CASE REPORT

OTITIS MEDIA WITH EFFUSION

Presentator :
dr. Solikin

Moderator :
dr. Danu Yudistira, MMR, Sp.T.H.T.K.L

Otorhinolaryngology Head and Neck Surgery Department

Faculty of Medicine, Public Health and Nursing
Gadjah Mada University
Dr. Sardjito Hospital Yogyakarta
2019
INTRODUCTION middle ear pressure, and immunological

Otitis media with effusion (OME) is a abnormalities, or a combination of these two

condition in which there is fluid in the middle factors are thought to be the main factors.

ear, but no signs of acute infection. As fluid Risk factors for OME include passive

builds up in the middle ear and eustachian smoking, bottle feeding, day-care nursery,

tube, it places pressure on the tympanic and atopy. Both children and adults can

membrane. The pressure prevents the develop OME. Children with development

tympanic membrane from vibrating properly, anomalies including the palate, palate

decreases sound conduction, and therefore muscles, decreased muscle tone for palate

results in a decrease in patient hearing. muscles, or bone development variations are

Chronic OME is defined as OME that persists at increased risk of development of OME,

for 3 or more months on examination or e.g., cleft palate, Down Syndrome.(3)

tympanometry.(1) OME is histologically a chronic

Epidemiological data about OME in inflammatory condition. An underlying

North America are controversial and stimulus leads to an inflammatory reaction

disparate. This disease, which especially with production of more mucin and altered,

affects children, shows a prevalence of 0.6% more viscous mucin types, which then

among adults, in contrast to the fact that 90% abnormal mucociliary clearance of the

of children under two years have had at least middle ear with functional blockage of the

one episode and about 80% of preschool eustachian tube, resulting in the

children experience OME. Many episodes accumulation of a thick, mucin-rich middle

will improve spontaneously within 3 months, ear effusion. The overexpression of mucin

but around 30-40% of children will genes is also exacerbated by cigarette smoke.

experience recurrence, and 51% will end 1 OME may occur as a consequence of AOM

year or more. The incidence of EOM taking an extended period of time to resolve;

decreases in adulthood.(1,2) eg, weeks or months.(4)

Etiology Otitis media with effusion is OME may occur as a residual effect

multiple. Otitis media with effusion occurs of AOM, or there may be no preceding

because of the interaction of various host history. Clinical features include a history of

factors, allergies, environmental factors, and hearing difficulties, poor attention,

Eustachian tube dysfunction. Negative behavioral problems, delayed speech and

1
language development, clumsiness, and poor
balance. Otoscopy is vital in making the
diagnosis, with sensitivity and specificity
quoted at 90% and 80%. The clinical findings
are variable, and include abnormal color (eg,
yellow/amber/blue),retracted/concave of the
tympanic membrane, and air–fluid levels.
Further evidence is obtained with an
audiogram (hearing testing typically showing
mild conductive hearing loss)
tympanogram (showing an immobile ear
(4,5)
drum or negative middle ear pressure).
There are several management
options to choose from, including watchful
waiting, medication (such as
vasoconstrictor, antihistamine, steroids), or
surgery. The goals of management are to
resolve the effusion, restore normal hearing
(if diminished secondary to the effusion), and
prevent future episodes or sequelae. A
hearing test is recommended if otitis media
with effusion persists for more than 3
months. In otitis media with effusion with a
low risk are re-examined intervals of 3-6
months until the effusion no longer exists. If
surgery in otitis media with effusion is
indicated, Tympanostomy Tube (TT) is the
(5,6)
initial procedure.
Presence of middle ear fluid result in
decrease mobility of tympanic membrane and
serve as a barrier to sound conduction
resulting deafness, the commonest symptom
of OME. The disease has a high rate of
spontaneous resolution. Middle ear
atelectasis and tympanosclerosis is the
possible complication of untreated OME.(3)
CASE REPORT
A 41 years old female came to the
ENT clinic with complaint of deafness on her
and left ear since approximately 2 months ago.
She felt fullness on her ear, and she has a
sensation of moving liquid every time she
changed the position of her head. She denied
about dizziness, any ear discharge, pain on
local the ear, facial palsy and fever. She also
denied any trauma of the head and the ear,
any bloody discharge from the nose and there
was no dual vision.
On general examination, the patient
was good condition, vital signs revealed
blood pressure 110/60 mmhg, respiration rate
20x/minute, heart rate 76x/minute, and
temperature 36.80C. On ENT examination,
from otoscopy and otoendoscopy the left ear
examination revealed the tympanic
membrane is intact, air bubbles appear and
cone of light in the tympanic membrane was
short, and limited movement from the
valsava maneuver. The right ear examination
revealed external auricle is normal, tympanic
membrane is intact, cone of light was normal.
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And conductive hearing loss of the left ear
was obtained by tuning fork. From the
audiometry examination was found left ear
mild conductive hearing loss.
On examination of the anterior and
posterior rhinoscopy was obtained both
inferior chonca were pale. There was no
discharge. Oropharyngeal examination was
within normal limit. From nasoendoscopy
examination, nasofaring within normal limit.
Based on the history and physical
examination, patients was diagnosed with
otitis media with effusion. Patient was given
antibiotic amoxycillin 3 x 500 mg and
combination with pseudoephedrine 3 x 60
mg.
The problem with this case is
diagnosis.
DISCUSSION
Otitis Media with Effusion (OME),
also known as “Glue Ear” or “Secretory
Otitis Media”, is an inflammatory condition
of the middle ear cleft, acute or chronic, with
collection of non-purulent fluid behind an
intact tympanic membrane. OME is called
chronic when the fluid persists for more than
three months.(2,6)
The etiological factors associated
with serous otitis media or otitis media with
effusion (OME) are well described in
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children. OME can occur in adults and
contributing factors are previous middle ear
surgery in the contra lateral ear, history of
middle ear disease in childhood, chronic
nasal symptoms of obstruction and nasal
fullness, cigarette smoking and a family
history of middle ear disease.(7)
From the anamnesis, this patient felt
deafness on her left ear since approximately
2 months ago. She felt fullness on her ear, and
she has a sensation of moving liquid every
time she changed the position of her head.
She denied about dizziness, any ear
discharge, pain on the ear, facial palsy and
fever. She also denied any trauma of the head
and the ear, any bloody discharge from the
nose and there was no dual vision.
Patients with otitis media with
effusion present different grades of
conductive hearing loss according to the type
of fluid or effusion (serous or mucous).
Tinnitus are usual as symptoms. Hearing loss
can range from 15 to 40 dB. These symptoms,
(without pain) do not cause children to
complain because they are a silent process.
Initially the effusion is serous as a transudate.
Then, due to the histological changes of the
middle ear mucosa (by an increase of goblet
cell metaplasia and mucus glands), the liquid
becomes seromucous, then mucoid and
finally, the effusion becomes thick and
stringy, like a glue (gummy ear).(2,3)
Upper respiratory tract infections can
lead to mucosal congestion in the eustachian
tube and nasopharynx. The resultant
congestion prevents normal eustachian tube
function and pressure regulation is altered
within the middle ear. If sustained, aspiration
of nasopharyngeal pathogens can occur into
the middle ear. Eustachian tube dysfunction
(ETD also caused by ciliary dysmotility,
nasopharynx carcinoma, cleft palate,
gastroesophageal reflux, and adenoid
hypertrophy, but these causes only account
for a minority of patients.(4,8)
One possible mechanism for the
development of otitis media with effusion is
an in situ reaction of the middle ear mucosa
for antigens inhaled through the nose or
nasopharynx. Although most clinical studies
suggest that there is no increase in IgE levels
in the middle ear, about 23% of patients
allergic to otitis media with effusion may
have a local allergic reaction in their middle
ear. In addition, several experimental studies
have shown that the middle ear mucosa can
react immunologically to antigen-IgE
interactions and that this mechanism may
occur in some allergic patients.(8,9)
From Physical Examination on from
otoscopy and otoendoscopy the left ear
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examination revealed the tympanic
membrane is intact, air bubbles appear and
cone of light in the tympanic membrane was
short, and limited movement from the
valsava maneuver. The right ear examination
revealed external auricle is normal, tympanic
membrane is intact, cone of light was normal.
And conductive hearing loss of the left ear
was obtained by tuning fork. From the
audiometry examination was found left ear
mild conductive hearing loss.
On examination of the anterior and
posterior rhinoscopy was obtained both
inferior chonca were pale. There was no
discharge. Oropharyngeal examination was
within normal limit. From nasoendoscopy
examination, nasofaring within normal limit.
Based on the history and physical
examination, patients was diagnosed with
otitis media with effusion.
OME is diagnosed with the presence
of fluid behind the tympanic membrane (an
air fluid level or bubble may be visible in the
middle ear), without acute onset or signs of
infection. On physical examination the
tympanic membrane (eardrum) is observed
from normal to atelectasic, with a yellow or
blue colour due to the accumulation of fluid
in the middle ear, turning to a brown colour
when the process becomes chronic in nature.
Pneumatic otoscopy is the best diagnostic
tool for OME because one can observe and
identify the lack of movement of the
tympanic membrane. Unfortunately, it is not
widely used. The diagnosis must be further
supported by other investigations like
audiometry and tympanometry.(2,9)
Individuals with normal hearing can
detect lower frequencies at a lower decibel
(i.e.,intensity) than higher frequencies,
meaning that a normal individual needs a
sound to be louder to perceive high
frequencies than lower frequencies. During
an audiometry, the range of frequencies that
an individual can perceive is plotted on an
audiogram. The decibel (dB) range of
individuals with OME is decreased in the
audiogram. Audiometry will demonstrate a
variable air bone-gap.(1,9)
Tympanometry is examination or
measurement of middle ear function,
including tympanic membrane mobility,
eustachian tube function, and tympanic
cavity condition. Tympanomteri presents a
tympanogram, a graph of the relative
flexibility of the osicular tympanic system
while the air pressure in the ear canal is
altered. Maximum flexibility is obtained at
normal air pressure, and decreases if the air
pressure is increased or lowered. Type A
indicates that the condition of the middle ear
is normal. Type B has fluid in the middle ear.
5
Type C has an eustachian tube function
disorder. Type AD has stiffness in the
auditory bone or otosclerosis. Type B
tympanogram with a flat curve and normal
canal volume shows a diagnostic direction to
effusion otitis media. Compared to all other
forms of tympanogram, type B has a
sensitivity between 56 and 73 percent and a
specificity between 50 and 98 percent in
detecting otitis media with effusion which is
confirmed surgical procedure.(1,4,10)
Allergy tests need to be considered to
confirmed diagnosed of OME. Allergy can be
associated cytokines were assumed to act
among the key regulators of the middle ear
inflammation of chronic OME. Eustachian
tube functions can be affected directly by the
mediators released in the nasal mucosa of
patients with AR or indirectly by the resultant
nasal obstruction. A significant association
was reported between OME, eosinophil
cationic protein values in middle ear effusion
and persistent symptoms.(10)
The patient was given antibiotic
amoxycillin 3 x 500 mg and combination
with pseudoephedrine 3 x 60 mg.
Management of otitis media with
effusion is divided into three, which are:
watchful waiting, medical therapy, and
surgical intervention. According to systemic
review that observes the course of the disease
with spontaneous resolution Otitis media
with effusion. The high rate of spontaneous
resolution Otitis media with effusion, so
observations can be given to Otitis media
with effusion sufferers who do not cause
interference. Hearing tests must be
performed if Otitis media with effusion lasts
up to 3 months or more or causes significant
hearing loss. If the average hearing threshold
is less than 20 dB, watchful waiting is
recommended, but if it's more than 40 dB
compared to healthy ones, surgical
intervention is recommended. Between 21
and 39 dB, management is based on duration
of effusion and severity of symptoms. Otitis
media with effusion generally resolves
(4,11)
spontaneously with watchful waiting.
However, if it is persistent,
myringotomy with tympanostomy tube
insertion is considered an effective treatment.
In this treatment, a ventilation tube allows for
air entry into the middle ear, preventing re-
accumulation of fluid. After this procedure,
many patients do not need additional therapy
due to the growth and development of the
Eustachian tube angle, which will allow for
(4,11)
drainage.
Pseudoephedrine acts directly on α-
adrenergic receptors in the mucosa of the
respiratory tract producing vasoconstriction
that results in shrinkage of swollen nasal
mucous membranes, reduction of tissue
hyperemia, edema, and nasal congestion, and
an increase in nasal airway patency; drainage
of sinus secretions is increased.(9,12)
Sympathomimetic effects of
pseudoephedrine presumably also may occur
in other areas of the respiratory tract,
including the eustachian tube; these effects
may improve or maintain eustachian tube
patency and allow equilibrtion of middle ear
pressure during external atmospheric
pressure changes (e.g., during descent of an
aircraft, underwater diving, hyperbaric
oxygenation).(9,12)
SUMMARY
A 41 years old female came to the
ENT clinic with complaint of deafness on her
left ear since approximately 2 months ago.
She felt fullness on her ear, and she has a
sensation of moving liquid every time she
changed the position of her head. The
patients was diagnosed with otitis media with
effusion. Patient was given antibiotic
amoxycillin 3 x 500 mg and combination
with pseudoephedrine 3 x 60 mg. The patient
was educated to came 1 month again for
control.

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REFERENCES 8. Llewellyn A, Norman G, Harden M,
1. Searight FT, Singh R, Peterson DC. Coatesworth A, Kimberling D,
Otitis Media With Effusion.2018 Schilder A, et al. Interventions for
Nov;102(6):1063-1079 adult Eustachian tube dysfunction: a
2. Zernotti et al. Otitis media with systematic review. Health Technol
effusion and atopy:is there a causal Assess.2014;(18)46
relationship?. World Allergy 9. Ahmady Roozbahany N, Majdinasab
Organization Journal.2017.10:37 N, Oroei M, Nateghinia S. Adult
DOI 10.1186/s40413-017-0168-x Onset Otitis Media with Effusion:
3. Kolegium Ilmu Kesehatan Telinga Prevalence and Etiology. 2016;
Hidung Tenggorok Bedah Kepala dan 2(1):7-9
Leher Indonesia. Modul Utama 10. Mills R, Hathorn I.Aetiology and
Otologi. Inflamasi Telinga pathology of otitis media with
Tengah.2015:Edisi II effusion in adult life.The Journal of
4. Qureishi A et al. Update on otitis Laryngology & Otology (2016), 130,
media – prevention and treatment. 418–424
Infection and Drug Resistance 11. Mohammed MA, Elsherief WT,
2014:7;15–24 Osman MM, Abdelmaksoud AA.
5. Zakrzewski L, Lee DT. An Role of medical management
algorithmic approach to otitis media in otitis media with effusion. Journal
with effusion. The Journal of family of Current Medical Research and
Practice.2013 Dec:Vol 62;12 Practice. 2016(1)24–7
6. Bhutta MF et al. Understanding the 12. Deck L, Sutter AIM, Guo L, Mir NA,
aetiology and resolution of chronic Driel ML.Nasal decongestants in
otitis media from animal and human monotherapy for the common
studies. 2017 Nov 1; 10(11): 1289– cold.Cochrane Database of
1300 Systematic Reviews.2016, Issue 10
7. Hurst DS. The Role of Allergy in
Otitis Media with Effusion.
Otolaryngologic Clinics of North
America. 2014