|Year : 2015 | Volume
| Issue : 3 | Page : 174-178
Clinico-audio-radiological and operative evaluation of otitis media with effusion
Karan Sharma, Raghav Mehan, Archana Arora
Department of ENT, Government Medical College, Amritsar, Punjab, India
|Date of Web Publication||17-Jul-2015|
Department of ENT, Government Medical College, 39 B Circular Road, Amritsar, Punjab
Source of Support: None, Conflict of Interest: None
Aims: Otitis media with effusion (OME) is a common cause of hearing and speech impairment in children. The correlation of the clinical, audiological, radiological, and intraoperative findings was carried out so as to make a protocol for early diagnosis and management of OME. It will help prevent the more serious sequelae of OME such as tympanosclerosis, chronic adhesive otitis media, and even chronic suppurative otitis media. Methods: 300 clinically diagnosed patients of OME were studied prospectively. Thereafter, patients underwent impedance audiometry, pure tone audiometry, and X-ray soft tissue nasopharynx for adenoids. The patients were given adequate medical treatment for 3 to 6 months, and the patients who did not respond to the treatment were subjected to adenoidectomy with ear examination under magnification and myringotomy with or without grommet insertion. Results: The mean age at presentation was 5.96 years. Only 32% patients gave a history of hearing loss. About 90% patients had mouth breathing, followed by snoring (84%). About 79% ears had abnormal tympanic membrane appearance and mobility; 65.5% had an abnormality on impedance audiometry; and 69.75% had an air condition threshold level of >20 dB. About 78% patients had either Grade III or Grade IV Adenoid hypertrophy. Adenoidectomy was done in all 300 patients with myringotomy in 472 ears. Grommets were inserted in 365 ears. There was a significant reduction in mean air conduction threshold with an improvement of 8.0 dB and 7.5 dB in right and left ears, respectively at 2 months postoperatively. At 6 th month postoperative, the average improvement from baseline dropped to 6.0 dB in right ear and 5.5 dB in the left ear. Conclusion: OME is the most frequent causes of silent hearing impairment in young children which needs a close vigil. All suspected children (on clinical and otoscopic findings) must be subjected to impedance audiometry and X-ray soft tissue nasopharynx for adenoids. After the failure of medical treatment for 3-6 months, the child should be subjected to myringotomy with adenoidectomy in the same sitting. Whenever a child is planned for tonsil or adenoid surgery, he/she must undergo evaluation for OME beforehand so that the child's hearing risk can be simultaneously taken care of in the same sitting.
Keywords: Adenoidectomy, Grommet, Impedance audiometry, Otitis media with effusion, Pure tone audiometry
|How to cite this article:|
Sharma K, Mehan R, Arora A. Clinico-audio-radiological and operative evaluation of otitis media with effusion. Indian J Otol 2015;21:174-8
| Introduction|| |
Otitis media with effusion (OME)/chronic serous otitis media/glue ear is one of the most common chronic otological conditions of childhood. It is defined as the presence of fluid behind an intact eardrum without signs and symptoms of acute infection.  The time fluid has to be present for the condition to be called chronic is usually taken as 12 weeks.  The prevalence of OME is bimodal with the first and largest peak of approximately 20% at 2 years of age and a second peak of approximately 16% at around 5 years of age. 
The clinical presentation of glue ear is often undramatic. The presenting features may be hearing difficulty, delayed language development, repeated earache, recurrent upper respiratory tract infections, behavioral, and poor educational progress. Older children may report aural fullness, tinnitus or vertigo. The examination may show an amber or blue discoloration of the eardrum with thickening and loss of landmarks. Bubbles or a fluid level may be visible. , Demonstration of impaired drum mobility using pneumatic otoscopy is much more reliable than a simple inspection. Clinical suspicion of hearing loss may be confirmed by pure tone audiometry (PTA). Tympanometry is a simple, quick, noninvasive, and objective test making it the ideal diagnostic test for OME. 
It is apparent that the adenoids are usually enlarged in children who have OME. Symptoms suggestive of adenoid hypertrophy are mouth breathing, snoring, nasal discharge, speech hyponasality, and occasionally epistaxis.  Diagnosis is made either by posterior rhinoscopy, rigid or flexible nasopharyngoscopy or soft tissue lateral radiograph of the nasopharynx, which reveals the size of adenoids and also the extent to which the nasopharyngeal air space has been compromised. 
Current medical options for the treatment of OME include antihistamine-decongestant mixtures, mucolytics, steroids, antibiotics, various kinds of Eustachian tube More Details manipulation (Valsalva and Politzer manoeuvres), and control of risk factors.  Conditions where surgery may be indicated are OME for >3 months with no benefit with medical management, bilateral OME with hearing loss >20 dB for more than 6 months, recurrent OME, balance disturbances, structural changes of tympanic membrane (TM) and language delay. The various surgical treatment options recommended are adenoidectomy alone, myringotomy alone, adenoidectomy with myringotomy with or without grommet insertion. 
The present study was conducted to evaluate the clinical, audiological, and radiological profile in patients of chronic OME and to study its correlation with adenoid hypertrophy. Furthermore, the role of adenoidectomy with insertion of tympanostomy tube in a single sitting as a treatment modality was studied for the prevention and management of the silent hearing impairment caused by OME and its subsequent complications such as tympanosclerosis, chronic adhesive otitis media, and even chronic suppurative otitis media. The subject of OME has long been a confused one and it is hoped that this study may help somewhat in clearing the muddle.
| Methods|| |
The present study was based on the analysis of 300 patients in the age group 3-12 years undergoing treatment for "chronic OME" in the Department of ENT, Government Medical College from 2010 to 2014. An informed consent was obtained from subjects/parents willing to participate in the study. Each case after being screened from the outpatient department was clinically evaluated by taking a proper history, general physical, and complete local ENT examination; followed by otoscopic examination under magnification (EUM). The criteria for making the diagnosis of OME was recurrent attacks of upper respiratory tract infections, mouth breathing, occasional bouts of otalgia, and dull looking/lusterless/retracted TM with restricted mobility on pneumatic otoscopy. Patients having acute otitis media, discharging ear with perforated or healed TM, sensorineural hearing loss, and congenital aural or palatal defects were excluded from the study. Thereafter, patients underwent impedance audiometry, PTA, and X-ray soft tissue nasopharynx for adenoids.
Impedance audiometry was done in all patients. The results were recorded as Type A - normal compliance, Type B - OME and Type C - reduced compliance or early stages of OME. On the basis of PTA, the patients were divided into four categories: <20 dB, 21-30 dB, 31-40 dB, and >40 dB. The severity of adenoid hypertrophy was assessed by digital X-ray soft tissue nasopharynx lateral view and grading was done based on the percentage of obstruction of nasopharyngeal airway as follows: Grade I <25%; Grade II 26-50%; Grade III 51-75%; and Grade IV >75%.
To begin with, medical treatment in the form of antihistamine-decongestant combinations, mucolytics and antibiotics was given for a period of 3-6 months. Those children who did not benefit with medical treatment were ultimately taken up for surgical intervention in the form of adenoidectomy with EUM and myringotomy with or without grommet insertion.
Adenoidectomy was done under general anesthesia. Myringotomy was performed using a myringotome in the anteroinferior quadrant. Shepard type grommet was inserted after suctioning the middle ear fluid. Patients were discharged after 24 h. Regular follow-up was done up to 3 months and thereafter at 6 months. PTA was done at 2 and 6 months follow-up.
The data so obtained was analyzed using standard statistical parameters. The clinical, audiological, radiological, and intraoperative observations were correlated with each other to evolve a management strategy for prevention, early detection and management of a common cause of a silent, invisible hearing impairment.
| Results|| |
The mean age of children included in our study was 5.96 with a minimum of 3 years and a maximum of 12 years. About 62% patients were males and 38% were females. Of 300 patients, only 32% complained of hearing loss. About 64% patients had a history of recurrent ear discomfort, e.g., recurrent earache, ear blockage, aural fullness. About 90% patients had mouth breathing, followed by snoring (84%), and speech hyponasality (36%) as symptoms suggestive of adenoid hypertrophy [Table 1]. Of 600 ears examined, 74% had dull and retracted TM, 3% had thin and retracted TM, and only 2% ears showed the characteristic air bubbles behind the eardrum whereas the rest 21% ears were normal on otoscopy [Table 2]. On pneumatic otoscopy, 57% ears had restricted TM mobility, 22% had no mobility, and 21% had normal mobility [Table 3].
Impedance audiometry was done in all patients. 34.5%, 50.17%, 15.33%, and ears showed Type A, Type B, and Type C tympanograms, respectively [Table 4]. Of the 600 ears on which PTA was conducted, 69.75% had an air conduction threshold of more than 20 dB which was considered pathological. Of these, 42.75% had an AC threshold from 21 to 30 dB, 13.67% had threshold between 31 and 40 dB, 13.33% had a threshold of more than 40 dB. In rest of 30.25% it was below 20dB.
Grades II, III, and IV hypertrophy of adenoids were seen in 22%, 54.67%, and 23.33% patients, respectively. Thus, 78% patients had either Grade III or Grade IV hypertrophy that is, more than 50% obstruction of the nasopharyngeal airway [Table 5].
All patients in our study were subjected to adenoidectomy and ear EUM under general anesthesia. As per indication, myringotomy was done in one or both ears. The ears from which any secretions were aspirated were subjected to tympanostomy tube (grommet) insertion in the same sitting. Myringotomy was done in 78.67% that is, 472 out of 600 ears. Of these, no secretions could be aspirated in 107 ears (22.67%). The aspirate was serous in 136 ears (28.81%) whereas mucoid in 48.52%. Grommets were inserted in 365 ears (77.33%) [Table 6]. No intraoperative and immediate postoperative complications were observed.
At 2 and 6 months follow-up, a statistically significant reduction in air conduction threshold was observed (repeated measures ANOVA, P < 0.0001). The average improvement in air conduction thresholds following adenoidectomy and grommet insertion was 8 dB in right ear and 7.5 dB in left ear at 2 months follow-up whereas at 6 th month follow-up, the average improvement dropped to 6.0 dB in right ear and 5.5 dB in the left ear. The sensitivity, specificity, positive predictive value, negative predictive value, and accuracy of various diagnostic parameters used in the study were calculated taking myringotomy as the gold standard. Type B tympanogram had the best balance of sensitivity and specificity of 85.07% and 93.94%, respectively [Table 7].
|Table 7: Sensitivity, specificity, positive predictive value, negative predictive value, and accuracy of various diagnostic parameters used in the study (taking myringotomy as the gold standard)|
Click here to view
| Discussion|| |
Various studies over the years have shown that, there is a definite and significant relationship between adenoid hypertrophy and OME, thus the need to take detailed history for adenoid hypertrophy in all cases of chronic OME and vice versa. Studies from developing world studying the clinical profile and surgical management in OME with hearing impairment are few in number. Availability of detailed data on the clinical profile and utility of combining tympanostomy with adenoidectomy in a single setting in children with OME may have a bearing on future management.
The mean age of the 300 patients in our study was 5.96 years. In an earlier study including 200 children, the mean age was 6.46 years.  The increased incidence in this age group can be attributed to the eustachian tube, which is short, horizontal, and floppy. Furthermore, this correlates with the age of adenoid hypertrophy and thus further strengthens the relationship between the two. Most of the patients in the present study had multiple symptoms of varying degree and duration. Mozaffarinia et al. conducted a similar study where the frequency of symptoms in patients with a final diagnosis of OME was reported. The most common symptoms were periodic otalgia in 26.3%, turning up television volume in 17.5%, aural fullness in 8.8%, hearing sounds like bursting bubble in 7% and hearing loss in only 1.8%. 
In our study, there was a poor correlation between hearing loss as a symptom of OME and the PTA thresholds. Only 32% complained of hearing loss whereas 69.75% patients had PTA AC threshold >20 dB. Lo et al. stated that no significant association was found between parent-suspected hearing loss and PTA findings (P = 0.69) in a case-control study, which used data from a school screening program in China.  This proves that OME is a cause of silent deafness and needs a high degree of suspicion for its diagnosis.
About 90% patients had a complaint of mouth breathing, 84% had a history of snoring and 36% patients had speech hyponasality, thus suggesting a strong correlation between adenoid hypertrophy and OME. The Guideline Development Group, England has also reached a consensus that the possibility of OME should be considered in children presenting with recurrent upper respiratory tract infections since the two conditions are commonly associated. 
Clinically, 74% ears had dull and retracted TM, 3% had thin and retracted TM and only 2% ears showed the characteristic air bubbles behind the eardrum, whereas the rest 21% were normal on otoscopy. On pneumatic otoscopy, 57% ears had restricted TM mobility, 22% had no mobility, and 21% had normal mobility. The sensitivity and specificity of otoscopy were found to be 95.52% and 54.55%, respectively. Another study also showed otoscopy to be having a high sensitivity but poor specificity. 
Impedance audiometry was done in all patients. About 34.5%, 50.17%, and 15.33% and ears showed Type A, Type B, and Type C tympanograms, respectively. A similar study showed Type B graph in 66.15% and Type C in 33.85%.  On conducting PTA, majority of cases had a mild conductive hearing loss. Bluestone stated that the average hearing loss in children with OME is 27 decibels.  This is the reason the diagnosis is often delayed because the hearing loss is fluctuating and is never profound. There was a good correlation between PTA findings and impedance audiometry findings with 89% agreement between the two.
The adenoid grading as per digital X-ray correlated well with the size of adenoid tissue on digital palpation, which was done intraoperatively in every case. There was also a good correlation of PTA findings and impedance audiometry findings with the radiological findings of adenoid hypertrophy. Hence, it is stated that a digital lateral radiograph of the nasopharynx is a very useful tool for assessing the severity of obstruction of the nasopharyngeal airway. Kurien et al. showed that lateral X-rays of the neck, besides being a noninvasive procedure, still remains a very reliable and valid diagnostic test in the evaluation of hypertrophied adenoids. 
Adenoidectomy was done in all the patients. Myringotomy was done in 78.67% that is, 472 out of 600 ears. Of these, no secretions could be aspirated in 107 ears (22.67%). The aspirate was serous in 136 ears (28.81%) whereas mucoid in 48.52%. A similar study showed serous aspirate in 24% and mucoid in 76%.  Grommets were inserted in 365 ears (77.33%). No intraoperative and immediate postoperative complications were observed.
The mean air conduction threshold levels on PTA showed statistically significant improvement following adenoidectomy and grommet insertion with about 8 dB improvement in right ear and 7.5 dB in left ear 2 months postoperative. At 6 th month, postoperative the average improvement from baseline dropped to about 6.0 dB in right ear and 5.5 dB in the left ear. According to Black et al., the mean dB gain at 7 weeks and 6 months are 4.5 and 3.5 dB, respectively.  However, Maw reported that there was a resolution in 36-46% of chronic effusions as a result of adenoidectomy. 
The patients included in the present study had persistent OME and the chances of spontaneous resolution in our setting would be extremely low. Furthermore, the anticipated reluctance of patients for constant follow-up and readmission for second surgery were the reasons for the surgical approach, which we had selected. This reiterates the goal of our study that children having chronic OME with adenoid hypertrophy should be managed aggressively and timely surgery (adenoidectomy with myringotomy in a single sitting) can help avoid hearing loss and developmental delay.
| Conclusion|| |
Whenever there is any deviation of the normal anatomy of TM on otoscopy in a child, the child must be subjected to pneumatic otoscopy and impedance audiometry. Thereafter, as per needs an X-ray soft tissue nasopharynx lateral view for adenoid and PTA needs to be performed. After the failure of medical treatment for 3 months, the child should be subjected to myringotomy with adenoidectomy in a single sitting. However, if the situation demands, it can also be combined with a tonsillectomy. Hence, for the prevention of this silent hearing impairment, the aim should be "peep into the ears of the child at the earliest available opportunity" and proceed accordingly if one suspects OME. We must keep a close vigil on this common disease entity causing a silent hearing loss and the treatment should be very methodical and meticulous. In this way, we can definitely contribute a lot for the National Program for Prevention and Control of Deafness in which OME has been assigned a major contributing factor for hearing impairment. Furthermore, it will contribute toward the global mission of SOUND HEARING 2030.
| Acknowledgments|| |
We are highly thankful to the Department of Radiology, Anesthesia and Pediatrics of our institution for their help throughout this study.
| References|| |
Bluestone CD, Klein JO. Definitions, terminology and classification. In: Otitis Media in Infants and Children. Philadelphia: WB Saunders; 1998. p. 1-21.
Gleeson M. Scott-Brown′s Otorhinolaryngology, Head and Neck Surgery. 7 th
ed. London: Hodder Arnold; 2008. p. 877.
Wilmot JF, Cable HR. Persistent effusion following acute otitis media: Tympanometry and pneumatic otoscopy in diagnosis. J R Coll Gen Pract 1988;38:149-52.
Scadding G. Non-surgical treatment of adenoidal hypertrophy: The role of treating IgE-mediated inflammation. Pediatr Allergy Immunol 2010;21:1095-106.
Khan F, Asif M, Farooqi GH, Shah SA, Sajid T, Ghani R. Management outcome of secretory otitis media. J Ayub Med Coll Abbottabad 2006;18:55-8.
Gleeson M. Scott-Brown′s Otorhinolaryngology, Head and Neck Surgery. 7 th
ed. London: Hodder Arnold; 2008. p. 1096.
Bluestone, Charles D. Definitions, terminology, and classification. In: Evidence-Based Otitis Media. 2 nd
ed. Hamilton, Canada: BC Decker; 2003. p. 124.
Rosenfeld RM, Culpepper L, Doyle KJ, Grundfast KM, Hoberman A, Kenna MA, et al
. Clinical practice guideline: Otitis media with effusion. Otolaryngol Head Neck Surg 2004;130:S95-118.
Yadav SP, Saxena S, Sharma H, Singh I, Singh J. Secretory otitis media: A school health survey. Indian J Otolaryngol Head Neck Surg 2006;58:250-2.
Mozaffarinia K, Teimouri Y, Sarrafinejad A. Secretory otitis media in pre-school children. Iran J Otorhinolaryngol 2010;22:87-92.
Lo PS, Tong MC, Wong EM, van Hasselt CA. Parental suspicion of hearing loss in children with otitis media with effusion. Eur J Pediatr 2006;165:851-7.
Surgical Management of Otitis Media with Effusion in Children - Clinical Guideline. National Collaborating Centre for Women′s and Children′s Health Commissioned by NICE. London: RCOG Press; 2008.
Spremo S, Markic Z, Kurbalija. Clinical importance of tympanometry in the diagnosis of chronic secretory otitis. Srp Arh Celok Lek 1998;126:242-7.
Kurien M, Lepcha A, Mathew J, Ali A, Jeyaseelan L. X-rays in the evaluation of adenoid hypertrophy: It′s role in the endoscopic era. Indian J Otolaryngol Head Neck Surg 2005;57:45-7.
Black NA, Sanderson CF, Freeland AP, Vessey MP. A randomised controlled trial of surgery for glue ear. BMJ 1990;300:1551-6.
Maw AR. Chronic otitis media with effusion (glue ear) and adenotonsillectomy: Prospective randomised controlled study. Br Med J (Clin Res Ed) 1983;287:1586-8.
[Table 1], [Table 2], [Table 3], [Table 4], [Table 5], [Table 6], [Table 7]