Summary

For children who have persistent otitis media with effusion and no other risk factors for developmental delay, are there any concerns about prolonged observation in light of the recent clinical practice guideline?

Educational objectives

At the conclusion of this activity, participants will be able to:

• Consider potential physical consequences of prolonged otitis media with effusion
• Consider potential developmental outcomes of prolonged otitis media with effusion

CME credit

This is an article from The Child's Doctor, Spring 2005 issue. You may take the quiz for learning purposes, but credits are no longer valid.

Author disclosures

Dr. Gerson has no industry relationships to disclose and does not refer to products that are still investigational or not labeled for the use in discussion.

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One of the recommendations in the 2004 clinical practice guideline on otitis media with effusion (OME) from the American Academy of Pediatrics, American Academy of Otolaryngology-Head and Neck Surgery, and the American Academy of Family Physicians [1] states: "Children with persistent OME who are not at risk should be reexamined at 3- to 6-month intervals until the effusion is no longer present, significant hearing loss is identified, or structural abnormalities of the eardrum or middle ear are suspected."

However, given the potential damage to the tympanic membrane (TM) and the subtle consequences of long term fluid, prolonged observation (more than 4 to 6 months) is controversial. As the guideline reads, fluid could be left alone indefinitely, possibly for years, unless the child has fallen behind in development, demonstrates mishearing, or already has damage to the ear drum or middle ear structures.

The guideline authors argue that with regular surveillance of children with persistent OME, the risks are low for physical, behavioral, or developmental sequelae. They also refer to studies that show developmental outcomes were not improved with surgery in children with persistent OME who were not at risk. There are several problems with this approach and some conflicting evidence.

Physical damage to tympanic membrane

TMs damaged from long term fluid and retraction may become thin and flimsy if they scar. Atelectasis of the TM or adhesive otitis are consequences that bring lifelong problems. Thus collapsing TMs can result in:

• Incudostapediapexy: TM sits on the junction between the incus and stapes, causing conductive hearing loss.
• Retraction pockets: Pockets can progress to cholesteatoma, with potential consequences of cerebrospinal fluid leak, ossicular erosion, facial nerve damage and permanent hearing loss. Tympanomastoidectomy is then required to remove the cholesteatoma.

Loss of tensile strength is not reversible by myringotomy and tubes, if surgery was delayed until TM damage has occurred during prolonged observation. At that point, the TM may be unable to hold a tube for very long, or unable to heal after a tube extrudes.

Although it can be argued that ears with myringotomy tubes can also become flimsy, the more common scarring from tubes results in a tympanosclerotic ear drum, presenting as white opaque plaques in the substance of the TM. Rarely the calcification will encompass the entire TM. Generally tympanosclerosis is only a cosmetic problem. It changes the appearance of the TM, but does not interfere with hearing. Tympanosclerosis can interfere with pneumatic otoscopy and tympanometry by making the TM less flexible, even though there is no appreciable change in hearing. It may also make the visual diagnosis of fluid more difficult.

There is, of course, the exception, and children who require multiple sets of tubes can have flimsy ear drums rather than tympanosclerosis. Children who require multiple sets of tubes, though, are by definition those who have long term eustachian tube dysfunction and would be at risk for scarring from prolonged fluid and retraction even if they have never had tubes.

Comfort level of the child

Another important point to consider is that children with effusion, especially young children, may not be in excruciating pain, but may have an ongoing level of discomfort. The Timmerman study indicates that parents tend to underestimate hearing loss and overestimate quality of life before tympanostomy. [2] Otolaryngologists hear from parents on a regular basis about improvements in overall mood, eating and sleeping behaviors, responsiveness, and improved balance after tube placement. [3] , [4]

Potential consequences of prolonged mild hearing loss

There is some data that children who have decreased hearing during early brain development have a higher incidence of auditory processing disorders even long after the susceptibility to otitis is resolved. [5] These children may be mislabeled as having attention deficit disorder, since they do not attend well to auditory stimuli.

Although hearing is considered normal up to 25 decibels (db), a child should be able to hear at 0-5 db. The difference between 0 db and 25 db is not insignificant considering that the audiogram is a logarithmic scale. Since normal conversation is generally at about 40 db, a child with 25 db hearing loss is at a disadvantage, especially in a noisy environment. In a busy classroom, this child is more likely to miss information and instructions.

Continuing controversies over treatment for OME are not surprising, even though this is a common childhood problem. The recent guideline was based on best available evidence, but studies on OME are always difficult, since this is a disease with natural fluctuations. A child who is clear on a given visit, may still have fluid more than 50% of the time. A child with fluid may be seen on successive visits shortly after upper respiratory infections, but be clear in between. Also, very large numbers of patients are needed for statistically significant studies, and the guideline authors list extensive research needs. Meanwhile, the OME guideline provides valuable advice, which combined with good clinical judgment and consideration of each child as an individual should help to standardize care of children with OME.

References

1. Rosenfeld RM, Culpepper L, Doyle KJ, et al. American Academy of Pediatrics Subcommittee on Otitis Media with Effusion; American Academy of Family Physicians; American Academy of Otolaryngology -- Head and Neck Surgery. Clinical practice guideline: Otitis media with effusion. Otolaryngol Head Neck Surg 2004 May;130(5 Suppl):S95-118.

2. Timmerman AA, Anteunis LJ, Meesters CM. Response-shift bias and parent-reported quality of life in children with otitis media. Arch Otolaryngol Head Neck Surg 2003 Sep;129(9):987-991.

3. Richards M, Giannoni C. Quality-of-life outcomes after surgical intervention for otitis media. Arch Otolaryngol Head and Neck Surg 2002 Jul;128(7):776-782.

4. Rosenfeld RM, Bhaya MH, Bower CM, et al. Impact of tympanostomy tubes on child quality of life. Arch Otolaryngol Head Neck Surg 2000 May;126(5):585-592.

5. Hall JW, Grose JH, Buss E, et al. The effect of otitis media with effusion on perceptual masking. Arch Otolaryngol Head Neck Surg 2003;129:1056-1062.