Adhesive Otitis Media

Adhesive otitis media is a chronic middle ear disease in which the tympanic membrane is drawn in and adheres to the promontory, ossicles or medial wall because of fibrous bands, loss of the mucosal air space and persistent negative middle ear pressure. It causes conductive hearing loss.

It follows prolonged otitis media with effusion, recurrent acute otitis media, or chronic Eustachian tube dysfunction. It is seen mainly in children and young adults. It may progress to retraction pockets and cholesteatoma.

Pathophysiology.

Chronic negative pressure and inflammation thin and atrophy the drum, which collapses on the medial wall. Fibrosis then fixes the membrane and erodes ossicles, and the middle ear space is obliterated.

Gradual hearing loss, ear fullness, tinnitus, recurrent ear infections and sometimes discharge from a retraction pocket. Pain is uncommon.

Red flags.

• Discharge or debris in a deep retraction pocket (cholesteatoma).
• Vertigo or facial weakness.
• Sensorineural loss.

Otoscopy and microscopy show a thin, retracted and immobile drum draped over the ossicles and promontory. Pneumatic otoscopy shows no movement. Pure tone audiometry shows conductive loss of 20 to 40 dB, and tympanometry shows a flat (type B) or very negative (type C) curve. CT of the temporal bone shows middle ear obliteration and ossicular erosion. Examine the nose and postnasal space to find the cause of Eustachian tube dysfunction.

Differential diagnosis.

• Tympanosclerosis.
• Cholesteatoma.
• Otosclerosis.
• Otitis media with effusion.
• Eustachian tube dysfunction.

Treat the cause of Eustachian tube dysfunction (allergic rhinitis, adenoid hypertrophy, nasopharyngeal mass). Mild disease is observed with regular audiometry, with a hearing aid for symptomatic loss. Ventilation tubes help in early disease. Surgery (tympanoplasty with cartilage graft, and ossiculoplasty) is for progressive retraction, ossicular erosion or cholesteatoma.

• Mometasone nasal spray 50 micrograms for each spray: 2 sprays into each nostril once daily for 8 to 12 weeks in allergic rhinitis or adenoid related Eustachian tube dysfunction; maximum 200 micrograms daily in each nostril; monitor for nose bleeding and local irritation; children over 3 years 1 spray in each nostril daily, maximum 100 micrograms daily.
• Cetirizine (allergic rhinitis): 10 mg orally once daily for the season; maximum 10 mg daily; monitor sedation; reduce to 5 mg daily when creatinine clearance is under 30 mL/min.

Advise against forceful nose blowing, and autoinflation by the Valsalva manoeuvre if the drum can move.

Monitoring. Otoscopy and audiometry every 6 months, and sooner with discharge.

Referral and escalation. ENT for retraction pockets that cannot be fully seen, discharge, or hearing loss.

Special groups. Children need adenoid assessment and audiometry at each review.