Source: Manual of Ambulatory Pediatrics 2010
SOAP Note – Otitis Media With Effusion (OME)
An accumulation of fluid in the middle ear characterized by decreased or absent mobility of the tympanic membrane and varying degrees of hearing loss.
I. Etiology
A. Eustachian tube obstruction or dysfunction, resulting in decreased pressure in the middle ear; the causes of eustachian tube obstruction include allergic rhinitis, upper respiratory infection, enlarged adenoids, cleft palate, passive smoke exposure, absence of breastfeeding, and Down syndrome.
B. Bacteriology closely mimics that of acute otitis media.
C. Also seen as sequela of otitis media when fluid becomes sterile but does not resolve.
D. May be caused by increased secretions of mucosa of middle ear
II. Incidence
A. The most frequent cause of air conduction hearing loss in school-age children; seen most often in 5to 7-year-olds
B. Approximately 10% of children will have middle ear effusion persisting for 3 months or longer following an episode of acute otitis media.
III. Subjective data
A. Complaints of
1. Ears popping
2. Ears feeling plugged or full
3. Voice sounding strange or hollow to child when he or she talks
B. Subjective hearing loss
1. Child may say he or she does not hear well.
2. Parents may notice diminished hearing.
3. Child does not respond well.
4. Child never listens.
5. Child sits close to television.
6. School grades go down.
7. Hearing loss may be noted on school audiologic examination.
C. May have history of otitis media, upper respiratory infection, or allergic rhinitis
D. Condition may be asymptomatic and found on routine well child visit.
IV. Objective data
A. Tympanic membrane
1. Dull
2. Opaque
3. Color varies from white to bluish to orange-blue.
4. Fluid level may be visualized behind tympanic membrane.
5. Air bubbles may be visualized (suggesting intermittent eustachian tube function).
6. Mobility absent or diminished (does not move inward with positive pressure but may move outward with negative pressure).
B. Rinne test reveals bone conduction greater than air conduction.
C. Other positive objective findings would be those associated with causes of eustachian tube obstruction.
1. Mouth breathing
2. Thin, watery nasal discharge
3. Nasal turbinates pale and boggy
D. Audiogram generally shows a conductive hearing loss with the median loss being 25 dB.
V. Assessment
A. Diagnosis is made by pneumatic otoscopy, which reveals decreased mobility or immobility of the tympanic membrane in the absence of acute inflammation.
B. Tympanometry and examination by acoustic reflectometry confirm diagnosis by demonstrating decreased compliance of tympanic membrane.
VI. Plan
A. Middle ear effusion may yield S. pneumoniae or H. influenzae on culture after tympanocentesis. In the recent past, because the effusion was not believed to be a sterile process, antibiotic therapy with amoxicillin, Augmentin, or trimethoprim-sulfamethoxazole was instituted. This practice is no longer supported because of concerns regarding the emergence of antibiotic-resistant organisms. Both the CDC and AAP guidelines state that antibiotics should not be prescribed for routine management of long-standing OME. Some studies have shown that with antimicrobial treatment, resolution occurred faster. However, there was no significant effect on long-term outcomes. Because antibiotics do not resolve the middle ear fluid and because of increasing resistance, antimicrobial treatment is not recommended as initial treatment.
B. Antibiotic treatment as for acute otitis media should be instituted if child has an acute exacerbation, with an inflamed tympanic membrane.
C. Eustachian tube autoinflation: Purpose is to build up positive pressure in nasopharynx. Although it has not been proven to relieve symptoms it can be utilized if the child is able to cooperate.
1. Have child hold his or her nose, keep lips closed, puff cheeks out, and swallow.
2. Have child chew sugarless gum.
D. Oral decongestants are not indicated as treatment for otitis media with effusion.
E. Corticosteroids have not yet been proven to be effective in the treatment of middle ear effusion.
F. Audiologic evaluation should be scheduled for children with OME for three months or longer, for those with language delays, learning problems, or suspected hearing loss.
VII. Education
A. Do not feed infant supine or give bottle in bed.
B. Explain that it is a temporary hearing loss and common in children; normal hearing will return.
C. Speech development may be affected.
D. Speak slowly and distinctly to child when you have his or her full attention, preferably face-to-face.
E. Do not punish for assumed inattentiveness, but be aware that manipulation may occur.
F. Habit of asking “what?” may be formed.
G. Notify school of problem if child of school age.
H. It may take 2 to 4 months for problem to resolve.
I. OME may recur as sequela to otitis media or seasonally in an allergic child.
J. With frequent recurrences in an allergic child, allergic rhinitis should be treated.
K. Recommend that child chew sugarless gum for eustachian tube autoinflation.
L. Limit passive smoke exposure and exposure to other known allergens.
VIII. Follow-up
A. There has been much controversy over the surgical treatment of serous otitis over the past several years, and treatment has changed from aggressive therapy to a more conservative watch-and-wait approach.
B. Child can be followed for 6 months or longer with a unilateral serous otitis.
C. Referral for consideration of a myringotomy may need to be made after 1 month of observation if child has bilateral serous otitis, especially if it is interfering with speech development or school progress.
D. Follow-up, therefore, must be individualized for each patient. Psychosocial factors and development, as well as tympanic membrane mobility and audiogram, must be assessed at each visit.
E. General guidelines
1. Recheck in 2 weeks. If tympanic membrane mobility and audiogram are not within normal limits, recheck in another 2 to 3 weeks.
2. Recheck in 2 to 3 weeks. The presence of air bubbles behind the tympanic membrane indicates intermittent functioning of the eustachian tubes. If child is not handicapped by the hearing loss, continue to recheck at 2to 4-week intervals.
3. Rechecks should include audiometric evaluation in addition to otoscopic examination.
4. Refer for evaluation for myringotomy with tube insertion if:
a. Persistent effusion between episodes of acute otitis media
b. Consistent hearing loss of 21 dB or greater
c. Persistent bilateral OME of 3 months or unilateral OME of 6 months
5. Note: Tube insertion will decrease scarring of tympanic membrane and middle ear space and diminish cholesteatoma formation and chronic conductive hearing loss in these children.
IX. Complications
A. Delayed speech development
B. Poor school progress
C. Problems with social adjustment
D. Cholesteatoma
E. Persistent TM perforation
F. Tympanosclerosis
X. Consultation/referral
A. Bilateral hearing loss (30–50 dB) interfering with speech development and school progress
B. Bilateral OME for 3 months or more
C. Unilateral OME for 6 months or more
D. For evaluation for respiratory allergy, obstructive adenoidal hypertrophy, immunodeficiency, submucous cleft palate