Ear, Nose and Throat (ENT), Head and Neck Surgery
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Last update: 10/5/14
BUBBLES IN THE EAR !
(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
*
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
(
Mouse over to zoom in)
(
Mouse over to zoom in)
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
(mouse over to zoom in)
(mouse over to zoom in)
Endoscopic view of the normal
nasopharynx (back portion of the nose):
© Vincent Tan ENT
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