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Last update:  10/5/14 

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BUBBLES IN THE EAR !

© Vincent Tan ENT

(source of unlabelled diagram: Netter Atlas of Anatomy)

The external ear canal (EAC)

Ear drum (normal)

The normal ear cross section. Notice the outer skin of the EAC is thicker and has glands (red asterisk) while the inner part is thinner with no glands.

The normal ear drum as seen on a microscope or endoscope

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What is Otitis Media with Effusion (OME) ? OME is also known as glue ear, secretory otitis media, middle ear effusion (MEE), nonsuppurative otitis media, and catarrhal otitis media. Otitis media with effusion (OME) refers to the accumulation of fluid within the middle ear space (the small space behind the ear drum). What do they normally present with ? OME is a common condition of early childhood in which an accumulation of fluid within the middle ear space causes hearing impairment (think of your reduced hearing being surrounded by water as you dive). The hearing loss is usually transient and self-limiting over several weeks, but may be more persistent, even fluctuating and lead to educational, language and behavioural problems. It may also present with recurrent ear infections or upper respiratory tract infections (URTI) and rarely balance problems and clumsiness.

What is it due to? OME can be due to the following causes: Malfunction of ET including viral upper respiratory tract infection, allergy, inborn muscular defects (associated with cleft palate, Down's syndrome, and other congenital craniofacial anomalies), obstruction anywhere within or in the region of the ET opening [eg. due to adenoids, nasopharyngeal cancer (NPC)], scarring of the same region, post radiotherapy for head and neck cancer. It is a common complication of acute otitis media due to prolonged disease process, partial resolution or inadequate antibiotic treatment. Other rarer causes include barotraumas, systemic factors like immunosuppression/immunodeficiency, immotile cilia syndromes. Children with Down's syndrome and cleft palate are particularly susceptible to OME. OME in these children are very common and are also likely to occur at an earlier age and be more persistent, therefore needing more specialized care. Other environmental factors have been shown in numerous epidemiologic studies to be strongly associated with increased prevalence of OME. These factors include: • bottle feeding, feeding while supine • placing a child in the supine position while bottle feeding substantially ? the risk of OME, presumably because it contributes to ET reflux during swallowing. • having a sibling with OME, • attending daycare, • having allergies to common environmental entities, • having a lower socioeconomic status, • living in a home in which people smoke, and • having a parental history of OME Breastfed babies have a lower risk of AOM and OME Is there a reason to worry? What is the chance of recovery ? That depends on the 2 categories of patients here Treatment does depend very much on the cause of OME. Category 1 : A child: OME   may   not   be   realized   by   the   parent   because   of   the   insidious   nature   of   the   condition,   and   it   is   generally   painless   (though   there   may   be   some   fever, discomfort   or   pain   during   the   active   infection   phase   i.e   acute   otitis   media). A   toddler   is   also   unlikely   to   complain   of   any   hearing   deficit,   therefore   missing the   symptom   altogether.   Therefore,   it   is   imperative   for   doctors   to   also   exclude   enlargement   of   the   adenoids   as   a   causative   reason   for   recurrent   AOM and   OME,   besides   the   fact   that   the   enlarged   adenoids   can   also   be   a   reservoir   of   infection   for   childhood   sinusitis.   This   can   be   easily   assessed   via   nasal endoscopy   by   the   ENT   specialist.   Once   recognised,   treatment   of   the   adenoid   becomes   the   keystone   in   preventing   these   infections.   The   good   news   is that   the   treatment   in   a   child   generally   has   a   good   clinical   outcome.   If   small,   it   can   be   medically   treated   or   surgically   removed   if   causing   obstruction. Please see here for more details on surgical removal. Other possibilities in child include a recurrence of the adenoidal enlargement, scarring over the Eustachian tube due to previous adenoidectomy As children with Down's syndrome and cleft palate are particularly susceptible to OME and their  OME are also likely to occur at an earlier age and be more persistent, all children with Down's syndrome and all children with cleft palate should be assessed regularly for OME. Category 2 : An Adult: Generally,   acute   otitis   media   is   not   as   common   in   the   adults.   However,   they   may   complain   of   hearing   loss.   In   an adult,    this    can    be    a    sinister    telltale    sign    of    a    mass    in    the    nasopharynx,    in    our    region    commonly    called nasopharyngeal   carcinoma   (NPC).   Another   common   possibility   is   lymphoma,   that   is   cancer   arising   from   the lymphatic   organs,   which   is   also   found   in   the   nasopharynx. There   are   of   course   less   common   tumours.   In   such   a scenario,   it   is   imperative   that   the   nasopharynx   is   endoscopically   assessed   and   if   a   mass   is   present,   a   biopsy   is taken to confirm the nature of the mass (whether cancerous or not). At times, it could be due to scarring or Eustachian tube dysfunction due to previous radiotherapy over that region. While the tumour can be confirmed to be absent based on white light nasal or NBI endoscopy, the damage to the ET can be irreversible as inner lining could have been permanently scarred. Another possibility is a recurrence of the previous tumour over the same site again.

What is expected during consultation ? After getting a thorough history from the child/parents or the patient, your doctor will inspect the ear with an otoscope to first and foremost confirm the presence of OME.  He/she may proceed with hearing test and/or tympanometry to diagnose any hearing defects or middle ear disease. A nasal endoscopy may also be necessary should a nasopharyngeal obstruction (ie adenoids or NPC) is suspected. All children with Down's syndrome and all children with cleft palate should be assessed regularly for OME. What is the treatment for this condition? Early phases of OME can be treated with a combination with local and systemic decongestants, antibiotics. However, this is considered controversial in some medical literature review as some quarters strongly support this while others oppose these medical therapies. Please discuss with your doctor for his/her personal preference or experience. It is also important to recognise any underlying cause (i.e allergy, adenoidal enlargement, immunodeficiency etc) and treat them if possible.   If OME is prolonged, usually beyond 3 months despite multiple nonsurgical intervention,  a ventilation tube (grommet or T-tube) may be inserted. Depending on tolerability, age of patients, this procedure can be done under local or general anaesthesia. Basically a tiny tube is inserted over the eardrum to ventilate the middle ear compartment and equalise the pressure with the external ear. Enlarged and obstructive adenoids, more so in the presence of recurrent URTI, rhinosinustis, need to be surgically removed. Nowadays, removal under endoscopic guidance results in better visualisation to ensure a more complete removal and avoid scarring the ET region, thus resulting in better outcome. This can be combined with long term management of any underlying allergic condition. In rare cases where there are chronic ear disease, a mastoidectomy (removal of the portions of the mastoid cavity, a structure housing the whole ear apparatus) may even be necessary to more effectively aerate the middle ear compartment.

Compare the normal on the left and large adenoids (non-cancerous growth) in the middle 2 pictures. In the right picture, the nasopharynx has a cancerous growth (partially covered by blood) !

© Vincent Tan ENT

It is a common complication of acute otitis media where the child can present with severe acute ear pain with fever, usually in association with upper respiratory tract infection (URTI) i.e  runny nose, cough and being generally unwell. The highest incidence of OME occurs in children < 2 years with fewer incidence after 5-6 year old, more commonly in the boys

A clinical examination of the ear using an otoscope/auriscope

Examination under microscopy of the ear

Left   picture   showing   a   small   incision   in   the   eardrum   called   ‘myringotomy’   (white   arrow)   and   fluid   is   being   suctioned   out (red   arrow).   Notice   the   bubble   (green   arrow).   Right   picture   showing   the   white   ventilation   tube   (red   arrow).   The   eardrum now looks healthier (white arrow)

© Vincent Tan ENT

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Eustachian Tube

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The ventilation tubes will normally extrude itself once the OME resolves and the underlying cause Is brought under control. Hearing aids should be offered to children with persistent bilateral OME and hearing loss as an alternative to surgical intervention where surgery is contraindicated or not acceptable. As for the cleft palate group of children, insertion of ventilation tubes should be offered as an alternative to those who have OME and persistent hearing loss. Will the hearing be forever affected? Once identified and treatment started, hearing is expected to recover to its prediseased state. However, in long standing OME where the ossicles (the 3 little tiny bones in the middle ear compartment) have been eroded or postradiotherapy for head and neck cancers where the radiotherapy effects with additional damage by some concurrent chemotherapy drugs lead to irreversible hearing damage, hearing levels, unfortunately, cannot be fully restored though some improvement is expected.

The     left     picture     showing     the     extruded grommet   sitting   amidst   the   ear   wax   in   the ear   canal.   The   ear   drum   in   the   background is regaining its normal contour The     right     picture     showing     a     long-term ventilation   tube,   called   the   ‘T-tube’,   green   in colour, still sitting in the eardrum

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Endoscopic view of the normal nasopharynx (back portion of the nose):

© Vincent Tan ENT

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