Adhesive Otitis Media - Causes, Risk Factors, Diagnosis, and Management

Introduction

Adhesive otitis media is a type of chronic otitis media in which there is fluid in the middle ear without signs of acute infection. This fluid build-up in the eustachian tube and middle ear causes pressure on the tympanic membrane, preventing proper vibration, reducing sound conduction, and difficulty in hearing. It is also referred to as otitis media with effusion (OME) that persists for three or more months.

What Is Adhesive Otitis Media?

Adhesive otitis media is a type of chronic otitis media in which there is the adhesion of medial ear structures occurs due to chronic inflammation. It can be complete or partial adhesions between thin retracted and atrophic pars tensa and the medial wall of the middle ear. Soft tissue debris covers the middle ear ossicles.

What Are the Risk Factors for Adhesive Otitis Media?

The risk factors include:

• Passive smoking.

• Bottle feeding.

• Daycare nursery.

• Atopy.

• Children or older adults.

• Down syndrome.

In children, the eustachian tube is more horizontal and short, as they grow it gets elongated and angles caudally. This increases the risk of developing ear infections. Children with developmental anomalies such as cleft palate–palate muscles, decreased muscle tone for palate muscles or palate, and bone development variations are at a higher risk of otitis media with effusion.

What Are the Causes of Adhesive Otitis Media?

The causes can be:

• Infections: Viral infections in the middle ear can cause inflammation and the production of excess fluid, which can become thick and sticky over time.

• Allergies: Allergic reactions can cause inflammation in the Eustachian tubes, which can lead to the accumulation of fluid in the middle ear.

• Environmental Factors: Exposure to pollutants or irritants such as cigarette smoke, dust, or pollen can irritate the Eustachian tubes, leading to fluid accumulation.

• Structural Issues: Abnormalities in the structure of the Eustachian tubes or middle ear can contribute to development of adhesive otitis media.

• Changes in Air Pressure: Rapid changes in air pressure, such as those that occur during air travel or scuba diving, can cause the Eustachian tubes to become blocked, leading to fluid buildup in the middle ear.

• Chronic Nasal Congestion: Conditions that cause chronic nasal congestion, such as sinusitis or rhinitis, can lead to the development of adhesive otitis media.

How Does Adhesive Otitis Media Occur?

The fluid builds up in the middle ear In children with post-acute otitis media, that inhibits the vibration of the tympanic membrane and subsequent transmission of sound into the inner ear. This results in decreased ability to communicate in noisy environments for children and the child may seem less attentive or reduced academic performance.

In some cases, due to large adenoids, there is an obstruction caused to the Eustachian tubes resulting in a poorly ventilated middle ear. This kind of obstruction results in otitis media with effusion. Since adenoids are lymphatic structures, they can allow bacteria into the eustachian tube and causes them to grow. This bacterial biofilm causes inflammation that facilitates blockage and fluid build-up within the middle ear.

What Are the Symptoms of Adhesive Otitis Media?

Symptoms include:

• Hearing loss.

• Communication difficulties.

• Lack of attention.

• Impaired speech.

• Impaired language development.

• Otalgia or earache.

• Aural fullness or sensation of ear popping.

• Tinnitus.

• A sensation of foreign body in the external auditory canal.

• Upper respiratory infections.

• Recurrent ear infections.

• Nasal obstructions.

How Is Adhesive Otitis Media Diagnosed?

The diagnosis is based on history and physical examination.

• History includes the presence of any symptoms associated with adhesive otitis media, recurrent ear or nasal infections, developmental anomalies, age of the patient, and acute otitis media.

• Physical examination includes signs of otitis media with effusion showing opacification of the tympanic membrane and loss of light reflex. There can be a retraction of the tympanic membrane with reduced mobility. In the case of gross retraction, tympanoplasty is advised to prevent retraction pocket formation.

• Evaluation with age-appropriate tympanometry and audiometry is tested in patients with OME. Flat tympanogram help in diagonis of OME.

• Hearing tests using auditory brainstem responses (ABR) tests, which detect electrical activity of the brainstem to acoustic stimuli are done in children (1 to 5 years of age) that detect frequency range and sound intensity levels to which the patient’s brain responds.

• ABR test can be performed in adults too, but a classic audiology examination is preferred. This involves playing sound to the patient’s left and right ears at different tones and intensities and patients are requested to raise their hand when they hear a sound in the left or right ear respectively.

• During an audiology exam, the levels of hearing loss are detected by the decibel range in the audio graph as:

  • Slight impairment: 26 to 40 dB.

  • Moderate impairment: 41 to 60 dB.

  • Severe impairment: 61 to 80 dB.

  • Severe hearing loss: 71 to 90 dB.

  • Profound impairment including deafness: 81 and above.

How Is Adhesive Otitis Media Managed?

Adhesive otitis media resolves by itself with proper monitoring. If it is persistent, myringotomy with tympanostomy tube insertion is an effective treatment.

• In this treatment, a ventilation tube is inserted to allow air entry into the middle ear, preventing the re-accumulation of fluid. Most of the patients do not require additional therapy past the treatment due to the growth and development of the eustachian tube angle that allows drainage.

• Adenoidectomy is done to remove enlarged adenoids and aids in the management of patients with adhesive otitis media or OME.

• Childhood hearing loss affects language development hence, hearing aids are considered a non-invasive treatment option.

• Factors to be considered for interventional treatment in OME patients are:

  1. Comorbidities of the patient.

  2. The severity of a hearing loss.

  3. OME present bilaterally or unilaterally.

  4. Effusion duration.

  5. Age of patient.

• Social factors such as:

  1. Cost.

  2. Patient consent.

  3. Familial assistance.

• OME is mostly caused by viral or allergic factors and not a bacterial infection, hence, antibiotics are not prescribed. Steroids have not proven to be effective and are not recommended. Watchful waiting for three months is the first line of treatment for OME.

What Is the Differential Diagnoses of Adhesive Otitis Media?

Differential diagnoses include:

• Acute otitis media.

• Nasopharyngeal carcinoma infiltrating the eustachian tube.

Conclusion

Adhesive otitis media a form of chronic otitis media or otitis media with effusion is caused due to fluid buildup in the middle ear. It usually resolves on its own and can interfere with a person’s hearing. This leads to communication and socialization difficulties. It commonly affects children below five years of age.