Family doctor

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/crèche/preschool
• An older sibling in childcare/crèche/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.