Glue Ear (Otitis Media with Effusion)

❍ At a glance

• OME is the most common cause of acquired conductive hearing loss in children. It is typically painless - the presenting concern is usually hearing difficulty noted by parents or teachers, language delay, or inattentiveness.
• The majority of OME resolves spontaneously within 3 months; 90% of cases in children over 2 resolve within 12 months without intervention.¹ Watchful waiting is appropriate for most children with recent-onset OME and mild or no hearing impact.
• Decongestants, antihistamines, steroids, and antibiotics have no evidence of benefit and should not be used.² Autoinflation (Otovent device) has modest evidence in children over 4 and can be offered alongside watchful waiting.³
• Refer for audiometry if OME is suspected with hearing difficulty, language delay, or behavioural concern. ENT threshold: bilateral OME with hearing loss ≥25 dB in the better ear persisting beyond 3 months.

❍ Presentation, assessment, and management

OME is typically painless and may be entirely asymptomatic. The presenting concern is usually hearing difficulty - parents may describe mishearing or misunderstanding speech, needing the television louder, inattentiveness at school, or poor response to being called. Teachers often notice the problem before parents. Children with OME may have delayed speech and language development, particularly if the effusion has been present during early language acquisition.

Otoscopy: the tympanic membrane may appear dull, opaque, or yellowish (the "amber drum"); there may be a visible air-fluid level or air bubbles behind the membrane; the light reflex is often distorted. Membrane mobility is reduced on pneumatic otoscopy. The tympanic membrane is not bulging and there is no discharge - these features suggest AOM rather than OME. Tympanometry (where available) shows a flat Type B curve indicating reduced membrane compliance from middle ear fluid.

The primary investigation is formal audiological assessment - refer any child with suspected OME and associated hearing loss for audiometry. A hearing loss of 25 dB or more in the better ear, or persistent OME on audiological review, is the threshold for considering ENT referral.

Watchful waiting is appropriate for most children with OME of recent onset and mild or no hearing impact - 90% of cases in children over 2 resolve within 12 months.¹ Decongestants, antihistamines, systemic or intranasal corticosteroids, and antibiotics have no evidence of benefit.² Autoinflation (Otovent balloon device, inflated through each nostril) has modest evidence in children over 4 and can be offered alongside watchful waiting.³ Address treatable contributing factors: active management of concurrent allergic rhinitis (intranasal corticosteroid) can improve drainage; tobacco smoke exposure is a modifiable risk factor.

For children with persistent OME and significant hearing loss, the definitive treatment is insertion of ventilation tubes (grommets) with or without adenoidectomy. Grommets provide immediate restoration of hearing and remain in place for an average of 9-12 months before extruding. They are appropriate for bilateral OME persistent beyond 3 months with associated hearing loss (≥25 dB in the better ear) affecting development, behaviour, or schooling.

❍ Referral criteria

Refer for audiology assessment: any child with suspected OME and associated hearing difficulty, language delay, or behavioural concern. Direct GP referral to audiology is available in most NZ DHB areas.

Refer to ENT for: bilateral OME with hearing loss ≥25 dB in the better ear persisting beyond 3 months; OME with significant speech and language delay; OME in children with Down syndrome (prone to persistent effusion and significant hearing impact), cleft palate, or other craniofacial abnormalities; parental or school concern about hearing impact that has not resolved with watchful waiting.