Glue Ear

Glue ear is chronic otitis media with effusion in which the middle ear fills with thick, sticky mucoid fluid that persists for 3 months or more, causing conductive hearing loss, most often in children aged 2 to 7 years.

• It is the commonest cause of acquired hearing loss in childhood.
• It results from eustachian tube dysfunction, adenoid enlargement, recurrent upper respiratory infection, allergy, cleft palate, Down syndrome, passive smoking and absence of breastfeeding.
• The incidence peaks at 2 years and 5 years.
• Most cases resolve spontaneously, but persistent fluid may cause developmental, speech and behavioural problems.

Symptoms are often subtle and detected by parents or teachers.

• Hearing difficulty: turning up the television, asking for repeats, not responding, poor school performance.
• Speech and language delay, inattention and behavioural change.
• Balance problems and clumsiness.
• Ear fullness, with little pain, fever or discharge.
• Otoscopy: dull, retracted, grey, yellow or amber eardrum; reduced mobility; visible fluid level or bubbles; retraction pockets.
• Differential diagnosis: acute otitis media, sensorineural hearing loss, cholesteatoma, attention deficit disorder, auditory processing disorder, cleft palate and nasopharyngeal tumour.
• Complications: speech delay, educational difficulty, behaviour disorders, tympanic membrane retraction, atrophy, adhesive otitis media, cholesteatoma and ossicular erosion.

Diagnosis is by otoscopy, tympanometry and audiometry.

• Pneumatic otoscopy shows poor drum mobility.
• Tympanometry: flat (type B) trace.
• Pure tone audiometry or age-appropriate hearing tests show conductive loss, usually 20 to 40 dB.
• Assess nasal obstruction, adenoids (lateral neck X-ray or nasendoscopy), allergy and palate.
• Check speech and language development.
• Nasopharyngeal examination in unilateral adult effusion.

Observe for 3 months, then intervene if hearing loss persists.

• Supportive: environmental measures (sit near the front of the class, face the child when speaking), avoid tobacco smoke, breastfeeding, and treat allergy.
• Autoinflation device (Otovent balloon) in children aged 4 to 11 years, three times daily for 1 to 3 months.
• Pharmacological: antibiotics, antihistamines, decongestants and oral steroids are not effective for chronic effusion. Intranasal steroids may help if adenoid hypertrophy or allergic rhinitis is present.
• Procedures: grommet insertion under general anaesthesia for bilateral effusion persisting 3 months with hearing loss of 25 to 30 dB or worse, or with speech and educational delay; adenoidectomy added in children with nasal obstruction or recurrent infection (and over 3 to 4 years); hearing aids as an alternative.
• Special groups: children with cleft palate, Down syndrome or developmental delay need earlier hearing assessment and intervention.
• Red flags: persistent unilateral effusion, hearing loss over 40 dB, retraction pocket with debris, otorrhoea, vertigo, speech delay and facial weakness.
• Follow-up: repeat hearing tests at 3 months. After grommets, review at 4 to 6 weeks and every 6 months until tubes extrude (usually 6 to 12 months). Water precautions as advised by the surgeon.