Otitis Media (Secretory)
(Serous Otitis Media; Otitis Media with Effusion)
Normally, the middle ear is ventilated 3 to 4 times a minute as the eustachian tube opens during swallowing, and oxygen is absorbed by blood in the vessels of the middle ear mucous membrane. If patency of the eustachian tube is impaired, a relative negative pressure develops within the middle ear, which can lead to fluid accumulation. This fluid may cause hearing loss.
Secretory otitis media is a common sequela to acute otitis media in children (often identified on routine ear recheck) and may persist for weeks to months. In other cases, eustachian tube obstruction may be secondary to inflammatory processes in the nasopharynx, allergies, hypertrophic adenoids or other obstructive lymphoid aggregations on the torus of the eustachian tube and in the Rosenmüller fossa, or benign or malignant tumors. The effusion may be sterile or (more commonly) contain pathogenic bacteria sometimes as a biofilm, although inflammation is not observed.
Patients may report no symptoms, but some (or their family members) note hearing loss. Patients may experience a feeling of fullness, pressure, or popping in the ear with swallowing. Otalgia is rare.
Various possible changes to the tympanic membrane (TM) include an amber or gray color, displacement of the light reflex, mild to severe retraction, and accentuated landmarks. On air insufflation, the TM may be immobile. An air-fluid level or bubbles of air may be visible through the TM.
Diagnosis of secretory otitis media is clinical and uses pneumatic otoscopy, in which an insufflator attached to the otoscope head is used to move the tympanic membrane (fluid in the middle ear, a perforation, or tympanosclerosis inhibits this movement). Tympanometry may be done to confirm middle ear effusion (ie, by showing lack of mobility of the tympanic membrane).
Adults and adolescents must undergo nasopharyngeal examination to exclude malignant or benign tumors. Nasopharyngeal malignancy should particularly be suspected in cases of unilateral secretory otitis media. If malignancy is suspected or demonstrated by biopsy, imaging studies should be done.
For most patients, watchful waiting is all that is required. Antibiotics and decongestants are not helpful. For patients in whom allergies are clearly involved, antihistamines and topical corticosteroids may be helpful.
If no improvement occurs in 1 to 3 months, myringotomy may be done for aspiration of fluid and insertion of a tympanostomy tube, which allows ventilation of the middle ear and temporarily ameliorates eustachian tube obstruction, regardless of cause. Tympanostomy tubes may be inserted for persistent conductive hearing loss secondary to middle ear fluid which does not clear. Tympanostomy tubes can help prevent recurrences of acute otitis media and secretory otitis media.
Occasionally, the middle ear is temporarily ventilated with the Valsalva maneuver or politzerization. To do the Valsalva maneuver, patients keep their mouth closed and try to forcibly blow air out through their pinched nostrils (ie, popping the ear). To do politzerization, the physician blows air with a special syringe (middle ear inflator) into one of the patient’s nostrils and blocks the other while the patient swallows. This forces the air into the eustachian tube and middle ear. Neither procedure should be done if the patient has a cold and rhinorrhea.
Persistent, recurrent secretory otitis media may require correction of underlying nasopharyngeal conditions. In children, particularly adolescent boys, a nasopharyngeal angiofibroma should be ruled out and, in adults, nasopharyngeal carcinoma must be ruled out. Children may benefit from adenoidectomy, including the removal of the central adenoid mass as well as lymphoid aggregations on the torus of the eustachian tube and in the Rosenmüller fossa. Antibiotics should be given for bacterial rhinitis, sinusitis, and nasopharyngitis. Demonstrated allergens should be eliminated from the patient’s environment and immunotherapy should be considered. Susceptible young children with prolonged hearing loss from longstanding serous otitis may require appropriate therapy to assure normal language development.
Because environmental pressure changes can cause painful barotrauma, scuba diving and air travel should be avoided or delayed when possible. If air travel cannot be avoided, chewing food or drinking (eg, from a bottle) may help in young children. A Valsalva maneuver or politzerization may help older children and adults.
Secretory otitis media is noninflammatory middle ear effusion usually following acute otitis media.
Diagnosis is clinical; adults and adolescents must undergo nasopharyngeal examination and sometimes imaging studies to exclude malignant or benign tumors.
Antibiotics and decongestants are not helpful.
If unresolved in 1 to 3 months, myringotomy with tympanostomy tube insertion may be needed.
Children may require appropriate therapy to assure normal language development.