When Do Adults With Otitis Media With Effusion Need an ENT Referral?

Judith Shannon Lynch, MS, MA, APRN-BC, FAANP

Disclosures

May 09, 2008

Question            

Question

When should I make a surgical referral for possible tympanostomy tubes in an adult patient with otitis media with effusion?

 

Response from Judith Shannon Lynch, MS, MA, APRN-BC, FAANP
Assistant Clinical Professor, Yale University School of Nursing, New Haven, Connecticut; Nurse Practitioner, ENT Associates, Waterbury, Connecticut


The incidence and prevalence of otitis media with effusion leading to chronic otitis media are well documented in the pediatric population.[1] When middle ear fluid is found in adult patients, however, it must be treated with suspicion, especially when unilateral in nature.

Otitis media with effusion (OME) is characterized by the presence of nonpurulent fluid, usually serous or mucoid, in the middle ear cavity.[2] Symptoms always involve some degree of hearing loss and a feeling of aural fullness. Adult patients also complain of crackling or popping tinnitus, the sensation of a foreign body in the external auditory canal, and mild diffuse aural pain. Complaints of acute ear pain are rare. There may be a vague sensation of disequilibrium without vertigo.

In children, OME most often occurs after an episode of acute otitis media when the eustachian tubes have not drained properly.[3] In adults, OME usually develops following a severe upper respiratory infection such as sinusitis, severe allergies, or rapid change in air pressure (barotrauma) after a plane flight or a scuba dive. Nasal drainage inflames the eustachian tube openings near the nasopharynx, resulting in eustachian tube dysfunction (ETD).

ETD is the main precursor of OME in the adult patient. Eustachian tubes provide 3 essential physiologic functions: equilibration of pressure between the middle and external ears, cleansing of secretions, and middle ear protection.[2] The many etiologies of ETD range from anatomic blockage to secondary inflammation from allergic rhinitis, frequent upper respiratory infection, or trauma. Some experts agree that viruses can directly damage the eustachian tube lining, decreasing mucillary clearance.[4]

Other factors that influence eustachian tube function include:

  • Severe nasal septal deviation with an obstructed airway;

  • The presence of tonsils and adenoids with obstruction to eustachian tubes;

  • A nasopharyngeal tumor near eustachian tube openings;

  • Radiation to the head and neck following cancer treatments; and

  • Radical head and neck surgery, on maxillary sinuses and/or palate, that transects the eustachian tube.

 

Patient Assessment

History

Always ask the patient how long the symptoms have been present. If the patient can tell you that a hearing loss was sudden, especially with no significant history of upper respiratory infection, allergy, or aural trauma, the problem may be due to a sudden unilateral sensorineural hearing loss. This demands an immediate referral to specialty care for evaluation and treatment.

With middle ear effusion, adult patients will usually complain of the following:

  • Dull pain or pressure with heaviness in the affected ear;

  • Clogging or plugging sensation with no/infrequent sounds of cracking, popping, or clearing;

  • Decreased hearing -- may be constant or intermittent;

  • Tinnitus -- humming, static, "crickets," or a sensation of "water sloshing"; and

  • A positive history of recent URIs or allergic disease.

Other important data to collect include:

  • Recent travel history;

  • Cigarette smoking or exposure to secondhand smoke;

  • Medication history including:

    1. Decongestants

    2. Mucolytics

    3. Antihistamines

    4. Antibiotics

    5. Nasal corticosteroids

  • History of chronic otitis media in childhood;

  • Use of a continuous positive airway pressure machine for obstructive sleep apnea -- this can cause pressure changes in the eustachian tubes resulting in dysfunction and effusion; and

  • Gastroesophageal reflux disease -- laryngeal-pharyngeal reflux can back up into the eustachian tubes.

Physical Examination

Otoscopic examination. Always use a pneumatic otoscope to evaluate effusion.

  • There is usually no extensive inflammation of, or purulent exudate behind the tympanic membrane;

  • Tympanic membrane appears dull with sluggish or no mobility;

  • May observe an air-fluid level or air bubbles floating in serous fluid;

  • Tympanic membrane is thick and scarred when there is a positive past history of chronic otitis media; and

  • Tuning fork examination (in the absence of an underlying neural hearing loss):

    1. Weber testing -- sound lateralizes to the impaired ear.

    2. Rinne testing -- bone conduction will be equal to or greater than air conduction.

Examination of the nose. There may be signs of allergic disease:

  • Turbinate bogginess and hypertrophy; and

  • Mucoid drainage or rhinorrhea.

Examination of the oropharynx.

  • Enlarged adenoids and/or tonsils; and

  • Mucoid postnasal drainage.

Examination of the eyes. Look for signs associated with allergy:

  • Watery eyes;

  • Injected conjunctivae; and

  • Allergic shiners -- dark circles under eyes.

Diagnostic Testing    

Diagnostic Testing

Audiometric evaluation will differentiate between conductive and sensorineural hearing loss. If unavailable, a gross screening of hearing, such as a Whisper Test, may be used during the encounter. A full audiometric evaluation should be encouraged as soon as possible.

Tympanometry is the most useful test to use in the diagnosis of OME in adults. It is an indirect measurement of eustachian tube and middle ear function that can detect the presence or absence of fluid or pressure in the middle ear space.[4] Interpretation is as follows:

  • Type A tympanogram denotes normal eustachian tube and middle ear function;

  • Type B with low volume is positive for middle ear fluid;

  • Type B with large volume is usually a sign of a tympanic membrane perforation; and

  • Type C with high negative pressure suggests eustachian tube inflammation and dysfunction.

Treatment        

Treatment

Antibiotics can be used if the patient has a recent history of upper respiratory infection and OME demonstrates viable pathogenic bacteria.[2] Good choices include amoxicillin, amoxicillin-clavulanate, and trimethoprim-sulfamethoxazole in appropriate doses for a 10-day course.

Decongestants and antihistamines are helpful in relieving associated nasal symptoms but have little effect on the effusion itself. Mucolytics may decrease the viscosity of middle ear fluid but generally do not improve the clearance rate of OME. Nasal corticosteroids show promise in clearing effusions and can be used safely in most adult patients. Oral corticosteroids given only for short periods (6-7 days) may be helpful in clearing fluid.

Referral    

Referral

When a unilateral effusion develops in an adult without a history of ear problems and no evident etiology, implications may be serious. Referral should be made to an ENT specialist who can use a flexible fiberoptic endoscope to view the nasopharyngeal area for tumors, benign or malignant, as well as for eustachian tube obstructions from structural defects. A computed tomography scan of the temporal bones is not necessary for diagnosis but can help to rule out complications of OME, such as mastoiditis that can cause chronic otitis media or cholesteatoma.[2]

Other reasons for referral include persistent or recurrent effusion, severe chronic eustachian tube dysfunction, or exhaustion of medical therapies available to the primary care provider. Any patient with an effusion and an underlying hearing loss should be referred so that hearing can be restored as soon as possible.

Once potentially serious causes for a unilateral effusion have been ruled out, a ventilation tube may be placed in the tympanic membrane of the affected ear. It can remain for several months before ear tissue rejects it. Water precautions must be observed during the time that the tube is present to prevent bacteria from gaining entry directly into the middle ear.

Conclusion

Conclusion

Uncomplicated OME can be handled easily in the primary care setting. Awareness of etiologies that necessitate referral to specialty care will optimize patient care and reduce provider liability.

 

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