History and exam
Key diagnostic factors
common
middle ear effusion
The presence of middle ear effusion without any signs of ear infection is a diagnostic criterion for OME.
On otoscopy, the tympanic membrane may appear dull, with golden fluid behind the drum. There may be bubbles or an air-fluid level.[2] The tympanic membrane may also be retracted. However, a normal looking tympanic membrane does not exclude OME, unless pneumatic otoscopy is normal as well.
no signs of acute infection
No signs of acute infection in the presence of middle ear effusion is a diagnostic criterion for OME.
Signs of acute infection (fever, ear pain, discharge from the ear, tympanic membrane bulging, and erythema) indicate acute otitis media rather than OME.
aural fullness or pressure
Approximately 13% of adults presenting with aural fullness are found to have OME.[60] This may be described as a feeling of ear blockage.
hearing loss
OME can be associated with a variable impact on hearing, from no hearing loss through to a moderate conductive hearing loss.[2]
Parents may notice signs of poor hearing, such as the child not responding when being called. Ask about indistinct speech, delayed language development or inattention. Infants and children may also present after a failed hearing screen or during the work up of speech delay.
Severe hearing loss may indicate pathology other than or in addition to OME and should be appropriately investigated.
Other diagnostic factors
common
slow progress within an education setting
A parent or caregiver may describe slow progress within an education setting, possibly due to hearing loss.[52]
failed hearing screen
Children may present with OME after failing a routine hearing screen through their school or primary care provider, or following a failed newborn hearing screen.
In one prospective study of 152 infants referred because of unilateral or bilateral failure of the universal newborn hearing screening test with an automated auditory brainstem response device, 84 (55.3%) had OME.[61] In infants with OME who fail a newborn hearing screen, follow-up is important to ensure that hearing is in fact normal once the OME resolves.[2]
speech delay
signs of ear discomfort
Prelingual children may show signs of ear discomfort such as ear tugging or scratching the pinna.
Risk factors
strong
childhood
OME is common in childhood. It can be found in over 50% of children ages <1 year and 60% of children ages <2 years.[1][18]
One study using routine examination of the eardrum found OME in 15% to 40% of children ages between 1 and 5 years.[1][37]
In one study to identify the prevalence of OME in primary school children, a maximum prevalence of 12.9% was found in children ages 5 to 6 years.[1][6]
In infants, the Eustachian tube is shorter and more horizontal than in older children and adults and is therefore less effective at clearing the contents of the middle ear.[13][14]
Children have been found to be less able than adults to equalize negative middle ear pressure.[15]
upper respiratory tract infection
acute otitis media
craniofacial anomalies
People with an unrepaired cleft palate almost universally experience chronic OME.[40] Abnormal muscular attachment of palatal muscles predisposes this population to Eustachian tube dysfunction and subsequent chronic OME.[41] After cleft palate repair, OME continues to be prevalent.[8]
Patients with trisomy 21 are also at increased risk of chronic OME. This may be secondary to poor active function of the Eustachian tubes.[11]
Eustachian tube dysfunction
genetic predisposition in children
daycare attendance
weak
allergic rhinitis
There is an association between allergy and OME, but there is currently no evidence of causation.[1] Children with OME have been found to have an increased prevalence of allergic rhinitis.[20] This may be secondary to allergy-related mucosal swelling and increased mucus production.[20]
Data suggest that age is an effect modifier of the association between allergic rhinitis and OME. Specifically, there is a significant association between allergic rhinitis and OME in children ages 6 years and older. The same association is not found in children younger than 6 years.[22]
environmental tobacco smoke
Tobacco smoking and exposure to second-hand tobacco smoke may increase the risk of otitis media with effusion. Proposed mechanisms include impaired mucociliary clearance of the Eustachian tubes and smoke-induced nasopharyngeal lymphoid hyperplasia.[23][24] In children, exposure to second-hand smoke is associated with higher odds of OME (and acute otitis media).[25]
sinonasal disease
nasopharyngeal malignancy
The rate of nasopharyngeal carcinoma as the cause of adult-onset OME has been found to be approximately 5% to 6%.[28][24] The mechanism of OME may be due to Eustachian tube orifice obstruction or Eustachian tube dysfunction secondary to infiltration of tubal musculature.[29] Adults presenting with OME, particularly if unilateral and persistent, should be assessed for nasopharyngeal carcinoma via endoscopy.[28]
gastroesophageal reflux disease (GERD)
Symptoms of GERD have been found more frequently in people with OME compared to those without OME.[30] Pepsin and Helicobacter pylori have also been found in middle ear effusions.[31][1] While there is an association, a causal relationship has not been established.[1] Furthermore, treating GERD has not been associated with an increased rate of resolution of OME.[32]
low socioeconomic status
Low socioeconomic status has been associated with OME.[10]
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