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Glue Ear – A Silent Disease In Children

Simona Serban

Bucharest, Romania
Institute of Phono-Audiology and ENT Functional Surgery Prof. Dorin Hociota

 

Abstract

Chronic otitis media (COM) is an important public health problem with substantial economic and societal consequences. Chronic otitis media is a major global cause of hearing impairment in children and this may have serious long-term effects on language, auditory and cognitive development with consequences in educational progress. Otitis media with effusion (OME) or “glue ear” is the most common cause of hearing impairment in children. OME can be easily ignored because it produces few specific symptoms except the hearing problems. The effects of hearing loss and recurrent ear infections in the long term can impair speech and language development, therefore early management of this condition is necessary.

Key words: otitis media with effusion, glue ear, hearing impairment, early management

 

Correspondence

Simona Serban
Institute of Phono-Audiology and ENT Functional Surgery Prof. Dorin Hociota
21 Mihail Cioranu Street, sector 5,
Bucharest, Romania
E-mail: This email address is being protected from spambots. You need JavaScript enabled to view it.

 

Introduction

The peak incidence of otitis media with effusion (OME) is from 2 to 6 years of age, with episodes of recurrence and persistence of illness in the late childhood. About 85% of children will experience an episode of fluid in the ears following an ear infection, during childhood. About 50% of episodes of OME resolve spontaneously within three months.

When the fluid results in a bilateral hearing loss for longer than six months, there may follow delay in development of speech and language with social communication impediments. Different behaviour problems are not uncommon, due to both the hearing loss and the associated poor physical health. OME must be differentiated from acute otitis media (AOM) to avoid unnecessary antimicrobial use.[1,2]

Diagnosing OME correctly is fundamental for proper case management. Pneumatic otoscopy has the best sensitivity and specificity. However, when the diagnosis of OME is uncertain, tympanometry should be considered as a complementary tool to pneumatic otoscopy. Tympanometry with a standard 226-Hz probe tone is reliable for infants older than 4 months and has good routine clinical practice.[3,4] In about 40% to 50% of cases with OME, there are no significant complaints to indicate a middleear effusion.[5,6] In some children, however, OME may have associated signs and symptoms caused by inflammation or the presence of effusion (not acute infection) such as mild intermittent ear pain, fullness or poor attention, behavioural changes, failure to respond to normal conversational level speech, or the need for loud sound levels when using audio equipment or watching television.

Also, clinicians should distinguish the child with OME (table 1) who is at risk for speech, language, or learning problems from other children with OME, and should more promptly evaluate hearing, speech, language, and need for intervention. Many professional associations have already implemented protocol guidelines for glue ear management (e.g., Surgical management of glue ear in children, National Institute for Health and Clinical Excellence, February 2008)

Table 1. Risk Factors for Developmental Difficulties after American Academy of Pediatrics

Permanent hearing loss independent of otitis media with effusion
Suspected or diagnosed speech and language delay or disorder
Autism-spectrum disorder and other pervasive developmental disorders
Syndromes (eg, Down) or craniofacial disorders that include cognitive, speech, and language delays
Blindness or uncorrectable visual impairment
Cleft palate, with or without associated syndrome
Developmental delay

 

Children with craniofacial malformations (cleft palate; Down syndrome; Robin sequence; coloboma, heart defect, choanal atresia, retarded growth and development, genital anomaly, and ear defect with deafness - [CHARGE] association) have a higher prevalence of chronic OME, hearing loss (conductive and sensory neural), and speech or language delay than children without these anomalies.[7-10]

Treatment options depend on factors like effusion duration, degree of hearing loss, sequels of the middle ear, speech and language development and may not require surgery in all cases.

1. Active observation

The probability for spontaneous resolution of OME is determined by the cause and duration of effusion.[11] About 75% to 90% of residual OME after an AOM episode resolves spontaneously after 3 months.[12–14] A percentage of 55% from children with OME improve in 3 months,11 but one third of these will have OME relapse within the next 3 months.4 Documented bilateral OME of 3 months duration or longer resolves spontaneously after 6 to 12 months in about 30% of children age 2 or older, with only marginal benefits if observed longer.[11]

Any intervention for OME (medical or surgical) other than observation carries some inherent harm. It is well known that perfect grommet doesn’t exist for the time being and any tube insertion harms tympanic membrane. The recommendation for a 3-month period of observation is based on a clear preponderance of benefit over harm and is consistent with the original OME guideline intent of avoiding unnecessary surgery.[15] A period of 3 months of active observation is preferred using pneumatic otoscopy, tympanometry, or both. Factors to determine the optimal interval(s) for follow-up include hearing levels (HLs), tympanic membrane inflammation and access to a health care system.

2. Medication

Antihistamines and decongestants are ineffective for OME and are not recommended for treatment. Antimicrobials and corticosteroids do not have long-term efficacy and are not recommended for common management. Although statistically significant benefits have been proved for some medications, they are for short time and relatively small in magnitude. Moreover, significant adverse events may occur with all medical therapies. Adverse effects of antihistamines and decongestants include insomnia, hyperactivity, drowsiness, behavioural change, and blood pressure variation. Oral steroids can produce behavioural changes, increased appetite, and weight gain. Other adverse effects include adrenal suppression, severe varicella infection, and aseptic necrosis of the femoral head. Although intranasal steroids have fewer adverse effects, one randomized trial [16] showed statistically equivalent outcomes at 12 weeks for intranasal beclomethasone plus antimicrobials versus antimicrobials alone for OME. Antimicrobial therapy, including sometimes steroids, has not been demonstrated to be effective in long-term resolution of OME, but in some cases this therapy can be considered an option because of short-term benefits, when surgery is not accepted by the parent or caregiver. In this circumstance a single course of therapy for 10 to 14 days may be used. The probability that the OME will cure long term with these regimens is small, and prolonged or repetitive courses of antimicrobials or steroids are strongly not recommended. Other nonsurgical therapies like autoinflation of the eustachian tube, oral or intratympanic use of mucolytics, and systemic use of pharmacologic agents other than antimicrobials, steroids and antihistamine-decongestants are not effective in clinical trials, therefore these therapies are not recommended in treating OME.

3. Hearing Assessment

Hearing testing is recommended when OME persists for 3 months or longer, or at any time the parents observe language delay, learning problems, or a significant hearing loss. Usually, conductive hearing loss accompanies OME[17] and may have negative consequences on binaural processing, sound localization,[18] and speech perception in noise. Studies examining hearing sensitivity in children with OME report that average pure tone hearing loss at 4 frequencies (500, 1000, 2000, and 4000 Hz) ranges from normal hearing to moderate hearing loss (0–55 dB). The hearing loss is about 25 dB hearing level (HL) in 50% of tested ears and over 35 dB HL [19] in about 20% of ears. Unilateral OME with hearing loss results in overall poorer binaural hearing than in infants with normal middle-ear function bilaterally. There is evidence that children experiencing great conductive hearing loss for the long periods may exhibit developmental and academic sequelae.[20] Audiologic assessment includes evaluating air-conduction and bone-conduction thresholds for pure tones, speech detection or speech recognition thresholds, if possible. The method of hearing assessment depends on the developmental age of the child and includes visual reinforcement or conditioned orienting response audiometry for infants aged 6 to 24 months, play audiometry for children aged 24 to 48 months, or conventional screening audiometry for children older than 4 years. The brain stem response audiometry is test of auditory pathway structural integrity, not hearing.

4. Surgery

When a child is considered a candidate for surgery, tympanostomy tube insertion is the preferred initial procedure; synchronous adenoidectomy should be performed if a definitive indication exists (e.g. nasal obstruction, chronic adenoiditis). 2nd step surgery consists of adenoidectomy and myringotomy, with or without tube insertion. Surgical indication for OME depends on hearing status, associated symptoms or the child’s developmental risk (Table 1). Surgery is indicated for children with OME lasting for more than 3 months with persistent hearing loss, recurrent or persistent OME in children at risk regardless of hearing status, and OME and structural damage to the tympanic membrane or middle ear. Tympanostomy tubes are recommended for primary surgery because randomized trials show a mean 62% relative decrease in effusion prevalence and an absolute decrease of effusion days per child during the next year.[21] Adenoidectomy plus myringotomy (without tube insertion) has comparable efficacy in children aged 4 years or older, [21] but is more invasive with additional surgical and anaesthetics risks. Adenoidectomy is recommended for initial OME surgery if a clear indication exists, such as adenoiditis, postnasal obstruction, or chronic sinusitis. Between 20% and 50% of children who have had tympanostomy tubes have a recurrence of OME after tube removal that may require additional surgery.[21] My-ringotomy plus adenoidectomy is effective for children aged 4 years or older[21], but tube insertion is recommended for younger children, when potential relapse of effusion must be diminished (e.g. children at risk). Tonsillectomy or myringotomy alone (without adenoidectomy) is not recommended to treat OME. Myringotomy alone, without tube placement or adenoidectomy, is ineffective for chronic OME because the incision closes soon after intervention. Laser-assisted myringotomy permits the middle ear ventilation for several weeks22, but there is no sufficient data to prove its efficacy. On the contrary, tympanostomy tubes ventilate the middle ear for an average of 12 to 14 months.[21] Sequels after tube insertion are common but in many cases do not affect function (tympanosclerosis, focal atrophy, or shallow retraction pocket). Perforations of tympanic membrane, which may require myringoplasty surgery, are seen in 2% of children after placement of short-term (grommet-type) tubes and 17% after long-term tubes.[23] Adenoidectomy has a incidence of hemorrhage of 0.2% - 0.5% and 2% incidence of transient velopharyngeal insufficiency.[24] Other undesirable complications of adenoidectomy, such as nasopharyngeal stenosis and persistent velopharyngeal insufficiency, can be avoided with appropriate patient selection and surgical technique.

Conclusion

Glue ear is a common condition but in many cases remains silent, therefore it is important to be recognised early and assessed by an Ear, Nose and Throat Specialist. The effects of hearing loss and long term recurrent ear infections can impair speech and language development and may lead to poor performance of the child in school due to hearing loss. If the glue ear is not causing any major problems, a period of active observation with medication for short time is often advisable. Surgery becomes the alternative when the fluid is recurrent or persistent more than three months with risk of irreversible sequels of the tympanic membrane or middle ear.

 

 

 

 

References

1. Dowell SF, Marcy MS, Phillips WR, Gerber MA, Schwartz B. Otitis media—principles of judicious use of antimicrobial agents. Pediatrics. 1998;101:165–171

2. Dowell SF, Butler JC, Giebink GS, et al. Acute otitis media: management and surveillance in an era of pneumococcal resistance—a report from the Drug-resistant Streptococcus Pneumoniae Therapeutic Working Group. Pediatr Infect Dis J. 1999;18:1–9

3. Block SL, Mandel E, McLinn S, et al. Spectral gradient acoustic reflectometry for the detection of middle ear effusion by pediatricians and parents. Pediatr Infect Dis J. 1998;17:560–564,580

4. Barnett ED, Klein JO, Hawkins KA, Cabral HJ, Kenna M, Healy G. Comparison of spectral gradient acoustic reflectometry and other diagnostic techniques for detection of middle ear effusion in children with middle ear disease. Pediatr Infect Dis J. 1998;17:556–559,580

5. Casselbrant ML, Furman JM, Rubenstein E, Mandel EM. Effect of otitis media on the vestibular system in children. Ann Otol Rhinol Laryngol. 1995;104:620–624

6. Orlin MN, Effgen SK, Handler SD. Effect of otitis media with effusion on gross motor ability in preschool-aged children: preliminary findings. Pediatrics. 1997;99:334–337

7. Corey JP, Caldarelli DD, Gould HJ. Otopathology in cranial facial dysostosis. Am J Otol. 1987;8:14–17

8. Schonweiler R, Schonweiler B, Schmelzeisen R. Hearing capacity and speech production in 417 children with facial cleft abnormalities [in German]. HNO. 1994;42:691–696

9. Ruben RJ, Math R. Serous otitis media associated with sensorineural hearing loss in children. Laryngoscope. 1978;88:1139– 1154

10. Brookhouser PE, Worthington DW, Kelly WJ. Middle ear disease in young children with sensorineural hearing loss. Laryngoscope. 1993;103:371–378

11. Cunningham C, McArthur K. Hearing loss and treatment in young Down’s syndrome children. Childcare Health Dev. 1981;7:357–374

12. Rosenhall U, Nordin V, Sandstrom M, Ahlsen G, Gillberg C. Autism and hearing loss. J Autism Dev Disord. 1999;29:349– 357

13. Teele DW, Klein JO, Rosner BA. Epidemiology of otitis media in children. Ann Otol Rhinol Laryngol Suppl. 1980;89:5–6

14. Shott SR, Joseph A, Heithaus D. Hearing loss in children with Down syndrome. Int J Pediatr Otorhinolaryngol. 2001;61:199– 205

15. Stool SE, Berg AO, Berman S, et al. Otitis Media With Effusion in Young Children. Clinical Practice Guideline, Number 12. AHCPR Publication No. 94-0622. Rockville, MD: Agency for Health Care Policy and Research, Public Health Service, US Department of Health and Human Services; 1994

16. Burke P, Bain J, Robinson D, Dunleavey J. Acute red ear in children: controlled trial of nonantibiotic treatment in general practice. BMJ. 1991;303:558–562

17. Besing J, Koehnke J. A test of virtual auditory localization. Ear Hear. 1995;16:220–229

18. Fiellau-Nikolajsen M, Lous J. Prospective tympanometry in 3-year-old children. A study of the spontaneous course of tympanometry types in a nonselected population. Arch Otolaryngol. 1979;105:461–466

19. American Speech-Language-Hearing Association Panel on Audiologic Assessment. Guidelines for Audiologic Screening. Rockville, MD: American Speech-Language-Hearing Association; 1996

20. Roberts JE, Zeisel SA. Ear Infections and Language Development. Rockville, MD: American Speech-Language-Hearing Association and the National Center for Early Development and Learning; 2000

21. van Balen FA, De Melker RA. Persistent otitis media with effusion: can it be predicted? A family practice follow-up study in children aged 6 months to 6 years. J Fam Pract. 2000;49:605– 611

22. Roberts JE, Burchinal MR, Jackson SC, et al. Otitis media in early childhood in relation to preschool language and school readiness skills among black children. Pediatrics. 2000;106:725–735

23. Bennett KE, Haggard MP, Silva PA, Stewart IA. Behaviour and developmental effects of otitis media with effusion into the teens. Arch Dis Child. 2001;85:91–95

24. Sano S, Kamide Y, Schachern PA, Paparella MM. Micropathologic changes of pars tensa in children with otitis media with effusion. Arch Otolaryngol Head Neck Surg. 1994;120:815–819