised to confirm if OME has resolved. Together with active observation, autoinflation using an “Otovent” may help. This involves the patient blowing up a special balloon with their nose, which in turn increases pressure in the nose and helps clear the Eustachian tube. Using an Otovent has varying degrees of success and a follow-up Audiological assessment is still required. Clearing the Eustachian tube has in the past also been attempted by using a wide range of medicines, including antihistamines, decongestants and steroid sprays. However research suggests that these medical treatments have little or no effect on shortening the duration of OME, and can cause side effects. Persistent OME lasting longer than a minimum of three months, with adverse affects to the child’s hearing, may require further surgical management with an ENT consultant. Grommet surgery involves draining fluid and inserting tubes in the ear drum with the view of ventilating the middle ear. After Grommet insertion a follow up audiological examination will be carried out to reassess hearing levels, and in most cases hearing will improve to normal levels. Grommets are not permanent and over time will fall out; therefore it is important to monitor hearing levels even after the initial post-op assessment. Grommet insertion is the most common and effective treatment for OME, however If surgery is not an option then the use of hearing aids for the duration of the OME is an effective management strategy.
As Lead Audiologist at Bupa Cromwell Hospital Scott carries out specialist hearing tests for children. This is a seperate clinic run by the Bupa Cromwell Hospital. Learn more