Serous otitis media Otitis media
WILLIAM H. LUM, D.O., F.O.C.O. Providence, Rhode Island
Serous otitis media is a major cause The term "serous otitis media" describes a of permanent conductive deafness. The condition for which there is an unusually large otologist, pediatrician, and general number of alternate terms, more or less de- scriptive and synonymous : "exudative middle practitioner should have a high level of ear catarrh," "secretory otitis media," "hydro- suspicion when confronted with the tympanum," "middle ear effusions," "acute fluid-filled ear in order that adequate non-suppurative otitis media," "acute salpin- treatment can be initiated promptly. gitis," "tubotympanitis," "otosalpingitis," "tu- The disease can be insidious in onset bal catarrh," "otitis media with effusion," and difficult to diagnose, but its early "catarrh of the middle ear," "hydrops ex vacuo," and "otitis media exudativa." recognition is essential since resistance Serous otitis media can be defined as an to treatment increases with the affliction of the eustachian tube and middle duration of the condition. The ear, with the accumulation of non-purulent pathogenetic mechanism of serous fluid in the middle ear which adversely affects otitis media is unknown but it is the hearing and/or comfort of the patient. believed that an obstruction of the Historically this is not by any means a new clinical entity, Politzer having first described eustachian tube prevents proper its symptoms and treatment in 1862. The litera- drainage and ventilation of the middle ture on the subject was rather sparse until the ear. The fluid is the result of disease, early 1940 s, but since the 1950 s many articles rather than a disease itself, and the have appeared. underlying cause must be determined and treated. In children, the most Incidence The reported incidence of serous otitis media frequent cause of tubal obstruction is has definitely been higher in the past 10 to 25 adenoidal hypertrophy. Many years. The increase may only be apparent, children with serous otitis media also that is, due to increased awareness. But it have sinusitis. Allergy may be an may be real, resulting from increased use of etiologic factor. Medical management antibiotics which change the purulent ear into by itself, however, seldom the fluid aseptic ear. In some clinics serous otitis media has become the most common accomplishes significant results. otologic diagnosis. Various hearing clinics re- It is usually necessary to perform port that it represents 25 per cent 1,2 of all con- myringotomy and gentle spot suction. ditions seen. The patients age ranges from 1 These procedures may be followed by to 80, but the majority are less than 8 years paracentesis of the drum and old.3 Armstrong4 reports that out of 6,000 pa- retrograde eustachian tube inflation. tients, 80 per cent were under 8 years old and 25 per cent were 3 years old or younger. The otologist, the pediatrician, and the gen- eral practitioner must recognize the impor- tance of this major cause of permanent con-
440/118 ductive deafness. Each would do well to regard low or absent. The chemical composition is un- the ear that contains fluid with respect and to certain. This fluid is really the result of a dis- adopt a high index of suspicion in recognizing ease, rather than a disease itself. the condition so that the patient can be treated early and adequately. Diagnosis The history usually is of great value in making Etiology a diagnosis, although in some cases there is no It is generally agreed that the most frequent history specifically referable to the ears. Most etiologic factor is a transient eustachian tube patients, however, have had episodes of middle inflammation leading to tubal obstruction. ear aches, if not painful acute otitis media. Thus, acute upper respiratory tract infections There usually have been self-limited simple with enlarged adenoids are causative, particu- respiratory tract infections sometimes treated larly if there have been recurrent attacks unnecessarily with antibiotics, or more serious treated with antibiotics. Acute otitis media, infections treated with antibiotics inadequately antibiotic-treated, is especially likely to be fol- either in dosage or duration. After apparent lowed by serous otitis media. An increase in recovery from such bouts, there has probably avirulent viral infections may follow the con- been no follow-up examination of the ears and trol of bacterial invasion. Allergy can be a hearing. In the infant or small child the mother factor in eustachian tube obstruction, even may report his pulling at his ears and crying though eosinophils are rarely present in the without apparent reason, 5 being restless and middle ear fluid. Other potential etiologic fac- irritable, or not appearing to hear well. He tors include sinus disease, chronic rhinitis, may have been accused of being inattentive or malignancy of the nasopharynx, cleft palate, even mentally retarded, and thus diagnosis and dental malocclusion, septal deflections, improp- treatment were delayed. Sudden failure to do er blowing of the nose, and nasal polyps. Sys- well in school should arouse suspicion. Serous temic conditions which can be related are en- otitis media often remains undiagnosed in docrine disorders, diabetes, obesity, cardiac school-aged children until a routine screening insufficiency, and cardiovascular renal disease. test of hearing reveals apparent deafness and Often several factors, in combination, cause the leads to referral. middle ear effusion. Although the pathogenetic mechanism is Symptoms largely unknown, it is believed that usually an There is no set pattern of symptoms charac- obstruction of the eustachian tube prevents teristic of all cases. The symptoms may be proper drainage and ventilation of the middle most distressing, but in some cases are non- ear. Consequent absorption of the oxygen in existent. A loss of hearing and a feeling of the contained air results in a negative pressure, fullness or heaviness in the involved ear usu- which, in turn, favors the transudation of ally is present. The patient may describe the serous fluid from the arterioles and capillaries. ear sensation as "stuffy, blocked, lifeless, lop- Thus the normally air-filled middle ear be- sided, rolling, woody," et cetera. Although his comes more or less filled with exudate. This hearing loss may be only 5 or 10 decibels, he fluid can be serous (thin and watery) or mucoid may complain that it is "driving him crazy," (thick and viscous). The bacterial content is et cetera. Autophony may be present with its
Journal A0A/vol. 67, December 1987 441/119 Serous otitis media
"speaking-through-the-ear" or "head-in-a-bar- deafness such as otosclerosis.4 rel" feeling. A sensation of creaking, water Pure tone audiograms generally show a uni- bubbling, and squeaking in the ear is frequent. form loss of 20-30 decibels, sometimes more, Hearing may be altered with change in head but sometimes less. However, these and tuning position. A few patients have a low-pitched fork tests are frequently unreliable or imprac- tinnitus. A systemic response, such as fever or tical, especially in young children. The Rinne malaise, almost never occurs. test will be negative. In unilateral cases, the Weber test will "lateralize" to the affected ear. Signs A few patients with secretory otitis media The signs of serous otitis media are mainly show an audiometric curve of pure perceptive those found on inspection of the ear drum. In or false-nerve-deafness, the cause of which is approximately 70 per cent of the cases, the probably an immobilization of the windows? disease is bilateral. While the external ear and Hearing losses are frequently fluctuating, the canal are normal, the tympanic membrane does patient hearing better at certain times than at not appear norma1. 6 Each case is different, but others, with as much as a 30-decibel variation. most show a dull retracted drum with a dis- Also, in clinically similar ears in different pa- persed light reflex, a prominent short process tients there is a wide and unexplained varia- of the malleus and foreshortening of the long tion in degree of impairment.4 process. The color varies considerably ; though Fluid in the middle ear should be suspected usually amber or yellow, it may be brown or and a diagnostic paracentesis is indicated when pearly or bluish. Transparency is generally in- a conductive hearing loss is present which is creased, giving an impression of oiliness or out of proportion to the amount of disease seen greasiness. Fluid levels are sometimes present by otoscopy. and may be made bubbly by inflation or shifted by a change of head position. When fluid ac- Treatment cumulation is considerable, the drum shows Determination of the etiologic factors in each limitation of its usual excursion on testing with given case should guide the physician in his Siegle s pneumatic otoscope. In Armstrong s selection of the appropriate treatment. Serous binaural transmission test, the fluid also causes fluid virtually never arises in the middle ear increased intensity of sound transmission from spontaneously. Rather, it is the result of the patient s affected ear along a Toynbee diag- disease, the cause of which must be determined nostic tube to the examiner s ear. This can be and treated. heard either by using a low-pitched tuning In the child, the most frequent cause of fork placed on the patient s vertex, or better, tubal obstruction is adenoid hypertrophy. A the patient s voice. In bilateral disease, with scrupulous adenoidectomy primarily or secon- a diagnostic tube in each ear, sounds are un- darily, with or without tonsillectomy, is needed usually loud and clear. In unilateral disease, in many cases. Myringotomy with spot suction the voice is heard much louder in the affected of the fluid is usually necessary also and is ear. This test thus serves as an objective varia- carried out under the same general anesthestic. tion of Weber s test in patients with serous The fluid may prove difficult to aspirate be- otitis media. It also facilitates differentiation cause of its viscous, glue-like nature. between fluid and non-fluid types of conductive After myringotomy and gentle spot suction,
442/120 Kapur5 advocates that one tip end of a diag- extruded spontaneously sooner or later. It can nostic tube be inserted snugly in the patient s be left in from a week to several months, dur- ear canal and the other tip be replaced with a ing which time most patients will have recov- Politzer bag. The bag is squeezed with gradu- ered normal function of the eustachian tube ally increasing pressure until a gurgling sound and will not require re-insertion of a vent tube. is heard, followed by the passage of air into the The principles discussed in relation to my- nasopharynx. By listening, it can be determined ringotomy, spot suction, and the use of vent whether the eustachian tube is open, blocked, tubes apply to adults as well as children. How- partially opened, or filled with fluid. Secretions ever, stable teen-agers and adults can be op- thusly blown down the tube are following the erated on in the ofice.f Cetacaine sprayed or normal direction of drainage of the middle ear. painted with a cotton swab on the drum helps With the burden removed from the cilia of the by affording some anesthetic effect, and the eustachian tube, they can function again. To non-inflamed drum is not unduly sensitive. The favor evacuation of the middle ear fluid, Kapur5 immediate recovery of hearing is very gratify- advocates two incisions in the drum, one in the ing indeed. posterior inferior quadrant and another in the Siegle s otoscope can be used in place of anterior quadrant. spot suction to get rid of the fluid through al- Many children with serous otitis media have ternating positive and negative pressures, and sinusitis as well. This condition should be the procedure can be repeated at follow-up watched for during the work-up and treated office visits as long as the drum remains open. appropriately on the basis of the findings. In cases with a patent vent tube in place, it Local use of cortisone-antibiotic drops until can be used to force air down through the eu- the drum has healed helps prevent suppuration stachian tube in a retrograde politzeration, to and promotes return to normal of the lining clean the eustachian tube until it resumes its epithelium. A high cure rate follows. physiologic state. For the occasional recurrence, insertion of Patients other than small children can usu- a vent tube is the treatment of choice. The ally perform the Valsalva maneuver and should tube serves not as a drain, but as a vacuum use it several times a day. If they are unable breaker to equalize pressures in and outside to inflate their ears, they may be provided with the middle ear. It aids recovery of the eusta- a Politzer bag and taught its use. Still another chian tube, making fluid removal easier. A method involves the use of a nasal tip attached number of materials are available which are to a toy balloon, with the patient closing one molded in ingenious constructions. However, nostril with a finger and inflating the balloon many feel that the use of plain, straight-sided, by blowing out the other nostril. If this does polyethylene or vinyl tubing serves adequately. not "pop" the ear, one balloon may be inserted The former requires cold sterilization ; the in a second to increase the resistance and there- latter can be boiled. The No. 90 tube is usually fore the inflation force needed. too small as it plugs easily, whereas the No. Medical management alone seldom accom- 160 is about right. Different diameter tubing plishes significant results. However, in the can be cut about 1 cm. long with a bevel at presence of a history of allergy which is sus- one end, and kept sterilized in Petri dishes pected of being an etiologic factor, the usual ready for use. Straight tubing usually will be allergic work-up and management are insti-
Journal AOA/vol. 67. December 1967 443/121 Serous otitis media
tuted. For several weeks after myringotomy a tion of the time and effort frequently involved nasal decongestant or vasconstrictor can help to bring about eventual resolution and nor- in reducing the obstruction at and near the malcy, rather than adhesions and permanent pharyngeal end of the eustachian tube. A vaso- deafness. Such explanations help reduce impa- constrictor s effectiveness is limited unless care- tience and foster co-operation. ful, adequate instruction is given in its proper use with regard to position, dosage, and repe- Conclusion tition. Serous otitis media threatens an increasing Eustachian tube catheterization is not of segment of the population with temporary and great help in removing thick secretions and even permanent hearing handicap. It is some- may cause damage to the eustachian tube open- times insidious in onset and difficult to diag- ing into the pharynx, even if the procedure is nose, and its resistance to treatment increases carried out with a nasopharyngoscope.5 the longer it is present. An awareness of its Antibiotics and chemotherapy have no place nature and a high index of suspicion when in the treatment of this condition. There is lit- confronted with possible victims of serous tle justification for instituting a program that otitis media is urged on our otologists, our pe- includes bougienage of the eustachian tube, diatricians, and our general practitioners. irrigation of the sinuses, determination of the basal metabolic rate, allergy consultation, et cetera, before doing a myringotomy.4 1. Freeman, M. S., and Freeman, R. J.: Serous otitis media. AMA Among the most resistant cases are those J Dis Child 99:683-7, May 60 2. Armstrong, B. W.: Chronic secretory otitis media: diagnosis with petechial hemorrhages resulting in a and treatment. Southern Med J 50:540-6, Apr 57 sanguinous exudate and characterized by a 3. Bell, H. L.: Management of secretory otitis. Report of cases. Eye Ear Nose Throat Monthly 40:614-8, Sep 61 blue drum. Myringotomy, an indwelling tube, 4. Armstrong, B. W.: Secretory otitis media—problems and pit- and use of the Politzer bag three or four times falls. JAMA 179:505-9, 17 Feb 62 5. Kapur, Y. P.: Serous otitis media in children. Arch Otolaryng a day will eventually clear up most of them. 79:38-48, Jan 64 Mastoidectomy is rarely indicated and then 6. Lemon, A. N.: Serous otitis media in children. Laryngoscope 72:37-44, Jan 62 only in the case of a blue drum which has 7. Goodhill, V.: Otosurgical developments and hard of hearing progressed to the development of cholestea- child. Trans Amer Aced Ophthal Otolaryng 61:711-22, Nov-Dec 67 toma.4 Repeated myringotomies, aspirations, and Presented at the annual meeting of the Osteopathic College of tube insertions are occasionally needed over a Ophthalmology and Otorhinolaryngology, New Orleans, November 16, 1966. period of years in particularly resistant cases. Dr. Lum, 1257 Narragansett Boulevard, Providence, Rhode Island Patients or their parents deserve an explana- 02905.
444/122