​Kembara Xtra - Medicine - Otitis Media Effusion

​Kembara Xtra - Medicine - Otitis Media Effusion 
Additionally known as serous otitis media, secretory otitis media, nonsuppurative otitis media, "ear fluid," or "glue ear"
Otitis medium with effusion (OME) is described as fluid in the middle ear without immediate indications of infection.
 More frequently, a pediatric illness
After acute otitis media (AOM), it may happen on its own due to inadequate eustachian tube function or as an inflammatory reaction.

Epidemiology 
90% of children, mostly between the ages of 6 months and 4 years, develop OME before entering school.
Aproximately 2.2 million new cases are reported each year in the US.
Prevalence
Adults are less likely to experience it, and it is typically linked to another disorder.


Pathophysiology and Etiology 
A persistent inflammatory condition when an underlying stimulus triggers an inflammatory response with increased mucin synthesis, functional obstruction of the eustachian tube, and thick buildup of mucin-rich middle ear effusion.
Biofilms, anatomical abnormalities, and AOM brought on by viruses or bacteria have been identified as stimuli producing OME. Young infants are more susceptible to OME due to shorter and more horizontal eustachian tubes, which become more vertical around the age of 7.
Nontypable Haemophilus influenzae, Streptococcus pneumoniae, and Moraxella catarrhalis are some of the prevalent infections that cause AOM.
● OME is frequently linked to head and neck malignancies (4.8%), smoking-induced nasopharyngeal lymphoid hyperplasia, adult-onset adenoidal hypertrophy, and paranasal sinus disease (66%).

Risk Elements 
A family history of OME, early daycare, exposure to cigarette smoke, bottle-feeding, and a low socioeconomic position are all risk factors.
The evidence is not clear, although malfunction of the eustachian tube may be a risk factor.
OME is linked to gastroesophageal reflux disease.

OME is normally not preventable, however the risk can be reduced by breastfeeding, limiting exposure to tobacco, and avoiding daycare centers while a child is young.

OME is a temporary and asymptomatic condition that affects many juvenile patients.
Hearing loss is the most typical symptom to be reported.
The ear may feel full or "pop" and cause only minor discomfort.
Infants may irritate themselves excessively, have trouble sleeping, or fail to react correctly to speech or sounds.
Clinical characteristics may include "a history of hearing difficulties, poor attention, behavioral problems, delayed speech and language development, clumsiness, and poor balance".
● A recent upper respiratory tract infection or recent episodes of AOM may have occurred in the past.


clinical assessment 

 A tympanic membrane (TM) that is cloudy and noticeably less mobile. In the middle ear, an air-fluid level or bubble may be apparent.
The TM may be retracted or concave, and the color may be aberrant (yellow, amber, or blue).
Clinical signs and symptoms of acute illness should not be evident in OME patients, but distinct redness of the TM may be seen in about 5% of cases.


AOM, Bullous Myringitis, Tympanosclerosis (which may result in reduced or nonexistent mobility of the TM), and Sensorineural Hearing Loss are the possible differential diagnoses.


Laboratory Results 
Initial examinations (lab, imaging)
Pneumatic otoscopy, which shows diminished or absent TM motion as a result of middle ear fluid, is the main diagnostic tool. Pneumatic otoscopy can diagnose OME with 94% sensitivity and 80% specificity. With a competent examiner, diagnostic accuracy ranges from 70% to 79%.


Tests in the Future & Special Considerations

Tympanometry can also be performed to confirm or rule out the diagnosis in infants older than four months, particularly when it's hard to tell if there is a middle ear effusion present.
Instead of using tympanometry, one option is to use acoustic reflectometry, which has a 64% specificity and 80% sensitivity.
Hearing tests are advised for OME lasting more than three months, and language testing is advised for kids with abnormal hearing tests. An audiogram may reveal minor conductive hearing loss.


Other/Diagnostic Procedures

The gold standard is myringotomy, although it is impractical for clinical application.


Management 

 OME improves or disappears in the majority of patients without medical intervention within 3 months, especially if it is linked to AOM.
According to current recommendations, observation should last for three months, during which time serial exams, tympanometry, and language testing are optional.
Adults with OME should be treated appropriately after being examined for any underlying disorders.


Medication The 2016 AAOHNS guideline advises against using antibiotics on a regular basis to treat OME. But according to a 2016 Cochrane analysis, children who received oral antibiotics had a higher chance of experiencing tympanogram-verified OME resolution in 2 to 3 months (number needed to treat = 5). Diarrhoea, vomiting, skin rashes, and allergic responses were among the adverse events (number needed to harm = 20). Importantly, no patient-focused outcomes (such as cognitive growth, language, quality of life, or speech) were reported.
Unknown outcomes include short-term hearing loss, a decline in AOM infections, or a requirement for breathing tubes.
● Antihistamines and decongestants provide no advantage above a placebo in the treatment of OME, according to the 2016 AAOHNS and a 2006 Cochrane review, and they may have negative side effects such sleeplessness, hyperactivity, and sleepiness.
The 2016 AAOHNS recommendation advises against using intranasal or oral corticosteroids. There was no evidence of a long-term benefit, and unfavorable side effects like weight gain and behavioral changes are probable.
Adults may get OME due to eustachian tube dysfunction brought on by allergic rhinitis or a recent upper respiratory illness. Decongestants, antihistamines, and nasal steroids may enhance results in adults, but this is uncertain.


Concerning Referral 
Indications for referring a patient to a surgeon for tympanostomy tube examination include the following:
 Chronic bilateral OME (less than three months) with hearing impairment
At-risk children with chronic OME or type B (flat) tympanogram who have speech, language, or learning issues as a result of baseline sensory, physical, cognitive, or behavioral factors

Further Therapies 

Surgery might not be necessary in some cases, thanks to hearing aids.


Surgical Techniques 
Tympanostomy tubes are advised as the first surgical procedure.
Risks include persistent TM perforations, myringosclerosis, retraction pockets, and purulent otorrhea.
In children older than 4 years old, adenoidectomy with myringotomy is just as effective as tympanostomy tubes, but it has more anesthetic and surgical risks.
Children with persistent OME alone shouldn't have adenoidectomy performed unless there is a clear rationale for the treatment for another issue (such as adenoiditis, chronic sinusitis, or nasal blockage).
Adenoidectomy (and contemporaneous tube installation) may be an option if OME requires a second surgery (for instance, if effusion returns after tubes have been withdrawn or lost their grip). Adenoidectomy has been found to lessen the requirement for additional OME surgeries in these circumstances.
Myringotomy or a tonsillectomy alone are not advised as treatments.


Alternative Therapies 
Tympanogram or audiometry and quality of life scores of patients may both benefit with autoinflation, which is the technique of opening the eustachian tube by elevating intranasal pressure (e.g., by forced exhale with closed mouth and nose).

Patient Follow-Up Monitoring
When a child is first diagnosed, and again at 12 to 18 months (if the initial diagnosis was made before 12 months), they should be checked for OME. At-risk conditions include blindness or other irreversible visual impairment, permanent hearing loss independent of OME, suspected or confirmed speech and language delay, Down syndrome or other craniofacial disorder, suspected or confirmed language delay, autism spectrum disorder or other pervasive developmental disorder, cleft palate, and unspecified developmental delay.
Patients with OME should undergo reevaluations and additional hearing tests every three to six months until the effusion has cleared or the child shows signs that necessitate surgical referral.


Prognosis 

A resolution of OME occurs in about 50% of children older than 3 years old within 3 months.

OME complications include permanent hearing loss, which raises the possibility of language, speech, and developmental problems. This is the most serious issue.
A cholesteatoma can develop as a result of inadequate middle ear airflow.

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