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Serous Otitis Media Otitis Media 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 1940s, but since the 1950s 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 Siegles pneumatic otoscope. In Armstrongs 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 patients affected ear along a Toynbee diag- disease, the cause of which must be determined nostic tube to the examiners 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 patients vertex, or better, tubal obstruction is adenoid hypertrophy. A the patients 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.
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