Otitis Media (middle ear inflammation) 

The most frequent primary diagnosis at visits to US physician offices by children younger than 15 years. Otitis media particularly affects infants and preschoolers: almost all children experience one or more episodes of otitis media before age 6.

The American Academy of Pediatrics, the American Academy of Family Physicians, and the American Academy of Otolaryngology--Head and Neck Surgery, with the review and approval of the Agency for Health Care Policy and Research of the US Department of Health and Human Services, convened a panel of experts to develop a guideline on otitis media for providers and consumers of health care for young children. Providers include primary care and specialist physicians, professional nurses and nurse practitioners, physician assistants, audiologists, speech-language pathologists, and child development specialists. Because the term otitis media encompasses a range of diseases, from acute to chronic and with or without symptoms, the Otitis Media Guideline Panel narrowed the topic. Two types of otitis media often encountered by clinicians were considered:

When the scientific evidence for management permitted, Guideline recommendations were broadened to include older children.

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Congenital or early onset hearing impairment is widely accepted as a risk factor for impaired speech and language development. In general, the earlier the hearing problem begins and the more severe it is, the worse its effects on speech and language development. Because otitis media with effusion is often associated with a mild to moderate hearing loss, most clinicians have been eager to treat the condition to restore hearing to normal and thus prevent any long-term problems.

Studies of the effects of otitis media with effusion on hearing have varied in design and have examined several aspects of hearing and communication skills. Because of these differences, the results cannot be combined to provide a clear picture of the relationship between otitis media with effusion and hearing. Also, it is uncertain whether changes in hearing due to middle ear fluid have any long-term effects on development. Evidence of dysfunctions mediated by otitis media with effusion that have persisted into later childhood, despite resolution of the middle ear fluid and a return to normal hearing, would provide a compelling argument for early, decisive intervention. There is, however, no consistent, reliable evidence that otitis media with effusion has such long-term effects on language or learning.

The following recommendations for managing otitis media with effusion are tempered by the failure to find rigorous, methodologically sound research to support the theory that untreated otitis media with effusion results in speech/language delays or deficits.

Recommendations and options were developed for the diagnosis and management of otitis media with effusion in otherwise healthy young children. The following steps parallel the management algorithm provided at the end of this document.

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Diagnosis and Hearing Evaluation

1. Suspect otitis media with effusion in young children. Most children have at least one episode of otitis media with effusion before entering school. Otitis media with effusion may be identified following an acute episode of otitis media, or it may be an incidental finding. Symptoms may include discomfort or behavior changes.
    
2. Use pneumatic otoscopy to assess middle ear status. Pneumatic otoscopy is recommended for assessment of the middle ear because it combines visualization of the tympanic membrane (otoscopy) with a test of membrane mobility (pneumatic otoscopy). When pneumatic otoscopy is performed by an experienced examiner, the accuracy for diagnosis of otitis media with effusion may be between 70% and 79%.
    
3. Tympanometry may be performed to confirm suspected otitis media with effusion. Tympanometry provides an indirect measure of tympanic membrane compliance and an estimate of middle ear air pressure. The positive predictive value of an abnormal (type B, flat) tympanogram is between 49% and 99%; that is, as few as half of ears with abnormal tympanograms may have otitis media with effusion. The negative predictive value of this test is better--the majority of middle ears with normal tympanograms will in fact be normal. Because the strengths of tympanometry (it provides a quantitative measure of tympanic membrane mobility) and pneumatic otoscopy (many abnormalities of the eardrum and ear canal that can skew the results of tympanometry are visualized) offset the weaknesses of each, using the two tests together improves the accuracy of diagnosis.
    

4. A child who has had fluid in both middle ears for a total of 3 months should undergo hearing evaluation. Before 3 months of effusion, hearing evaluation is an option. A change in hearing threshold is both a clinical outcome and a possible indicator of the presence of otitis media with effusion. Methods used to determine a child's hearing acuity will vary depending on the resources available and the child's willingness and ability to participate in testing. Optimally, air- and bone-conduction thresholds can be established for 500, 1000, 2000, and 4000 Hz, and an air-conduction pure tone average can be calculated. This result should be verified by obtaining a measure of speech sensitivity. Determinations of speech reception threshold or speech awareness threshold alone may be used if the child cannot cooperate for pure tone testing. If none of the test techniques is available or tolerated by the child, the examiner should use his/her best judgment as to adequacy of hearing. In these cases, the health care provider should be aware of whether the child is achieving the appropriate developmental milestones for verbal communication.
   Although hearing evaluation may be difficult to perform in young children, evaluation is recommended after otitis media with effusion has been present bilaterally for 3 months, because of the strong belief that surgery is not indicated unless otitis media with effusion is causing hearing impairment (defined as equal to or worse than 20 decibels hearing threshold level in the better-hearing ear).
    
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Longitudinal studies of otitis media with effusion show spontaneous resolution of the condition in more than half of children within 3 months from development of the effusion. After 3 months the rate of spontaneous resolution remains constant, so that only a small percentage of children experience otitis media with effusion lasting a year or longer. In most children, episodes of otitis media with effusion do not persist beyond early childhood. The likelihood that middle ear fluid will resolve by itself underlies the recommendations made for management of otitis media with effusion.

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Scientific evidence showed that the following environmental factors may increase potential risks of getting acute otitis media or otitis media with effusion:

Because the target child for Guideline recommendations is beyond the age when the choice of breast-feeding versus bottle-feeding is an issue, this risk factor was not considered at length.

Passive smoking (exposure to another's tobacco smoke) is associated with higher risk of otitis media with effusion. Although there is no proof that stopping passive smoking will help prevent middle ear fluid, there are many health reasons for not exposing persons of any age to tobacco smoke. Therefore, clinicians should advise parents of the benefits of decreasing children's exposure to tobacco smoke.

Studies of otitis media with effusion in children cared for at home compared to those in group child-care facilities found that children in group child-care facilities have a slightly higher relative risk (less than 2.0) of getting otitis media with effusion. Research did not show whether removing the child from the group child-care facility helped prevent otitis media with effusion.

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Observation OR antibiotic therapy are treatment options for children with effusion that has been present less than 4 to 6 months and at any time in children without a 20-decibel hearing threshold level or worse in the better-hearing ear. Most cases of otitis media with effusion resolve spontaneously. Meta-analysis of controlled studies showed a 14% increase in the resolution rate when antibiotics were given. Length of treatment in these studies was typically 10 days.

The most common adverse effects of antibiotic therapy are gastrointestinal. Dermatologic reactions may occur in 3% to 5% of cases; severe anaphylactic reactions are much rarer; severe hematologic, cardiovascular, central nervous system, endocrine, renal, hepatic, and respiratory adverse effects are rarer still. The potential for the development of microbial resistance is always present with antibiotics.

For the child who has had bilateral effusion for a total of 3 months and who has a bilateral hearing deficiency (defined as a 20-decibel hearing threshold level or worse in the better-hearing ear), bilateral myringotomy with tube insertion becomes an additional treatment option. Placement of tympanostomy tubes is recommended after a total of 4 to 6 months of bilateral effusion with a bilateral hearing deficit. The principal benefits of myringotomy with insertion of tympanostomy tubes are the restoration of hearing to the pre-effusion threshold and clearance of the fluid and possible feeling of pressure. While patent and in place, tubes may prevent further accumulation of fluid in the middle ear. Although there is insufficient evidence to prove that there are long-term deleterious effects of otitis media with effusion, concern about the possibility of such effects led the panel to recommend surgery, based on their expert opinion. Tubes are available in a myriad of designs, most constructed from plastic and/or metal. Data comparing outcomes with tubes of various designs are sparse, and so there were assumed to be no notable differences between available tympanostomy tubes.

Insertion of tympanostomy tubes is performed under general anesthesia in young children. Calculation of the risks for two specific complications of myringotomy with tympanostomy tube insertion showed that tympanosclerosis might occur after this procedure in 51%, and postoperative otorrhea in 13%, of children.

A number of treatments are not recommended for treatment of otitis media with effusion in the otherwise healthy child age 1 through 3 years.

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What is Eustachian Tube?

The Eustachian tube is only channel of communication between the nasopharynx and the middle ear for the purpose of equalizing the pressure of the external air and that contained in the middle ear (see figure).

The natural ventilator of the middle ear is the eustachian tube. The middle ear is aerated only when the eustachian tube is opened, which take place during the act of deglutition. The tube is otherwise closed, so intended by nature to protect the middle ear from unnecessary exposure from the nasopharynx.

Large pressures in the middle ear cavity can affect the inner ear by way of the cochlear windows(Round window and Oval window).

When you travel by plane, you may sometimes feel ear fullness. But this feeling will disappear by swallowing or chewing. Your Eustachian Tube is working in this way.

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The Table summarizes the benefits and harms identified for management interventions in the target child with otitis media with effusion.

Outcomes of Treating Otitis Media With Effusion *

* The target patient is an otherwise healthy child age 1 through 3 years with no craniofacial or neurologic abnormalities or sensory deficits.

‡ Outcomes are reported as differences from observation, which is treated as the base case. When possible, meta-analysis was performed to provide a mean and associated confidence interval (CI).

§ Difference from base case not statistically significant.

¶ Risks were not examined in detail because no benefits were identified.

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Algorithm

The notes below are an integral part of the algorithm that follows.