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Serous Otitis Media

Serous otitis media is an accumulation of fluid in the middle ear, which occurs either from incomplete resolution of acute otitis media or from the obstruction of the eustachian tube from noninfectious causes. It is most commonly observed among children, and symptoms include hearing loss and a sense of fullness and pressure in the ear. Diagnosis is made through physical examination, and treatment is indicated only if the symptoms persists for months.


Presentation

The clinical presentation of serous otitis media can be asymptomatic, and about 40-50% of documented cases report no symptoms. However, the most common clinical presentation of patients is hearing loss, and sometimes parents of children are the first to notice these changes. In addition to hearing loss, a sense of fullness and pressure is also reported by patients. Further, a popping sensation in the ear when swallowing is also observed.

Patient history is vital in the setting of serous otitis media, as most cases occur after an acute infection of the middle ear. In all patients who had a prior middle ear infection, the suspicion toward serous otitis media must be made, especially if symptoms last for a prolonged period of time.

The otoscopic examination is performed to evaluate the status of the tympanic membrane and the surrounding structures. During otoscopy, a grayish color of the tympanic membrane may be observed, displacement of the light reflex, and a certain degree of retraction. If a pneumatic otoscope is used, the tympanic membrane may be immobile.

Soft Tissue Mass
  • In all cases, the computed tomographic scans showed three imaging signs: soft tissue mass filling the middle ear or mastoid, hyperostosis of the petrous bone, and hairy aspect of the intracranial margins of the affected bone.[ncbi.nlm.nih.gov]
Otalgia
  • Head and neck symptoms Children may show signs of earache or otalgia through the pulling of the affected ear.[ehealthhall.com]
  • Cysts of the nasopharynx may be asymptomatic, but if one enlarges or becomes inflamed, the patient may experience nasal obstruction, headaches, postnasal discharge with a foul odor, eustachian tube dysfunction with resulting otalgia, and serous otitis[acronymfinder.com]
  • Fever was the most common presenting sign/symptom, observed in 8 patients, followed by otalgia, neck stiffness, headache, and confusion. An opaque and bulging tympanic membrane was observed in 8 patients.[entjournal.com]
  • In adolescents and adults, otalgia is a more common presenting symptom than in children under the age of 2. [ 1 ] Indeed, in adults, otalgia may occur without fever or hearing loss and may be the only presenting feature.[patient.info]
  • […] children three months to seven years of age, researchers collected middle ear fluid samples by tympanocentesis. 3 Physicians diagnosed AOM based on pneumatic otoscopic findings behind an inflamed tympanic membrane and at least one of the following: otalgia[aafp.org]
Hearing Problem
  • If your child isn't old enough to say "My ear hurts," here are a few things to look for Tugging at ears Crying more than usual Fluid draining from the ear Trouble sleeping Balance difficulties Hearing problems Your health care provider will diagnose an[icdlist.com]
  • ’, or glue ear', is the accumulation of serous or mucoid fluid (but not mucopurulent fluid) in the middle ear cavity without signs and symptoms of an acute infection (1,2) it often results in conductive hearing loss and is the most frequent cause of hearing[gpnotebook.co.uk]
  • One common symptom of OME is hearing problems. In younger children, behavior changes can be a symptom of hearing problems. For example, a child may turn the television up louder than usual. They may also tug or pull on their ears.[healthline.com]
Ear Discharge
  • NIH: National Institute on Deafness and Other Communication Disorders Cholesteatoma (Medical Encyclopedia) Ear discharge (Medical Encyclopedia) Ear examination (Medical Encyclopedia) Ear infection - acute (Medical Encyclopedia) Ear infection - chronic[icdlist.com]
  • Chronic Suppurative Otitis Media Chronic Suppurative OM is a result of an episode of an acute OM but is characterized by a persistent ear discharge due to the perforation of the tympanic membrane.[ehealthhall.com]
  • There was a of purulent ear discharge 8 days prior to eye symptoms. No history of trauma was obtained. Examination revealed proptosis with zygomatic abscess extending to the post-auricular.[ajol.info]
  • Discharge 258 Intravenous Antibiotics for Otorrhea 261 Evaluation and Treatment of Recurrent PostTympanostomy Otorrhea 266 Workup and Management of Chronic Otorrhea 271 MethicillinResistant Staphylococcus aureus Otorrhea 278[books.google.de]
Ear Fullness
  • However, sometimes there is enough fluid in the middle ear space that you will notice one or more of the following symptoms: Pain Hearing loss Ear fullness Child pulling at their ear Child has a change in behavior If you notice a prolonged behavior change[verywellhealth.com]
Dizziness
  • Serous Otitis Media Symptoms: Itching and pain in the infected ear Loss of hearing Running a fever Throwing up Discharge of pus from the infected ear Feeling dizzy (sometimes) Serous Otitis Media Treatment : There are many ways that you can find relief[diethealthclub.com]
  • This cyst is chronically infected and if left untreated can rarely erode into the facial nerve causing paralysis of the face, the inner ear causing deafness, and dizziness and the brain causing meningitis and death.[entusa.com]
  • There have also been recommendations in the literature to prescribe an antibiotic for serous otitis media (an accumulation of fluid in the middle ear due to poor drainage), which may have played a part in Ruth's dizziness (Macknin, 1988).[medical-dictionary.thefreedictionary.com]
  • Hain, MD of Chicago Dizziness and Balance Page last modified: November 24, 2016 Definition of Otitis Media The term otitis media means that there is inflammation of the middle ear.[dizziness-and-balance.com]
Vertigo
  • Individuals may or may not suffer with symptoms to include: intermittent ear pain hearing loss speech delays balance problems delayed motor skills feeling of fullness in ears recurrent vertigo watery discharge Adults typically complain of aural fullness[saent.net]
  • Typically caused by a virus and less commonly bacteria, common symptoms include dizziness, vertigo, loss of balance, flickering of the eyes (nystagmus), and tinnitus or hearing loss. Labyrinthitis is classified to subcategory 386.3.[fortherecordmag.com]
  • Fever, vertigo and otalgia should prompt urgent referral to exclude intratemporal or intracranial complications. Hearing loss is common in the affected ear. Ask about the impact of this on speech development, school or work.[patient.info]
  • Serous otitis media may be associated with both hearing loss and vertigo. Chronic otitis media may be associated with a chronically draining ear, mastoiditis, and cholesteatoma.[dizziness-and-balance.com]
Cranial Nerve Involvement
  • Abstract In a prospective study of 271 new patients with nasopharyngeal carcinoma, 36 (13.3%) were found to have cranial nerve involvement.[ncbi.nlm.nih.gov]
  • Nasopharyngeal cancer can present with nasal obstruction, epistaxis, purulent rhinorrhea, headache, ear pain, serous otitis media , cervical lymphadenopathy, and cranial nerve involvement.[acronymfinder.com]
Sensation Disorder
  • Disorders Neurologic Manifestations Nervous System Diseases Signs and Symptoms[clinicaltrials.gov]

Workup

Workup comprises a targeted physical examination, including an otoscopic examination of the ears, in order to determine the cause of hearing loss. Tympanometry may be performed to confirm the presence of fluid in the middle ear, and thus establishing the diagnosis of serous otitis media [9].

In addition to ear examination, the workup should include a full examination of the nasal cavity and pharynx, to exclude other causes that may be responsible for obstruction of the eustachian tube, such as hypertrophied adenoids, or malignant and benign tumors.

Treatment

Serous otitis media resolves on its own in a period of two to three weeks, and no therapy is usually required. However, if the condition gains a chronic course, treatment is necessary and is primarily targeted to the underlying cause.

The middle ear can be temporarily ventilated with the Valsalva maneuver. The maneuver is performed by keeping the mouth fully closed and both nostrils pinched. The patient tries to blow the air forcibly through the nostrils, which will result in an air trying to reach the middle ear through the eustachian tube, and "ear popping" will occur as a result, leading to a temporary relief. Another maneuver is called politzerization, which requires the presence of a physician and includes blowing air with a middle ear inflator into one of the patient's nostrils while keeping the other nostril tightly closed. While the patient swallows, the air is forced into the eustachian tube and the middle ear. However, neither of these procedures should be performed if the patient is suffering from rhinorrhea or other respiratory infections.

If no improvement occurs after one to three months, myringotomy may be performed [10]. Myringotomy comprises incision of the tympanic membrane, in order to relieve the pressure in the middle ear and drain the existing fluid, which can sometimes be performed by insertion of tympanostomy tubes [11], which aid in the process of drainage. Tympanostomy tubes may be also inserted for patients with a persistent conductive hearing loss, but also to prevent recurrent acute otitis media, which may cause further complications.

Patients who are suffering from allergies need to receive proper therapy including antihistamines and topical corticosteroids, which may be helpful in alleviating symptoms. Patients with hypertrophied adenoids and those with discovered tumors should be treated surgically. Antibiotics and decongestants are not effective therapeutic strategies [12], hence antibiotic therapy is given only if there is an evidence of additional bacterial rhinitis, sinusitis, or nasopharyngitis.

Prognosis

Serous otitis media generally has a good prognosis, and most episodes spontaneously resolve without treatment and need for intervention. However, this condition often goes undiagnosed, and chronic serous otitis media may cause permanent hearing loss. Moreover, it is considered to be the leading cause of a hearing loss in young children. In some children, even appropriate surgical therapeutic measures may not prevent the recurrence of serous otitis media, and it is estimated that about 20-50% of children will have a recurrence after spontaneous ventilation tube extrusion, which then requires placement of such tubes for years. Additionally, it is associated with delayed language development in children younger than 10 years. All of these factors implicate the potentially debilitating consequences of this condition and signify the importance of prompt diagnosis and proper therapy when necessary.

Etiology

Serous otitis media may occur as a result of several conditions, the most common being an incomplete resolution of bacterial otitis media (most commonly caused by Streptococcus pneumoniae), which makes the middle ear susceptible to fluid accumulation and improper drainage. Secondary inflammatory processes in the nasopharynx, such as rhinitis, sinusitis, and pharyngitis may also be responsible for the development of this condition, through mechanical obstruction of the eustachian tube. Non-infectious causes, such as the presence of hypertrophic adenoids, lymphoid aggregations, but also malignant and benign tumors may be the causes as well, through the same mechanism. Allergic conditions, such as hay fever, in which swelling of mucous membranes could occur, may also cause obstruction of the eustachian tube. Congenital conditions, such as cleft palate [3], have also been implicated as causes of serous otitis media [4].

Epidemiology

Serous otitis media is most commonly diagnosed in children [5], and it was estimated that about 90% of children had at least one episode of serous otitis media by four yeas of age [6]. Additionally, the prevalence rate of serous otitis media decreases with age, being about 3-4% in children between six to eight years. However, this condition may be observed in any individual, regardless of age and gender.

Sex distribution
Age distribution

Pathophysiology

Under physiological conditions, the eustachian tube serves as a ventilation mechanism, thus establishing the pressure equilibrium, and is the primary route for removal of secretions. The eustachian tube is still immature and underdeveloped in young children, which is why this condition is much more commonly observed among them [7].

When the functions of the eustachian tube are disrupted, as in the presence of acute otitis media, or mechanical obstruction from any causes, negative pressure inside the middle ear is created as a result of mucosal absorption of oxygen and other substances, which leads to the formation of a transudate fluid within the middle ear. This fluid (which is called serous because of its composition) accumulates in the middle ear, leading to obstruction of the hearing apparatus, thus causing symptoms of impaired hearing. If this fluid is not drained, or removed from the middle ear, it may cause permanent hearing loss. Initially, this fluid is sterile, but it is a favorable medium for bacterial growth.

It is mentioned that serous otitis media most commonly occurs after acute otitis media. In the setting of acute otitis media, the bacterial infection of the middle ear causes disruption of a regular function of the middle ear and creates favorable conditions for the development of serous otitis media. Newer theories suggest that some other factors are involved in the pathogenesis of serous otitis media, such as extraesophageal reflux, which brings into question other mechanisms that are involved in the development of this condition [8].

Prevention

Factors which may aid in the prevention of serous otitis media:

  • Environmental factors - avoiding cigarette smoke, allergens, and pollution have been suggested for patients with recurrent and chronic infections of the ear, because of their supposed effects on ear drainage. It is postulated that elimination of household smoking may reduce the incidence of serous otitis media while avoiding allergens reduces the symptoms of mucosal swelling, which may be beneficial for patients suffering from this condition.
  • Hygiene measures - Regular hand washing and proper hygiene have been mentioned as strategies for reducing the risk of serous otitis media.

Prevention of consequences of serous otitis media can be achieved primarily through a timely diagnosis since the majority of cases reach chronic stage due to missed diagnosis.

Summary

Serous (or secretory) otitis media occurs due to insufficient drainage of fluid inside the middle ear, leading to fluid accumulation [1]. It most commonly occurs after acute otitis media (most commonly caused by bacterial infection), or due to obstruction of the eustachian tube from noninfectious causes [2]. It is one of the leading causes of deafness in children and is primarily encountered among young children. The course of illness may be asymptomatic, but symptoms are often present, including hearing loss, and a feeling of pressure and fullness in the affected ear. It is not uncommon that family members recognize a hearing loss of the patient first. The diagnosis of serous otitis media is made clinically and by performing otoscopy. Also, tympanometry may be performed to confirm the presence of the fluid in the middle ear. The clinical examination must comprise nasopharyngeal inspection, to exclude malignant or benign tumors as causes of eustachian tube obstruction. Treatment comprises supportive therapy in most cases, while myringotomy with tympanostomy may be indicated if the disease does not spontaneously regress within a few months. Underlying nasopharyngeal conditions which may cause this condition to be chronic should be managed, such as adenoidectomy, while antibiotic therapy is given only if the development of bacterial rhinitis, sinusitis and nasopharyngitis occur. Prognosis is good, the majority of cases resolve either with or without treatment, but about 5% of children who do not receive proper treatment for chronic serous otitis media experience permanent hearing loss.

Patient Information

Serous (or secretory) otitis media implies the presence of fluid in the middle ear, in which the key components of the hearing apparatus are located. This condition most commonly occurs after an acute infection of the middle ear (most commonly due to bacteria), or due to other causes that cause obstruction of the eustachian tube, which is responsible for normal ventilation of the middle ear. When the eustachian tube is obstructed, the negative pressure inside the middle ear causes the surrounding cells to create small amounts of fluid, which accumulate over time and cause hearing difficulties and may even cause hearing loss.

Apart from preceding otitis media, other causes include enlarged adenoids (lymphoid tissue in the throat), allergies, but also malignant and benign tumors that mechanically obstruct the eustachian tube.

Serous otitis media most commonly occurs in young children, which can be partly explained by the fact that the eustachian tube is not completely formed until three years of age, making children particularly prone to this condition.

The most common clinical presentation is hearing loss, which is often noticed by family members, while a sense of pressure or fullness is also commonly reported. This condition may be asymptomatic as well. A definite diagnosis is achieved through a detailed examination of the ear with an otoscope, with which the physician evaluates the status of the eardrum, and can indirectly assess the status of the middle ear. Other procedures may aid in the diagnosis, such as tympanometry.

Serous otitis media can spontaneously resolve without any therapy. However, if the condition becomes chronic, and remains untreated, it may lead to permanent hearing loss, and this condition is the most common cause of hearing loss among children, which is why this condition must be diagnosed promptly and treated properly.

The fluid that is chronically accumulated inside the middle ear needs to be drained, and it is performed through a procedure called myringotomy, which implies incision of the eardrum, and sometimes a placement of a tube that aids in draining the fluid from the middle ear. These tubes may often stay there for months, or sometimes even years, if necessary. Antibiotics and decongestants are not effective for treatment of this condition, and bacterial infection is not responsible for the accumulation of fluid, which is why antibiotics will not help.

Treatment strategies also include the elimination of the underlying cause, such as surgical removal of enlarged adenoids, or managing allergies with proper drugs.

References

Article

  1. Shekelle PG, Takata G, Newberry SJ, et al. Management of acute otitis media: update. Evid Rep Technol Assess. 2010;198:1–426.
  2. Jacobs MR, Dagan R, Appelbaum PC, et al. Prevalence of antimicrobial-resistant pathogens in middle ear fluid. Antimicrob Agents Chemother. 1998; 42(3):589–595.
  3. Harman NL, Bruce IA, Callery P, et al. MOMENT -- Management of Otitis Media with Effusion in Cleft Palate: protocol for a systematic review of the literature and identification of a core outcome set using a Delphi survey. Trials. 2013;14(1):70.
  4. Siddartha, Bhat V, Bhandary SK, Shenoy V, Rashmi. Otitis media with effusion in relation to socio economic status: a community based study. Indian J Otolaryngol Head Neck Surg. 2012; Mar;64(1):56-58.
  5. Teele DW, Klein JO, Rosner BA, et al. Epidemiology of otitis media in children. Ann Otol Rhinol Laryngol Suppl. 1980;89(3 Pt 2):5.
  6. Tos M. Epidemiology and natural history of secretory otitis. Am J Otol. 1984;5(6):459-462.
  7. Bluestone CD, Beery QC, Andrus WS. Mechanics of the eustachian tube as it influences susceptibility to and persistence of middle ear effusions in children. Ann Otol Rhinol Laryngol. 1972;83(Suppl 11):27-34.
  8. Crapko M, Kerschner JE, Syring M, et al. Role of extra-esophageal reflux in chronic otitis media with effusion. Laryngoscope. 2007.
  9. Watters GW, Jones JE, Freeland AP. The predictive value of tympanometry in the diagnosis of middle ear effusion. Clin Otolayngol Allied Sci. 1997;22(4):343–345.
  10. Rosenfeld RM, Culpepper L, Doyle KJ, et al. Clinical practice guideline: Otitis media with effusion. Otolaryngol Head Neck Surg. 2004;130(Suppl 5):S95-118.
  11. Arrieta A, Singh J. Management of recurrent and persistent acute otitis media: new options with familiar antibiotics. Pediatr Infect Dis J. 2004;23(Suppl 2):S115–S124.
  12. Gluth MB, McDonald DR, Weaver AL, et al. Management of eustachian tube dysfunction with nasal steroid spray: a prospective, randomized, placebo-controlled trial. Arch Otolaryngol Head Neck Surg. 2011; 137(5):449–455.

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Last updated: 2018-06-22 04:53