Key Points
- Otitis media with effusion (OME) is defined as the presence of fluid in the middle ear (Figure 1, Table 1) without signs or symptoms of acute ear infection.
- By contrast, acute otitis media (AOM) is the rapid onset of signs and symptoms of inflammation in the middle ear, most often with ear pain and a bulging eardrum.
- Synonyms for OME include ear fluid and serous, secretory, or nonsuppurative otitis media.
- About 90% of children have OME before school age, and they develop, on average, 4 episodes of OME every year.
- In the first year of life, >50% of children will experience OME, increasing to >60% by age 2 years.
- OME is largely asymptomatic, and many episodes are therefore undetected, including those episodes in children with hearing difficulties or school performance issues.
- When children aged 5-6 years in primary school are screened for OME, about 1 in 8 are found to have fluid in one or both ears.
- The prevalence of OME in children with Down syndrome or cleft palate, however, is much higher, ranging from 60-85%.
- Most episodes of OME resolve spontaneously within 3 months, but about 30%-40% of children have repeated OME episodes and 5%-10% of episodes last ≥1 year.
- At least 25% of OME episodes persist for 3 months or longer and may be associated with hearing loss, balance (vestibular) problems, poor school performance, behavioral problems, ear discomfort, recurrent AOM, or reduced QOL.
- Less often, OME may cause structural damage to the tympanic membrane that requires surgical intervention.
Table 1. Abbreviations and Definitions of Common Terms
Term and Definition
- Otitis media with effusion (OME)
- The presence of fluid in the middle ear without signs or symptoms of acute ear infection.
- Chronic OME
- OME persisting for 3 months or longer from the date of onset (if known) or from the date of diagnosis (if onset is unknown).
- Acute otitis media (AOM)
- The rapid onset of signs and symptoms of inflammation of the middle ear.
- Middle ear effusion
- Fluid in the middle ear from any cause. Middle ear effusion is present with both OME and AOM, and may persist for weeks or months after the signs and symptoms of AOM resolve.
- Hearing assessment
- A means of gathering information about a child’s hearing status, which may include caregiver report, audiologic assessment by an audiologist, or hearing testing by a physician or allied health professional using screening or standard equipment, which may be automated or manual. Does not include use of noisemakers or other non-standardized methods.
- Pneumatic otoscopy
- A method of examining the middle ear by using an otoscope with an attached rubber bulb to change the pressure in the ear canal and see how the eardrum reacts. A normal eardrum moves briskly with applied pressure but when there is fluid in the middle ear the movement is minimal or sluggish.
- Tympanogram
- An objective measure of how easily the tympanic membrane vibrates and at what pressure it does so most easily (pressure- admittance function). If the middle ear is filled with fluid (e.g., OME), vibration is impaired and the result is a flat, or nearly flat, tracing. If the middle ear is filled with air, but at a higher or lower pressure than the surrounding atmosphere, the peak on the graph will be shifted in position based on the pressure (to the left if negative, to the right if positive).
- Conductive hearing loss
- Hearing loss from abnormal or impaired sound transmission to the inner ear, which is often associated with effusion in the middle ear, but can be caused by other middle ear abnormalities as tympanic membrane perforation, or ossicle abnormalities
- Sensorineural hearing loss
- Hearing loss that results from abnormal transmission of sound from the sensory cells of the inner ear to the brain.
Diagnosis
Figure 1. Location of the Middle Ear Space
Figure 2. Comparison of OME (top) with AOM (bottom)
Figure 3. Position of the Eustachian Tube
Figure 4. Normal, Type A Tympanogram Result
Figure 5. Abnormal, Type B, Tympanogram Results
Table 2. Summary of Guideline Key Diagnostic Action Statements
| Statement | Action | Strength |
|---|---|---|
| 1a. Pneumatic otoscopy | The clinician should document the presence of middle ear effusion with pneumatic otoscopy when diagnosing otitis media with effusion (OME) in a child. | S |
| 1b. Pneumatic otoscopy | The clinician should perform pneumatic otoscopy to assess for OME in a child with otalgia, hearing loss, or both. | S |
| 2. Tympanometry | Clinicians should obtain tympanometry in children with suspected OME for whom the diagnosis is uncertain after performing (or attempting) pneumatic otoscopy. | S |
| 3. Failed newborn hearing screen | Clinicians should document in the medical record counseling of parents of infants with OME who fail a newborn hearing screen regarding the importance of follow-up to ensure that hearing is normal when OME resolves and to exclude an underlying sensorineural hearing loss. | R |
| 4a. Child at-risk | Clinicians should determine if a child with OME is at increased risk for speech, language, or learning problems from middle ear effusion because of baseline sensory, physical, cognitive, or behavioral factors (Table 4). | R |
| 4b. Evaluating at- risk children | Clinicians should evaluate at-risk children (Table 4) for OME at the time of diagnosis of an at-risk condition and at 12-18 months of age (if diagnosed as being at-risk prior to this time). | R |
| 5. Screening healthy children | Clinicians should NOT routinely screen children for OME who are not at-risk (Table 4) and do not have symptoms that may be attributable to OME, such as hearing difficulties, balance (vestibular) problems, poor school performance, behavioral problems, or ear discomfort. | R (against) |
Table 3. Practical Tips for Performing Pneumatic Otoscopy
Pneumatic Otoscopy Tip and Rationale
- After attaching the speculum to the otoscope, squeeze the pneumatic bulb fully, then firmly cover the tip of the speculum with your finger and let go of the bulb.
- The bulb should stay compressed after blocking the speculum if there are no air leaks. If the bulb opens (e.g., the pressure is released), check the speculum for a tight fit and the bulb and tubing for leaks.
- Choose a speculum that is slightly wider than the ear canal to obtain an air-tight seal.
- A speculum that is too narrow cannot form a proper seal and will give false-positive results.
- Before inserting the speculum squeeze the pneumatic bulb halfway (about 50% of the bulb width), then insert it into the canal.
- Squeezing the bulb first allows the examiner to apply both negative pressure (by releasing the bulb) and positive pressure (by further squeezing).
- Insert the speculum deep enough into the ear canal to obtain an air-tight seal, but not deep enough to cause pain.
- Limiting insertion to the cartilaginous (outer) portion of the ear canal is painless, but deep insertion that touches the bony ear canal and periosteum can be very painful.
- Examine tympanic membrane mobility by squeezing and releasing the bulb very slightly and very gently several times.
- Many children have negative pressure in their middle ear space, so both positive (squeezing the bulb) and negative (releasing the bulb) pressure are needed to fully assess mobility. Using slight and gentle pressure will avoid unnecessary pain.
- Diagnose OME when movement of the tympanic membrane is sluggish dampened, or restricted; complete absence of mobility is not required.
- When OME is absent the tympanic membrane will move briskly with minimal pressure. Motion is reduced substantially with OME, but with enough pressure some motion is almost always possible.
Table 4. Risk Factors for Developmental Difficulties in Children With Otitis Media with Effusiona
- Permanent hearing loss independent of otitis media with effusion
- Suspected or confirmed speech and language delay or disorder
- Autism-spectrum disorder and other pervasive developmental disorders
- Syndromes (e.g., Down) or craniofacial disorders that include cognitive, speech, or language delays
- Blindness or uncorrectable visual impairment
- Cleft palate, with or without associated syndrome
- Developmental delay
a Sensory, physical, cognitive, or behavioral factors that place children who have otitis media with effusion at increased risk for developmental difficulties (delay or disorder)
