Otitis media with effusion (glue ear)
What is glue ear?
Glue ear (also known as otitis media with effusion) is an inflammation of the middle ear resulting in an accumulation of fluid without symptoms of infection. If symptoms of infection become present (fever, pain, drainage from the ear), it is then known as an acute otitis media (middle ear infection).
Glue ear is extremely common and affects approximately 80% of children at some point during their childhood.
What causes glue ear?
Children are prone to developing glue ear in the first 2 to 4 years of life for several reasons. The Eustachian tubes in children are shorter and more horizontal than those of adults, which lets bacteria and viruses find their way into the middle ear more easily, where they can cause inflammation and subsequent fluid build up. Also, the adenoids which are gland-like structures located in the back of the nose near the Eustachian tubes, are large in children and can interfere with the opening of the Eustachian tubes. The adenoids can also act as a reservoir for infection.
Several other factors can contribute to children getting glue ear, such as bottle feeding, secondhand exposure to cigarette smoke (this causes inflammation and blockage of the Eustachian tubes) and childcare attendance (where children are more exposed to the bugs that result in glue ear from other children). Glue ear is more common in boys and in children with a family history of ear infections. They are also more common during the winter season, when lots of people get upper respiratory tract infections or colds.
Are certain children more prone than others to developing glue ear?
Yes, children with Down syndrome and cleft palate are more prone to developing both glue ear due to an abnormality in the structure and function of their Eustachian tubes.
What are the symptoms of glue ear?
The main symptom in children with glue ear is hearing loss. This hearing loss may lead to speech impairment and delay and poor school performance. Some children complain of ear discomfort or pain. Occasionally, it may affect balance. The fluid in the middle ear can also become infected and result in one or recurrent attacks of acute otitis media.
How long does it last?
This varies from child to child but can last from several weeks to many months.
How is it diagnosed?
Many children are referred to the ENT clinic for a hearing check after having failed a school hearing test, and are diagnosed there. Others are first taken to the GP by parents who complain that their child is too loud, not listening when being spoken to, asking for things to be repeated or listening to the television at loud volumes. Your GP should usually be able to make a diagnosis based on the symptoms and by examining the ear and looking at the ear drum. A formal hearing test will also show the hearing loss and a pressure test on the ears (known as a tympanogram) will show flat traces, signifying that there is fluid behind the ears (a tympanogram trace is peaked in health).
What is the treatment?
The majority of cases (approximately 75%) will spontaneously resolve with a “wait and see” approach, which is usually undertaken for approximately 3 months. During this time, an Otovent device can be tried. This is a special balloon that the child blows up with their nose in an attempt to force air up the Eustachian tubes and encourage a resolution of the fluid collection in the middle ear. In many cases an Otovent device can hasten resolution of the glue ear. Read more about the Otovent device here.
Antibiotics and nasal decongestants have not been shown to be useful in the treatment of glue ear.
What are the surgical options?
For children who do not recover naturally after a 3-month period of watchful waiting and still have evidence of glue in both ears, ventilation tubes (grommets) can be inserted. These tubes allow ventilation of the middle ear by bypassing the dysfunctional Eustachian tube, and prevent the build up of fluid or pus behind the ear drum. Sometimes, removal of the adenoids (an adenoidectomy) may also be indicated. Mr Trinidade can discuss in more detail whether grommet insertion and adenoidectomy is right for your child.
Grommets are not usually considered in children who have glue in only one ear as the chance of them developing it in both ears and becoming deaf are very small. These children have a much higher chance of natural resolution of their glue ear than children who have it in both ears.
Is surgery the only option for children with glue ear who do not resolve naturally after 3 months?
No. Natural resolution of glue can take longer in some children. As a good alternative to surgery, children may try hearing aids as a temporary solution to their hearing difficulty and stop wearing them after the glue finally resolves. Regular hearing tests can help decide when the child no longer needs them.
For children with Down syndrome, hearing aids are usually recommended as a first line of treatment over grommets as grommets tend to give more problems in these children, such as a higher rate of grommet infections and early extrusion of the grommets from the ear.
In children with cleft palate, it is usually recommended that grommets be inserted at the time of their cleft palate repair after assessment for glue ear by an ENT surgeon.
Do all children with glue ear need treatment?
No. Many children with glue ear will be diagnosed on a routine examination and have no symptoms at all, nor will their speech or school work be affected. In these children, simply watching and waiting until it resolves can be enough. Only children who are struggling with poor hearing or other symptoms and not showing signs of improvement over time need treatment. Otherwise, uncomplicated glue ear is not harmful to your child.
Can glue ear be prevented?
Some of the risk factors for glue ear cannot be changed, such as a family history of frequent ear infections or the child’s gender, but certain lifestyle choices can help protect children:
Breastfeeding infants for at least 6 months provides natural immunity and helps to prevent the development of early episodes of ear inflammation and fluid accumulation. If a baby is bottle-fed, hold the baby at an angle instead of lying the child down with the bottle.
Second-hand smoke has been shown to greatly increase the risk of glue ear. Even if the smoker in the home smokes outside, smoke particles inhaled from their clothes can have the same effect.
While not always possible, minimizing exposure to large groups of children (such as in childcare centres) can protect your child from some of the upper respiratory infections that can lead to glue ear.
Parents and children should wash their hands well and often. This is one of the most important ways to stop the spread of germs that can cause colds that could result in middle ear inflammation.
Further in-depth reading on glue ear can be found in the National Institute for Health and Clinical Excellence (NICE) Guidelines here.
A picture of glue ear. The amber-coloured glue can be seen behind the ear drum. There are bubbles within it - this is air ventilating up from the Eustachian tube, suggesting natural resolution of the glue. Surgery will be unecessary in this case.