MIDDLE EAR EFFUSION

Facilitator: Dr. Zephania Saitabau

University of Dodoma-College of
Health Sciences
 Synonyms:
Non-suppurative otitis media,
Glue ear,
Secretory otitis media,
Serous otitis media ,
Otitis Serosa.
BRIDGING THE GAP: MIDDLE EAR ANATOMY
The middle ear is an air-
containing cavity in the Petrous
part of the temporal bone.
The middle ear cleft consists
of: Tympanic cavity, Mastoid air
cell system and Eustachian
tube
Function: sound transmission,
middle ear pressure equilibrium
 EUSTACHIAN TUBE
A tube connecting middle ear and nasopharynx, approximately
36mm long, inclined at 45 degree in adult but more horizontal in
children
The eustachian tube is an essential communication between the
nasopharynx and the middle ear.
It is responsible for pneumatization of the middle ear and clearance
of middle ear secretions
Mucosa has mucous producing cells and ciliated cells
 Contn…Eustachian tube
Usually closed
Opens during swallowing, yawning, and sneezing
Opening involves cartilaginous portion
Tensor veli palatini responsible for active tubal
opening
Eustachian tube anatomical differences btn children
and adults
• Children • Adults
 Shorter  Longer
 Longer bony portion  Ant 2/3- cartilaginous and
 10 degree angle of Post 1/3- bony
inclination (more  45 degree angle of
horizontal) inclination (Less horizontal)
 Wider  Less wider
 Nasopharyngeal orifice 4-  Nasopharyngeal orifice 8-
5 mm in infants 9 mm
 Definition of Middle Ear Effusion
This is a disorder of the middle ear in which the mucosal
lining shows chronic inflammatory change and an effusion
which in most cases is sterile
 PATHOGENESIS
• Middle ear effusion arises due to changes of middle ear
pressure because of conditions that interfere with
Eustachian tube function.
• Under normal circumstances, air is being reabsorbed from
the middle ear cleft into the mucoperiosteum. The tendency
towards negative middle ear pressure is countered by
intermittent opening of the ET which restores pressure back
to atmospheric level.
 Contn…Pathogenesis
• Oedema or obstruction of the eustachian tube will lead to
negative middle ear pressure.
• Since the walls of the middle ear are rigid and hence cannot
collapse to counter the negative pressure effect, fluid from
capillaries in the mucoperiosteum transudate into the
middle ear space leading to MEE.
 Characteristics of the fluid

(1)MUCOID – Glue like

(2)Serous
(3)Bloody
(4)Purulent
 AETIOLOGY
• Eustachian tube obstruction.
• Allergy.
• Upper respiratory tract infection
• Barotrauma.
• Tumors.
• Cleft palate.
• Radiation therapy
 EUSTACHIAN TUBE OBSTRUCTION
The peak age incidence of MEE corresponds to the period
of maximum hyperplasia of lymphoid tissue in the
nasopharynx (2-3years)
(a) Direct closure of the eustachian tube orifice by excessive
adenoid tissue
(b) Obstruction of lymphatic vessels draining the middle ear
and eustachian tube. This leads to mucosal oedema and
MEE.
 ALLERGY
The incidence of MEE has been found to be twice as
common in allergic children than in a control group.
The allergic oedema act by causing ET obstruction.
UPPER RESPIRATORY TRACT INFECTION
Both viral and bacterial infection in the URT may lead
to ET oedema and obstruction; and hence MEE.
 BAROTRAUMA
This occurs mainly in:
• Air travel
• Elevators
• Deep sea diving.
In this individuals, during descent the middle ear pressure becomes
negative with respect to atmospheric pressure.
The ET fails to allow air in to equalize the pressure. This leads to
retraction of the tympanic membrane, ear ache and middle ear
exudate.
In severe cases, capillary walls rupture leading to a bloody effusion
( haemotympanum)
 TUMORS

Unilateral middle ear effusion should alert the

physician into the possibility of a nasopharyngeal
tumour.
In this situation the effusion is usually serous.
 CLEFT PALATE
Children with cleft palate, or who have had cleft
palate, have a higher incidence of MEE.
This is due to dysfunction of the muscles of the soft
palate ( tensor and levator veli palatini muscles).
These muscles also act on the ET.
 RADIATION THERAPY
MEE is commonly found after radiation therapy to the
head and neck.
This is a serous effusion, which occurs due to
obstruction of lymphatic drainage of the middle ear
and ET.
 CLINICAL FEATURES
Conductive hearing loss
Otalgia
Tinnitus
Autophony
TM changes such as Dull, retracted tympanic
membrane etc
 Tympanic membrane features
(i) The normal translucent appearance plus a cone of light
disappears. The drum becomes dull or yellowish in
colour.
(ii) The TM becomes retracted, the incudo-stapedial joint may
appear more prominent with apparent shortening of the
handle of malleus.
(iii) Fluid levels or bubbles may be seen through the tympanic
membrane; usually in serous effusions.
(iv) Blue tympanic membrane, this is seen in
haemotympanum.
 Hearing loss
• This is the main presenting complain.
• In children: The hand cap may present as a change in
behavior. The child becomes dull and indifferent to
command. He may be thought of as rude by teachers
or parents.
• Adults: They will complain of hearing loss sometimes
associated with autophony i.e. hearing of ones own
voice.
 INVESTIGATIONS
• X-ray of the nasopharynx: To assess adenoid
hypertrophy.
• Pure tone audiometry: This will show conductive
hearing loss pattern. Stiffness of the round window
may lead to a mixed hearing loss pattern.
• Tympanometry: Will show negative middle ear
pressure or a flat curve.
Type B tympanogram seen in MEE
Pure tone audiogram
slide_19.jpg
ADENOID HYPERTROPHY
 TREATMENT OF MEE
Medical treatment.
• Antibiotics.
• Decongestants.
• Antihistamines.
• Eustachian tube ventilation exercises:
Valsava maneuver.
Chewing gum.
Surgical treatment.
• Adenotomy: This should be performed in all children with
MEE and adenoid hypertrophy who have not responded to
medical treatment for more than three months.
• Myringotomy + tympanostomy (grommet) tubes insertion
In this procedure an incision is made in the lower anterior
(anterior-inferior) quadrant of the tympanic membrane and a
tube inserted.
This ventilates the middle ear from the EAC.
MYRINGOTOMY AND GROMMET TUBE INSERTION
 SEQUELAE OF MIDDLE EAR EFFUSION
Tympanic Membrane Atrophy.
 In long standing cases the fibrous layer disappears [thin
tympanic membrane]
Ossicular Chain Erosion.
Osteolysis and Ischaemia—ossicular chain discontinuity
and fibrous union
Chronic Ottitis Media
Cholesterol Granulomas.
THE END