OTITIS MEDIA WITH EFFUSION /Non suppurative otitis media

Synonyms: Serous Otitis Media, Secretory Otitis Media, Mucoid Otitis Media, “Glue Ear”.

Definition: This is an insidious condition characterized by accumulation of nonpurulent effusion in the middle ear cleft. Often the effusion is thick and viscid but sometimes it may be thin and serous. The fluid is nearly sterile. The condition is commonly seen in school-going children.

Pathogenesis

Two main mechanisms are thought to be responsible:

• Malfunctioning of Eustachian Tube: Fails to aerate the middle ear and is also unable to drain the fluid.
• Increased Secretory Activity of Middle Ear Mucosa: Biopsies confirm increase in number of mucus or serous-secreting cells.

Aetiology

1. Malfunctioning of Eustachian Tube

• Adenoid hyperplasia.
• Chronic rhinitis and sinusitis.
• Chronic tonsillitis: Enlarged tonsils mechanically obstruct the movements of soft palate and interfere with physiological opening of ET.
• Tumours: Benign and malignant tumours of nasopharynx. Always exclude in unilateral serous otitis media in an adult.
• Palatal defects: e.g., cleft palate, palatal paralysis.

2. Allergy

Seasonal or perennial allergy to inhalants or foodstuff (common in children). Obstructs ET by oedema and leads to increased secretory activity (middle ear mucosa acts as a shock organ).

3. Unresolved Otitis Media

Inadequate antibiotic therapy in acute suppurative otitis media (ASOM) may inactivate infection but fail to resolve it completely. Low-grade infection lingers, stimulating mucosa to secrete fluid. Goblet cells and mucous glands increase.

4. Viral Infections

Adeno- and rhinoviruses of upper respiratory tract may invade middle ear mucosa and stimulate increased secretory activity.

Clinical Features

1. Symptoms (Children 5–8 years)

• Hearing loss: Presenting and sometimes the only symptom. Insidious onset, rarely exceeds 40 dB. May pass unnoticed or be discovered during screening.
• Delayed and defective speech: Due to hearing loss.
• Mild earaches: History of URI with mild earaches.

2. Otoscopic Findings

Hearing Tests

• Tuning Fork Tests: Conductive hearing loss.
• Audiometry: Conductive hearing loss of 20–40 dB. (Occasional SNHL due to fluid pressure on round window; reversible).
• Impedance Audiometry (Objective): Reduced compliance and flat curve ('B' type).
• X-ray Mastoids: Clouding of air cells.

Treatment

Aim: Removal of fluid and prevention of recurrence.

1. Medical

• Decongestants: Topical (drops/sprays) or systemic to relieve ET oedema.
• Antiallergic Measures: Antihistaminics, steroids, desensitization.
• Antibiotics: Useful in URI or unresolved ASOM.
• Middle Ear Aeration: Valsalva manoeuvre, politzerization, or chewing gum (to encourage swallowing).

2. Surgical

Indicated when fluid is thick and medical treatment fails.

• Myringotomy and Aspiration: Incision in TM. Saline/chymotrypsin may be needed for thick mucus. "Beer-can" principle (two incisions) used for glue-like secretions.
• Grommet Insertion: Provides continued aeration. Left for weeks/months until spontaneous extrusion.
• Tympanotomy / Cortical Mastoidectomy: For loculated fluid or cholesterol granuloma.
• Causative Factor Treatment: Adenoidectomy, tonsillectomy, antral washout.

Biofilm

Clinical Relevance: Implicated in chronic OME, rhinosinusitis, tonsil/adenoid infections. Forms on tympanostomy tubes.

Sequelae

• Atrophic TM & Atelectasis: Fibrous layer dissolves, TM thins and retracts.
• Ossicular Necrosis: Commonly long process of incus.
• Tympanosclerosis: Hyalinized collagen/chalky deposits leading to fixation.
• Retraction Pockets & Cholesteatoma: Invagination of atrophic pars tensa.
• Cholesterol Granuloma: Due to stasis.