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, sometimes leading to fluid accumulation. This fluid may cause hearing loss.
Serous otitis media is a common sequela to acute otitis media Otitis Media (Acute) Acute otitis media is a bacterial or viral infection of the middle ear, usually accompanying an upper respiratory infection. Symptoms include otalgia, often with systemic symptoms (eg, fever... read more or upper respiratory infection in children (often identified during a routine ear recheck) and may persist for weeks to months. Eustachian tube obstruction may also be secondary to the following:
Inflammatory processes in the nasopharynx
Other obstructive lymphoid aggregations on the torus of the eustachian tube and in the Rosenmüller fossa
Benign or malignant tumors
The effusion may be sterile or (more commonly) contain pathogenic bacteria sometimes as a biofilm, although inflammation is not observed. Rarely, a spontaneous cerebrospinal fluid (CSF) leak due to erosion through the lateral skull base may manifest as otitis media with effusion.
Symptoms and Signs of Serous Otitis Media
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 during swallowing. Otalgia is rare.
Various possible changes to the tympanic membrane include an amber or gray color, displacement of the light reflex, mild to severe retraction, and accentuated landmarks. During air insufflation, the tympanic membrane may be immobile. An air-fluid level or bubbles of air may be visible through the tympanic membrane.
Diagnosis of Serous Otitis Media
Examination with pneumatic otoscopy
Diagnosis of serous otitis media is clinical plus pneumatic otoscopy. For pneumatic otoscopy, 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 Hearing Loss Worldwide, about half a billion people (almost 8% of the world's population) have hearing loss ( 1). More than 10% of people in the US have some degree of hearing loss that compromises their... read more may be done to confirm middle ear effusion (by showing reduced mobility of the tympanic membrane).
If an effusion persists for> 8 weeks, adults and adolescents must undergo nasopharyngeal examination to exclude malignant or benign tumors. Nasopharyngeal malignancy should be suspected, particularly in patients with unilateral serous otitis media. If malignancy is suspected, imaging studies should be performed.
Treatment of Serous Otitis Media
If unresolved, myringotomy with tympanostomy tube insertion
If recurrent in childhood, sometimes adenoidectomy
For most patients, watchful waiting is all that is required. Antibiotics and decongestants are not helpful. If allergies are clearly involved, antihistamines and nasal 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 Pathophysiology secondary to middle ear fluid that does not clear. Tympanostomy tubes can help prevent recurrences of acute otitis media Otitis Media (Acute) Acute otitis media is a bacterial or viral infection of the middle ear, usually accompanying an upper respiratory infection. Symptoms include otalgia, often with systemic symptoms (eg, fever... read more and serous 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 (popping the ear). To do politzerization, the clinician 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. Patients may be instructed to gently pinch their nostrils and swallow (called autoinsufflation). This maneuver can be repeated several times throughout the day to aerate the middle ear.
Persistent, recurrent serous otitis media may require correction of underlying nasopharyngeal conditions. In children, particularly adolescent boys, a nasopharyngeal angiofibroma should be ruled out; 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/or nasopharyngitis. Demonstrated allergens should be eliminated from the patient’s environment and immunotherapy should be considered.
Susceptible young children with prolonged hearing loss due to long-standing serous otitis may require appropriate therapy Treatment of Hearing Loss in Children Worldwide, about half a billion people (almost 8% of the world's population) have hearing loss ( 1). More than 10% of people in the US have some degree of hearing loss that compromises their... read more to ensure normal language development. Balloon dilation of the eustachian tube has been used as an alternative to tympanostomy tube placement (1 Treatment reference Serous otitis media is an effusion in the middle ear resulting from incomplete resolution of acute otitis media or obstruction of the eustachian tube without infection. Symptoms include hearing... read more ). While the patient is under general anesthesia, a specialist inserts a balloon into the eustachian tube and briefly dilates the tube before removing the balloon. This procedure is an option for patients with recurrent serous otitis media and those who do not wish to have a tympanostomy tube placed. Caution should be used for some patients with mild eustachian tube dysfunction symptoms (eg, a sense of fullness, pressure, or popping in the ear) because this procedure can cause patulous eustachian tube dysfunction; symptoms include a sense of fullness and autophony (when patients hear their own breathing), which can cause them distress.
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 young children. A Valsalva maneuver or politzerization (during descent of an airplane, people should pinch their nose shut, hold their mouth closed, and try to blow gently out through their nose; this maneuver forces air through the blocked eustachian tube) may help older children and adults.
1. Poe D, Anand V, Dean M, et al: Balloon dilation of the eustachian tube for dilatory dysfunction: A randomized controlled trial. Laryngoscope 128 (5):1200–1206, 2018. doi: 10.1002/lary.26827 Epub 2017 Sep 20.
Serous otitis media is noninflammatory middle ear effusion usually after acute otitis media or after an upper respiratory infection.
Diagnosis is clinical; for adults and adolescents, do a 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 and/or direct visualization of the nasopharynx may be needed .
Children with prolonged hearing loss may require appropriate therapy to ensure normal language development.