Middle ear effusions (M.E.E.) or Serous Otitis Media (S.O.M.) or Glue ears are amongst the most commonly encountered diagnoses in otological practice especially in children. Tell a patient he has fluid in the ear, and the first cause he will suspect is bath water entering the ear. This, naturally, is untrue since fluid effusions occur behind intact ear drums and there is no scope for the water to enter the middle ear cavity through an intact eardrum. Effusions (i.e. fluid collections) form behind intact eardrums due to alterations in the middle ear physiology - due to a dysfunction of the eustachian tube - which is responsible for middle ear aeration.
But before we go ahead, a few words about the middle ear physiology with an attempt to simplify it with a simple analogy.
The middle ear as can be seen from the diagram is a closed cavity bounded on its lateral side by an elastic ear drum & is aerated by the eustachian tube which is the source for oxygenation especially for the millions of glands which are present in it's lining pseudostratified ciliated columnar (respiratory) epithelium. Thus the middle ear cavity can be likened to a room (middle ear) full of people (glands) which has no doors or windows ; only an A.C. duct (eustachian tube) for ventilation.
If there is inadequate functioning of the eustachian tube, there is a relative hypoxia which causes the mucous glands to secrete in far greater quantity than normal which results in a fluid accumulation in the middle ear.
Going back to our analogy, the same situation that would result if our A.C. duct developed a malfunction. The people in the room would start sweating and if we would stretch our imagination for the sake of this example, the collective sweat would start accumulating in the room.
WHAT ARE THE CAUSES OF S.O.M. ?
Obviously, we have to think of causes of eustachian tube occlusion.
1. In children less than the age of 13 years, adenoids are the major cause.
2. Salpingitis: i.e. inflammation of the eustachian tube due to an U.R.T.I.. This often represents the presuppurative stage of an acute otitis media; not progressing to suppuration due to immunity or treatment.
3. Sinusitis: Thick mucoid fluid plugging the tubal isthmus
4. Nasopharyngeal Carcinomas: especially in adults with a unilateral disease not responding to the standard line of treatment. In fact, persistent unilateral middle ear effusions may be the only presenting feature of nasopharyngeal carcinomas.
5. Allergy: especially associated with an allergic rhinitis.
6. Rarer causes include - Palatal paralysis, cleft palate, nasopharyngeal atresias & paratubal adhesions.
WHAT ARE THE SYMPTOMS OF S.O.M. / M.E.E. ?
Roughly we could say they are the symptoms experienced by many of us in the ear during a severe cold - ear block, deafness, sometimes hearing changing with different head positions (due to postural fluid positions), bubbling sounds in the ear & occasionally tinnitus.
However in children, the picture maybe entirely different since they are often unable to express their symptoms. Many have never experienced normal hearing if the condition has developed soon after birth. I have seen children fall back in their studies due to this condition especially if they are made to sit behind in a class.
CLINICAL SIGNS & INVESTIGATIONS:
Clinically, a severely retracted drum with evidence of fluid behind the drum is seen. There is no perforation. However, small perforations may develop which may be regarded as beneficial and are often looked upon as God sent ventilation tubes.
Audiometry confirms a conductive hearing loss
Tympanometry is usually confirmatory.
Additional investigations may be required to determine the cause - e.g. X-ray P.N.S. to diagnose an associated sinusitis. Sinoscopy is also of immense value in resistant M.E.E.s especially since a latent sinus drip or a nasopharyngeal Ca can be easily diagnosed.
TREATMENT:
Medical : Antibiotics, antihistamines with systemic nasal decongestants, nose drops. Steroids are useful only if no active sinusitis exists. Mucolytics may be of value especially if steroids are contraindicated. Ear drops are of no value since they do not penetrate an intact ear drum. They are to be prescribed only in the presence of ear discharge which would indicate the presence of a perforation. In our analogy, medical treatment would amount to trying to repair the fault in the A.C. system.
Surgical : It follows logically, that if medical treatment fails, surgical removal of the fluid through a minute hole in the drum (Myringotomy), may be required. But then what is the guarantee against recurrence ? - The guarantee exists only if we can ensure that middle ear aeration is permanently ensured. This is achieved by creating an alternative pathway for aeration (inserting a small teflon tube -grommet- through this hole to maintain its patency). Going back to our analogy, if the A.C. is still irreparable or prone to repeated failures, one would consider providing a simple extra window to the room.
The procedure performed is called Myringotomy with "grommet" insertion.
Often, surgery is also required for the underlying cause which can be done at the same sitting - e.g. Adenoidectomy, Sinus wash, Nasopharyngeal biopsy etc.
WHAT IS A "GROMMET" ?
As mentioned earlier, M.E.E.s often require making a small hole in the drum to drain out the accumulated fluid. It is also often advisable to retain the patency of this hole (which would otherwise heal) because it amounts to providing an alternate pathway for aeration. Even if eustachian tube dysfunction were to persist, the middle ear would be oxygenated & hence remain healthy.
Grommets or ventilation tubes are tubes made of non reactive material like teflon which are inserted through the ear drum to provide an alternative pathway for middle ear aeration.
How safe are they? Extremely safe. Grommet insertion is achieved without any external incision, and is only a 20 minute procedure. In adults it is done under local anesthesia & the patient can be discharged within 2 hours without any bandage or dressing. Children require short G.A. In fact, this is amongst the most commonly performed operations on children in the U.S.A. Often in children grommet insertion is combined with an adenoidectomy.
Another excellent property they have is that they help in restoration of natural eustachian tube function and are automatically extruded and do not have to be surgically removed.
But before we go ahead, a few words about the middle ear physiology with an attempt to simplify it with a simple analogy.
The middle ear as can be seen from the diagram is a closed cavity bounded on its lateral side by an elastic ear drum & is aerated by the eustachian tube which is the source for oxygenation especially for the millions of glands which are present in it's lining pseudostratified ciliated columnar (respiratory) epithelium. Thus the middle ear cavity can be likened to a room (middle ear) full of people (glands) which has no doors or windows ; only an A.C. duct (eustachian tube) for ventilation.
If there is inadequate functioning of the eustachian tube, there is a relative hypoxia which causes the mucous glands to secrete in far greater quantity than normal which results in a fluid accumulation in the middle ear.
Going back to our analogy, the same situation that would result if our A.C. duct developed a malfunction. The people in the room would start sweating and if we would stretch our imagination for the sake of this example, the collective sweat would start accumulating in the room.
WHAT ARE THE CAUSES OF S.O.M. ?
Obviously, we have to think of causes of eustachian tube occlusion.
1. In children less than the age of 13 years, adenoids are the major cause.
2. Salpingitis: i.e. inflammation of the eustachian tube due to an U.R.T.I.. This often represents the presuppurative stage of an acute otitis media; not progressing to suppuration due to immunity or treatment.
3. Sinusitis: Thick mucoid fluid plugging the tubal isthmus
4. Nasopharyngeal Carcinomas: especially in adults with a unilateral disease not responding to the standard line of treatment. In fact, persistent unilateral middle ear effusions may be the only presenting feature of nasopharyngeal carcinomas.
5. Allergy: especially associated with an allergic rhinitis.
6. Rarer causes include - Palatal paralysis, cleft palate, nasopharyngeal atresias & paratubal adhesions.
WHAT ARE THE SYMPTOMS OF S.O.M. / M.E.E. ?
Roughly we could say they are the symptoms experienced by many of us in the ear during a severe cold - ear block, deafness, sometimes hearing changing with different head positions (due to postural fluid positions), bubbling sounds in the ear & occasionally tinnitus.
However in children, the picture maybe entirely different since they are often unable to express their symptoms. Many have never experienced normal hearing if the condition has developed soon after birth. I have seen children fall back in their studies due to this condition especially if they are made to sit behind in a class.
CLINICAL SIGNS & INVESTIGATIONS:
Clinically, a severely retracted drum with evidence of fluid behind the drum is seen. There is no perforation. However, small perforations may develop which may be regarded as beneficial and are often looked upon as God sent ventilation tubes.
Audiometry confirms a conductive hearing loss
Tympanometry is usually confirmatory.
Additional investigations may be required to determine the cause - e.g. X-ray P.N.S. to diagnose an associated sinusitis. Sinoscopy is also of immense value in resistant M.E.E.s especially since a latent sinus drip or a nasopharyngeal Ca can be easily diagnosed.
TREATMENT:
Medical : Antibiotics, antihistamines with systemic nasal decongestants, nose drops. Steroids are useful only if no active sinusitis exists. Mucolytics may be of value especially if steroids are contraindicated. Ear drops are of no value since they do not penetrate an intact ear drum. They are to be prescribed only in the presence of ear discharge which would indicate the presence of a perforation. In our analogy, medical treatment would amount to trying to repair the fault in the A.C. system.
Surgical : It follows logically, that if medical treatment fails, surgical removal of the fluid through a minute hole in the drum (Myringotomy), may be required. But then what is the guarantee against recurrence ? - The guarantee exists only if we can ensure that middle ear aeration is permanently ensured. This is achieved by creating an alternative pathway for aeration (inserting a small teflon tube -grommet- through this hole to maintain its patency). Going back to our analogy, if the A.C. is still irreparable or prone to repeated failures, one would consider providing a simple extra window to the room.
The procedure performed is called Myringotomy with "grommet" insertion.
Often, surgery is also required for the underlying cause which can be done at the same sitting - e.g. Adenoidectomy, Sinus wash, Nasopharyngeal biopsy etc.
WHAT IS A "GROMMET" ?
As mentioned earlier, M.E.E.s often require making a small hole in the drum to drain out the accumulated fluid. It is also often advisable to retain the patency of this hole (which would otherwise heal) because it amounts to providing an alternate pathway for aeration. Even if eustachian tube dysfunction were to persist, the middle ear would be oxygenated & hence remain healthy.
Grommets or ventilation tubes are tubes made of non reactive material like teflon which are inserted through the ear drum to provide an alternative pathway for middle ear aeration.
How safe are they? Extremely safe. Grommet insertion is achieved without any external incision, and is only a 20 minute procedure. In adults it is done under local anesthesia & the patient can be discharged within 2 hours without any bandage or dressing. Children require short G.A. In fact, this is amongst the most commonly performed operations on children in the U.S.A. Often in children grommet insertion is combined with an adenoidectomy.
Another excellent property they have is that they help in restoration of natural eustachian tube function and are automatically extruded and do not have to be surgically removed.
