Otitis Media (Serous)

Patients may report no symptoms, but some (or their family members) note hearing loss. Patients may experience a feeling of fullness, pressure, or popping in the ear during swallowing. Otalgia is rare.

Various possible changes to the tympanic membrane include an amber or gray color, displacement of the light reflex, mild to severe retraction, and accentuated landmarks. During air insufflation, the tympanic membrane may be immobile. An air-fluid level or bubbles of air may be visible through the tympanic membrane.

Serous Otitis Media

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TONY WRIGHT, INSTITUTE OF LARYNGOLOGY AND OTOLOGY/SCIENCE PHOTO LIBRARY

• Examination with pneumatic otoscopy

• Tympanometry

• Nasopharyngeal examination

Diagnosis of serous otitis media is clinical plus pneumatic otoscopy. For pneumatic otoscopy, an insufflator attached to the otoscope head is used to move the tympanic membrane; fluid in the middle ear, a perforation, or tympanosclerosis inhibits this movement. Tympanometry may be done to confirm middle ear effusion (by showing reduced mobility of the tympanic membrane).

If an effusion persists for> 8 weeks, adults and adolescents must undergo nasopharyngeal examination to exclude malignant or benign tumors. Nasopharyngeal malignancy should be suspected, particularly in patients with unilateral serous otitis media. If malignancy is suspected, imaging studies should be performed.

• Observation

• If unresolved, myringotomy with tympanostomy tube insertion

• If recurrent in childhood, sometimes adenoidectomy

For most patients, watchful waiting is all that is required. Antibiotics and decongestants are not helpful. If allergies are clearly involved, antihistamines and nasal corticosteroids may be helpful.

If no improvement occurs in 1 to 3 months, myringotomy may be done for aspiration of fluid and insertion of a tympanostomy tube, which allows ventilation of the middle ear and temporarily ameliorates eustachian tube obstruction, regardless of cause. Tympanostomy tubes may be inserted for persistent conductive hearing loss secondary to middle ear fluid that does not clear. Tympanostomy tubes can help prevent recurrences of acute otitis media and serous otitis media.

Occasionally, the middle ear is temporarily ventilated with the Valsalva maneuver or politzerization. To do the Valsalva maneuver, patients keep their mouth closed and try to forcibly blow air out through their pinched nostrils (popping the ear). To do politzerization, the clinician blows air with a special syringe (middle ear inflator) into one of the patient’s nostrils and blocks the other while the patient swallows. This forces the air into the eustachian tube and middle ear. Neither procedure should be done if the patient has a cold and rhinorrhea. Patients may be instructed to gently pinch their nostrils and swallow (called autoinsufflation). This maneuver can be repeated several times throughout the day to aerate the middle ear.

Persistent, recurrent serous otitis media may require correction of underlying nasopharyngeal conditions. In children, particularly adolescent boys, a nasopharyngeal angiofibroma should be ruled out; in adults, nasopharyngeal carcinoma must be ruled out. Children may benefit from adenoidectomy, including the removal of the central adenoid mass as well as lymphoid aggregations on the torus of the eustachian tube and in the Rosenmüller fossa. Antibiotics should be given for bacterial rhinitis, sinusitis, and/or nasopharyngitis. Demonstrated allergens should be eliminated from the patient’s environment and immunotherapy should be considered.

Susceptible young children with prolonged hearing loss due to long-standing serous otitis may require appropriate therapy to ensure normal language development. Balloon dilation of the eustachian tube has been used as an alternative to tympanostomy tube placement (1). While the patient is under general anesthesia, a specialist inserts a balloon into the eustachian tube and briefly dilates the tube before removing the balloon. This procedure is an option for patients with recurrent serous otitis media and those who do not wish to have a tympanostomy tube placed. Caution should be used for some patients with mild eustachian tube dysfunction symptoms (eg, a sense of fullness, pressure, or popping in the ear) because this procedure can cause patulous eustachian tube dysfunction; symptoms include a sense of fullness and autophony (when patients hear their own breathing), which can cause them distress.

Because environmental pressure changes can cause painful barotrauma, scuba diving and air travel should be avoided or delayed when possible. If air travel cannot be avoided, chewing food or drinking (eg, from a bottle) may help young children. A Valsalva maneuver or politzerization (during descent of an airplane, people should pinch their nose shut, hold their mouth closed, and try to blow gently out through their nose; this maneuver forces air through the blocked eustachian tube) may help older children and adults.