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chronic serous otitis media (glue ear, otitis media with effusion)

Etiology: 1) persistence of secretions within the middle ear secondary to occlusion of the eustachian tube which drains the middle ear 2) precipitating factors a) allergic or vasomotor rhinitis b) upper respiratory tract infection (viral) c) acute otitis media d) low grade bacterial infections by the same organisms that cause acute otitis media e) gastric reflux ? [3] 3) risk factors - speech & language delay - autism - craniofacial disorders - cleft palate Pathology: - pepsin & pepsinogen found in high concentrations in 83% of middle ear effusions from children age 8-10 [3] Clinical manifestations: 1) ear fullness 2) conductive hearing loss: low grade (15- 20 dB) 3) tympanic membrane a) appearance variable: dull, retracted, opaque, air-fluid levels, air bubbles or normal b) mobility decreased or absent c) clear fluid in middle ear 4) pain & fever are absent 5) recurrent otitis media Laboratory: 1) pneumatic otoscopy 2) tympanography Complications: - cholesteoma Differential diagnosis: 1) cerumen impactation 2) previously perforated tympanic membrane 3) obstructing nasopharyngeal tumor Management: 1) conservative measures - avoid exposure to passive smoke - autoinflation of eustachian tube - exhalation against a closed glottis & nasal passages - observation for 12 weeks 2) pharmacologic agents a) indications: - symptoms persisting >12 weeks - recurrent acute otitis media: (see acute otitis media) b) antibiotics: 2-4 week course - amoxicillin clavulanate (Augmentin) - cefaclor (Ceclor) - sulfa combination - erythromycin/sulfisoxazole (Pediazole) - Bactrim c) prednisone - 1 mg/kg/day for 7 days - use only in conjunction with antibiotic treatment - avoid if risk of varicella contact d) antihistamines: not indicated e) oral decongestants: not indicated f) nasal steroids not recommended [4]; do not use [6] - ciclesonide (Omnaris) for 14 days provided benefit in one clinical trial - at least 3 other clinical trials concluded no benefit - dexamethasone for three weeks, - beclomethasone for 12 weeks - mometasone for 3 months g) oral prednisolone of no benefit [7] 3) referral to otolaryngologist - symptoms persisting > 16 weeks - tympanostomy tube(s) if surgery - avoid adenoidectomy unless there is nasal obstruction, chronic adenoiditis, or another underlying condition [6] 4) document in the medical record outcome of management [6]

Related

middle ear effusion (otitis media with effusion)

General

chronic otitis media

References

  1. Saunders Manual of Medical Practice, Rakel (ed), WB Saunders, Philadelphia, 1996, pg 80-81
  2. Medical Knowledge Self Assessment Program (MKSAP) 11, 15, American College of Physicians, Philadelphia 1998, 2009
  3. Journal Watch 22(6):45, 2002 Tasker A et al, Lancet 359:493, 2002
  4. Prescriber's Letter 19(2): 2012 COMMENTARY: Nasal Steroids for Otitis Media with Effusion PATIENT EDUCATION HANDOUT: Fluid in the Middle Ear (Otitis Media with Effusion) PATIENT EDUCATION HANDOUT SPANISH VERSION: Liquido en el oido medio (otitis media con derrame) GUIDELINES: Otitis Media With Effusion (2004) Detail-Document#: 280206 (subscription needed) http://www.prescribersletter.com
  5. New synthesis on Otitis Media with Effusion (2006) includes recommendations from AAFP/AAOHNS/AAP, CCHMC, SIGN, and UMHS. http://www.guideline.gov/Compare/comparison.aspx?file=OTITIS_OME1.inc
  6. Rosenfeld RM et al Clinical Practice Guideline: Otitis Media with Effusion. Executive Summary (Update) Otolaryngology-Head and Neck Surgery. 2016, 154(2) 201-214 PMID: 26833645 http://oto.sagepub.com/content/154/2/201.full.pdf+html
  7. Francis NA, Cannings-John R, Waldron CA et al. Oral steroids for resolution of otitis media with effusion in children (OSTRICH): A double-blinded, placebo-controlled randomised trial. Lancet 2018 Aug 18; 392:557 PMID: 30152390 Free PMC Article https://www.thelancet.com/journals/lancet/article/PIIS0140-6736(18)31490-9/fulltext