|
GLUE EAR AND OTITIS MEDIA - a patient's guide
Dr Colin Brown - ENT Surgeon, Starship Hospital
What is it?
"Otitis media" means there is fluid behind the eardrum
in the middle ear. The type of fluid present varies, and
thus there is a spectrum of disease from "Acute Otitis Media"
through to "Glue Ear" (sometimes also called Otitis Media
with Effusion).
When the eardrum is red and bulging, with fluid or pus
behind the eardrum, often associated with pain and fever,
this is called "acute otitis media." "Glue Ear" often follows
"Acute Otitis Media" or may occur on its own. Fluid is present
behind the eardrum, but there is no fever, and the eardrum
is not inflamed or bulging. In some instances, the eardrum
is actually retracted inwards to varying degrees.
What causes Otitis Media?
Both glue ear and acute otitis media occur most commonly
in young children, usually as a result of temporary malfunction
of the Eustachian tube, which connects the middle ear to
the back of the nose.
The Eustachian tube normally allows air to circulate through
the middle ear, and allows mucus to drain from the middle
ear in to the throat. In young children, the tube is smaller,
flatter and shorter. It is easier for bugs (bacteria and
viruses) to travel in to the tube, which may result in swelling
of the lining of the tube, and an increase in mucus production
in the tube. This may cause it to block. It follows that
as children grow, they are less likely to have trouble with
otitis media.
Are some children more likely to develop Otitis Media?
We know some important risk factors, but not all the reasons
why some children develop otitis media.
The most important risks include:
A family history of Otitis Media
Exposure to tobacco smoke ("passive smoking")
Exposure to other children in child care/crиche/preschool
An older sibling in childcare/crиche/preschool/ early
primary school
There is no clear evidence supporting allergy as a causal
factor in the development of otitis media.
There is some limited evidence linking bottle feeding
to early development of acute otitis media. This may be
because of the immune protective effect of antibodies passed
through breast milk.
What are the symptoms of Otitis Media?
Acute Otitis Media may result in severe ear pain, fever,
grumpiness/misery and night waking. The hearing is reduced.
More severe complications (burst eardrum with discharge
from the ear, mastoiditis, meningitis) are uncommon, but
do occur. Rarely, a child may have few symptoms even with
very inflamed ears. Balance may be temporarily affected
in some children.
Glue ear may have few symptoms. There is usually no fever,
but ear pain may still occur, particularly at night when
children lie down. There is usually hearing loss: in some
children this may be only mild, and in others, this may
be sufficient to delay speech and language development for
many years. This may have implications for effective learning
at preschool and school. Often parents feel, erroneously,
their child is ignoring them. Balance may be affected and
the child may seem clumsy.
How is Otitis Media diagnosed?
Pneumo-Otoscopy is the best way to diagnose Otitis Media.
Your Doctor performs this. A small torch with a magnifying
lens and a funnel attachment is inserted in to the outer
ear canal and the eardrum and ear canal are examined. An
attachment with a small air reservoir puffs air into the
ear canal and moves the ear drum in and out a little. Limited
movement of the eardrum can help confirm Glue Ear in doubtful
cases.
Tympanometry is a test to assess the movement of the eardrum.
Air is puffed in and out of the ear canal and a probe in
the ear canal detects sound echoing off the eardrum. Tympanometry
may be useful in doubtful cases, and is also used as a screening
tool for Glue Ear, particularly in preschools and kindergartens.
Tympanometry is not a hearing test and a "pass" on this
test does not necessarily mean that a child can hear - it
just means that it is very unlikely Glue Ear is present
at the time of the test.
Hearing Testing is a very valuable tool in the assessment
of glue ear and its impact on the hearing of an individual
child. No child is too young to be tested, however testing
does need extra time and special techniques in children
under age two and a half to three years of age. Your doctor
may recommend a hearing test if Otitis Media has been present
for three months. A qualified audiologist should perform
hearing testing. This may be at the Public Hospital, National
Audiology Centre, or at a private Audiology Centre.
What treatment is recommended, and is it necessary?
Acute Otitis Media:
Antibiotic treatment is recommended for acute otitis media.
This has a modest effect in the reduction of pain and fever
and may reduce the risk of complications of acute otitis
media. However, there remains some dispute about the benefits
of antibiotics - some doctors believe there is not enough
evidence to provide antibiotic treatment for acute otitis
media in some older and otherwise healthy children. Although
this issue is yet to be clarified, most doctors prefer to
err on the side of caution and to treat children (and adults)
with antibiotics for Acute Otitis Media.
Paracetamol is usually effective too, for reduction of
pain and fever.
Grommets may be recommended for recurrent episodes of
Acute Otitis Media. There is no absolute definition of the
number of episodes required before grommet insertion is
recommended, but a rule of thumb is 6 episodes in a year.
This would also depend upon the time of year (more likely
to be recommended if Acute Otitis Media is recurrent through
the summer months, when the incidence should usually be
at its lowest) and individual factors, such as predisposing
risk factors and occurrence of complications of Acute Otitis
Media.
Glue Ear:
Because most episodes of Glue Ear resolve without treatment,
regular observation alone is often recommended for three
months if the eardrums are otherwise of normal appearance.
Once fluid has been present behind the eardrum for three
months, it is considered unlikely to resolve for a considerable
time (sometimes years). Continued observation alone may
be an option after this time if hearing is completely normal
and there has been no ear drum damage. Treatment options
include:
A prolonged course of antibiotics (most commonly amoxycillin
or cotrimoxazole) for two to four weeks. Antibiotics have
a very modest improvement in the clearance of middle ear
fluid, and it cannot be said for sure whether the benefit
is only temporary. More concerns are being raised also about
the complications of antibiotic usage, including the development
of antibiotic resistance, allergic reactions, diarrhoea
and thrush.
Grommet (ventilation tube) insertion. This results in
resolution of the middle ear fluid, and in addition reduces
occurrence of Acute Otitis Media. Grommets are discussed
further below.
Other treatments, which have been used, include decongestants
(e.g. pseudoephedrine), antihistamines (e.g. phenergan)
and steroids (e.g. prednisone). There is no evidence for
their effectiveness or benefit.
What are Grommets?
These are tiny plastic flanged tubes, which are inserted
through a small nick in the eardrum to allow air into the
middle ear until the Eustachian Tube begins to function
normally. They come in various different sizes, which last
in the eardrum for different durations depending on the
size of the flange inserted into the middle ear. The most
common ventilation tubes last between 6-9 months and 12-15
months. This may vary considerably in individual children.
Tube selection is sometimes dependent on personal preference
of the surgeon, influenced by the season at time of insertion
and the desired duration of action.
Grommets eliminate middle ear fluid by allowing air in
to the middle ear from the outside - they are not "drains".
Allowing air in from the outside through the grommet enables
mucus and fluid to drain in the normal way down the Eustachian
tube. There is usually improvement in hearing and reduction
in frequency of acute otitis media episodes. Parents often
report improvement in balance and walking ability, and an
improvement in well being and happiness of the child. Many
times, there is an improvement in sleeping at night.
The grommets are inserted while under a short general
anaesthetic (asleep). The surgery is performed by a specialist
Ear, Nose and Throat Surgeon (Otolaryngologist, Head and
Neck surgeon) and usually takes 10 -15 minutes. Children
are often able to return home an hour or so afterwards.
There is not usually any pain in the ears afterwards. Follow
up with the family doctor and specialist is necessary until
the grommets have come out and the eardrums have healed
without further Otitis Media. Approximately 25% of children
have the requirement for further grommet insertion after
the first grommets extrude (come out), and of this group,
another 25% have the requirement for a further set of grommets
after that.
What are the risks of grommet insertion?
General Anaesthetic
The risk of complications from a short anaesthetic provided
by a specialist anaesthetist for an otherwise healthy child
are extremely low. They should be discussed with the anaesthetist
prior to surgery.
Ear Drum Perforation
A small risk exists (0.5% - 1.5%) of a persisting hole
in the eardrum after the grommets come out (extrude). An
operation to repair the hole may thus be necessary when
your child is older, often around 8-10 years of age. The
operation has a success rate of 85- 95% in experienced hands.
Holes or perforations left after grommet extrusion vary
in size and consequence. The main problems experienced are
intermittent discharge (often as a result of water going
in to the ear from the outside) and mild hearing loss. There
are no studies which clearly answer whether the rate of
perforated or damaged ear drums is significantly higher
after grommet extrusion than the natural course of events
if the ears had not been treated, nor is there evidence
which would enable early identification of children who
are more at risk of this complication.
Discharge from the ear
This may occur from time to time in some (up to 40%) of
children. It is not normally painful, but does mean that
the ear is infected and should be treated. Ear drops (e.g.
"Sofradex") for 5-7 days, rather than oral medicines are
usually required to treat this.
Ear drum scarring
There is commonly a small scar in the eardrum after the
grommets extrude. This does not damage the hearing in any
way. More significant scarring can occur in the eardrum
or middle ear, but is usually a result of more severe disease
than as a result of grommet insertion.
Water and swimming
Swimming is normally safe with grommets in place. They
will not fall out, but there is a small risk of ear infection
and resultant discharge through the grommet. As treatment
of an infection is usually straightforward and routine ear
protection can be very aggravating to parents and children,
many doctors don't recommend ear plugs as a matter of course.
There is often considerable geographical variation in recommendations
- mostly dependent on local water conditions and quality.
If necessary, protect your child's ears from soapy water
or from water in swimming pools and rivers/lakes. Swimming
in the sea has a lower risk of ear infection. To protect
the ears, use cotton wool mixed with Vaseline, insert into
the ears and then cover with another layer of Vaseline on
the outside. Silicone putty, or earplugs are available from
most pharmacies. Custom fitted earplugs ("Docs Pro Plugs")
can be very useful for regular swimmers.
Getting help
This information is written for general information only.
For more advice, please consult with your doctor.
Written by Dr Colin R S Brown, MB., ChB., FRACS. Dr Brown
is a Specialist Otolaryngologist (ENT Surgeon) and works
at the Starship Children's Hospital in Auckland as a specialist
in children's ear disorders. He is also has a specialist
private practice in Auckland.
|
