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185]

ORIGINAL ARTICLE

Clinicoaudioradiological and operative

evaluation of otitis media with effusion
Karan Sharma, Raghav Mehan, Archana Arora
Department of ENT, Government Medical College, Amritsar, Punjab, India

Abstract

Aims: Otitis media with effusion(OME) is a common cause of hearing and speech impairment in children.
The correlation of the clinical, audiological, radiological, and intraoperative findings was carried out so
as to make a protocol for early diagnosis and management of OME. It will help prevent the more serious
sequelae of OME such as tympanosclerosis, chronic adhesive otitis media, and even chronic suppurative otitis
media. Methods: 300 clinically diagnosed patients of OME were studied prospectively. Thereafter, patients
underwent impedance audiometry, pure tone audiometry, and Xray soft tissue nasopharynx for adenoids. The
patients were given adequate medical treatment for 3 to 6 months, and the patients who did not respond to
the treatment were subjected to adenoidectomy with ear examination under magnification and myringotomy
with or without grommet insertion. Results: The mean age at presentation was 5.96years. Only 32% patients
gave a history of hearing loss. About 90% patients had mouth breathing, followed by snoring(84%). About
79% ears had abnormal tympanic membrane appearance and mobility; 65.5% had an abnormality on
impedance audiometry; and 69.75% had an air condition threshold level of>20 dB. About 78% patients
had either Grade III or Grade IV Adenoid hypertrophy. Adenoidectomy was done in all 300patients with
myringotomy in 472 ears. Grommets were inserted in 365 ears. There was a significant reduction in mean air
conduction threshold with an improvement of 8.0 dB and 7.5 dB in right and left ears, respectively at 2 months
postoperatively. At 6th month postoperative, the average improvement from baseline dropped to 6.0 dB in
right ear and 5.5 dB in the left ear. Conclusion: OME is the most frequent causes of silent hearing impairment
in young children which needs a close vigil. All suspected children(on clinical and otoscopic findings) must
be subjected to impedance audiometry and Xray soft tissue nasopharynx for adenoids. After the failure
of medical treatment for 36 months, the child should be subjected to myringotomy with adenoidectomy in
the same sitting. Whenever a child is planned for tonsil or adenoid surgery, he/she must undergo evaluation
for OME beforehand so that the childs hearing risk can be simultaneously taken care of in the same sitting.
Keywords: Adenoidectomy, Grommet, Impedance audiometry, Otitis media with effusion, Pure tone audiometry

Introduction
Otitis media with effusion (OME)/chronic serous otitis
media/glue ear is one of the most common chronic
otological conditions of childhood. It is defined as the
presence of fluid behind an intact eardrum without signs
and symptoms of acute infection.[1] The time fluid has to
be present for the condition to be called chronic is usually
taken as 12weeks.[2] The prevalence of OME is bimodal with
the first and largest peak of approximately 20% at 2years
of age and a second peak of approximately 16% at around
5years of age.[3]
Address for correspondence: Dr.Karan Sharma,

Department of ENT, Government Medical College, 39B Circular Road,

Amritsar, Punjab, India.
Email:[email protected]

174

The clinical presentation of glue ear is often undramatic. The

presenting features may be hearing difficulty, delayed language
development, repeated earache, recurrent upper respiratory
tract infections, behavioral, and poor educational progress.
Older children may report aural fullness, tinnitus or vertigo.
The examination may show an amber or blue discoloration of
the eardrum with thickening and loss of landmarks. Bubbles
or a fluid level may be visible.[4,5] Demonstration of impaired
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DOI:
10.4103/0971-7749.161017

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Sharma, etal.: Clinico-audio-radiological and operative evaluation of otitis media with effusion

drum mobility using pneumatic otoscopy is much more

reliable than a simple inspection. Clinical suspicion of hearing
loss may be confirmed by pure tone audiometry (PTA).
Tympanometry is a simple, quick, noninvasive, and objective
test making it the ideal diagnostic test for OME.[3]
It is apparent that the adenoids are usually enlarged in
children who have OME. Symptoms suggestive of adenoid
hypertrophy are mouth breathing, snoring, nasal discharge,
speech hyponasality, and occasionally epistaxis.[4] Diagnosis
is made either by posterior rhinoscopy, rigid or flexible
nasopharyngoscopy or soft tissue lateral radiograph of the
nasopharynx, which reveals the size of adenoids and also
the extent to which the nasopharyngeal air space has been
compromised.[6]
Current medical options for the treatment of OME
include antihistaminedecongestant mixtures, mucolytics,
steroids, antibiotics, various kinds of eustachian tube
manipulation (Valsalva and Politzer manoeuvres), and
control of risk factors.[7] Conditions where surgery may be
indicated are OME for>3 months with no benefit with medical
management, bilateral OME with hearing loss >20 dB for
more than 6 months, recurrent OME, balance disturbances,
structural changes of tympanic membrane(TM) and language
delay. The various surgical treatment options recommended
are adenoidectomy alone, myringotomy alone, adenoidectomy
with myringotomy with or without grommet insertion.[8]
The present study was conducted to evaluate the clinical,
audiological, and radiological profile in patients of chronic
OME and to study its correlation with adenoid hypertrophy.
Furthermore, the role of adenoidectomy with insertion of
tympanostomy tube in a single sitting as a treatment modality
was studied for the prevention and management of the silent
hearing impairment caused by OME and its subsequent
complications such as tympanosclerosis, chronic adhesive
otitis media, and even chronic suppurative otitis media. The
subject of OME has long been a confused one and it is hoped
that this study may help somewhat in clearing the muddle.

with restricted mobility on pneumatic otoscopy. Patients

having acute otitis media, discharging ear with perforated or
healed TM, sensorineural hearing loss, and congenital aural
or palatal defects were excluded from the study. Thereafter,
patients underwent impedance audiometry, PTA, and Xray
soft tissue nasopharynx for adenoids.
Impedance audiometry was done in all patients. The results
were recorded as Type Anormal compliance, Type BOME
and Type Creduced compliance or early stages of OME. On
the basis of PTA, the patients were divided into four categories:
<20 dB, 2130 dB, 3140 dB, and >40 dB. The severity of
adenoid hypertrophy was assessed by digital Xray soft tissue
nasopharynx lateral view and grading was done based on
the percentage of obstruction of nasopharyngeal airway as
follows: Grade I<25%; Grade II 26-50%; Grade III 51-75%;
and Grade IV>75%.
To begin with, medical treatment in the form of
antihistaminedecongestant combinations, mucolytics and
antibiotics was given for a period of 36 months. Those
children who did not benefit with medical treatment were
ultimately taken up for surgical intervention in the form of
adenoidectomy with EUM and myringotomy with or without
grommet insertion.
Adenoidectomy was done under general anesthesia.
Myringotomy was performed using a myringotome in the
anteroinferior quadrant. Shepard type grommet was inserted
after suctioning the middle ear fluid. Patients were discharged
after 24 h. Regular followup was done up to 3 months and
thereafter at 6 months. PTA was done at 2 and 6 months
followup.
The data so obtained was analyzed using standard statistical
parameters. The clinical, audiological, radiological, and
intraoperative observations were correlated with each other to
evolve a management strategy for prevention, early detection
and management of a common cause of a silent, invisible
hearing impairment.

Methods

Results

The present study was based on the analysis of 300patients in

the age group312years undergoing treatment for chronic
OME in the Department of ENT, Government Medical
College from 2010 to 2014. An informed consent was obtained
from subjects/parents willing to participate in the study. Each
case after being screened from the outpatient department was
clinically evaluated by taking a proper history, general physical,
and complete local ENT examination; followed by otoscopic
examination under magnification (EUM). The criteria for
making the diagnosis of OME was recurrent attacks of upper
respiratory tract infections, mouth breathing, occasional
bouts of otalgia, and dull looking/lusterless/retracted TM

Clinical profile

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The mean age of children included in our study was 5.96 with
a minimum of 3years and a maximum of 12years. About 62%
patients were males and 38% were females. Of 300patients,
only 32% complained of hearing loss. About 64% patients
had a history of recurrent ear discomfort, e.g., recurrent
earache, ear blockage, aural fullness. About 90% patients had
mouth breathing, followed by snoring (84%), and speech
hyponasality (36%) as symptoms suggestive of adenoid
hypertrophy[Table1]. Of 600 ears examined, 74% had dull
and retracted TM, 3% had thin and retracted TM, and only 2%
ears showed the characteristic air bubbles behind the eardrum
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Sharma, etal.: Clinico-audio-radiological and operative evaluation of otitis media with effusion

whereas the rest 21% ears were normal on otoscopy[Table2].

On pneumatic otoscopy, 57% ears had restricted TM mobility,
22% had no mobility, and 21% had normal mobility[Table3].

Audiological profile
Impedance audiometry was done in all patients. 34.5%,
50.17%, 15.33%, and ears showed Type A, Type B, and Type C
tympanograms, respectively[Table4]. Of the 600 ears on which
PTA was conducted, 69.75% had an air conduction threshold
of more than 20 dB which was considered pathological. Of
these, 42.75% had an AC threshold from 21 to 30 dB, 13.67%
had threshold between 31 and 40 dB, 13.33% had a threshold
of more than 40 dB. In rest of 30.25% it was below 20dB.

Radiological profile
Grades II, III, and IV hypertrophy of adenoids were seen
in 22%, 54.67%, and 23.33% patients, respectively. Thus,
78% patients had either Grade III or Grade IV hypertrophy
that is, more than 50% obstruction of the nasopharyngeal
airway[Table5].

Surgical profile
All patients in our study were subjected to adenoidectomy
and ear EUM under general anesthesia. As per indication,
myringotomy was done in one or both ears. The ears
from which any secretions were aspirated were subjected
to tympanostomy tube (grommet) insertion in the same
sitting. Myringotomy was done in 78.67% that is, 472 out
of 600 ears. Of these, no secretions could be aspirated in
Table 1: Chief complaints
Symptoms*

Number of patients

Percentage

96
192
270
252
108

32
64
90
84
36

Hearing loss
Recurrent ear discomfort
Mouth breathing
Snoring
Speech hyponasality
*Not mutually exclusive

Table 2: Appearance of TM on otoscopy

Appearance

Number of ears

Percentage

126
444
12
18
600

21
74
2
3
100

Normal
Dull and retracted
Air bubbles present
Thin and retracted
Total

TM: Tympanic membrane

Mobility

Number of ears

Percentage

Normal
Absent
Restricted
Total

126
132
342
600

21
22
57
100

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At 2 and 6 months followup, a statistically significant

reduction in air conduction threshold was observed(repeated
measures ANOVA, P < 0.0001). The average improvement
in air conduction thresholds following adenoidectomy and
grommet insertion was 8 dB in right ear and 7.5 dB in left ear
at 2 months followup whereas at 6th month followup, the
average improvement dropped to 6.0 dB in right ear and 5.5 dB
in the left ear. The sensitivity, specificity, positive predictive
value, negative predictive value, and accuracy of various
diagnostic parameters used in the study were calculated taking
myringotomy as the gold standard. Type B tympanogram had
the best balance of sensitivity and specificity of 85.07% and
93.94%, respectively[Table7].

Discussion
Various studies over the years have shown that, there is
a definite and significant relationship between adenoid
hypertrophy and OME, thus the need to take detailed history
for adenoid hypertrophy in all cases of chronic OME and vice
versa. Studies from developing world studying the clinical
profile and surgical management in OME with hearing
impairment are few in number. Availability of detailed data
on the clinical profile and utility of combining tympanostomy
with adenoidectomy in a single setting in children with OME
may have a bearing on future management.
Table4: Impedance audiometry
Type of graph
Type A
Type B
Type C
Total

Number of ears

Total (%)

207
301
92
600

34.50
50.17
15.33
100

Table 5: Distribution of adenoid grading on Xray

nasopharynx
Grade of adenoid

Number of patients

Percentage

0
66
164
70
300

0
22
54.67
23.33
100

I
II
III
IV
Total

Table 6: Intraoperative finding on myringotomy

Table 3: Mobility of TM on pneumatic otoscopy

TM: Tympanic membrane

107 ears(22.67%). The aspirate was serous in 136 ears(28.81%)

whereas mucoid in 48.52%. Grommets were inserted in 365
ears (77.33%) [Table 6]. No intraoperative and immediate
postoperative complications were observed.

Finding on myringotomy

Dry
Serous aspirate
Mucoid aspirate
Total
Number of grommets inserted

Number of ears

Percentage

107
136
229
472
365

22.67
28.81
48.52
100
77.33

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Sharma, etal.: Clinico-audio-radiological and operative evaluation of otitis media with effusion

Table7: Sensitivity, specificity, positive predictive value, negative predictive value, and accuracy of various
diagnostic parameters used in the study (taking myringotomy as the gold standard)
TM appearance
TM mobility
PTA threshold
B Type tympanogram
C Type tympanogram
Adenoid grade

Sensitivity (%)

Specificity (%)

Positive predictive value (%)

Negative predictive value (%)

Accuracy(%)

95.52
95.52
91.04
85.07
14.93
77.61

54.55
54.55
48.48
93.94
63.64
9.09

81.01
81.01
78.21
96.61
45.45
63.41

85.71
85.71
72.73
75.61
26.92
16.67

82.00
82.00
77.00
88.00
31.00
55.00

TM: Tympanic membrane, PTA: Pure tone audiometry

The mean age of the 300patients in our study was 5.96years.

In an earlier study including 200 children, the mean age
was 6.46years.[9] The increased incidence in this age group
can be attributed to the eustachian tube, which is short,
horizontal, and floppy. Furthermore, this correlates with the
age of adenoid hypertrophy and thus further strengthens
the relationship between the two. Most of the patients in the
present study had multiple symptoms of varying degree and
duration. Mozaffarinia etal. conducted a similar study where
the frequency of symptoms in patients with a final diagnosis
of OME was reported. The most common symptoms were
periodic otalgia in 26.3%, turning up television volume in
17.5%, aural fullness in 8.8%, hearing sounds like bursting
bubble in 7% and hearing loss in only 1.8%.[10]
In our study, there was a poor correlation between hearing
loss as a symptom of OME and the PTA thresholds. Only
32% complained of hearing loss whereas 69.75% patients had
PTA AC threshold>20 dB. Lo etal. stated that no significant
association was found between parentsuspected hearing loss
and PTA findings(P=0.69) in a casecontrol study, which
used data from a school screening program in China.[11] This
proves that OME is a cause of silent deafness and needs a high
degree of suspicion for its diagnosis.
About 90% patients had a complaint of mouth breathing,
84% had a history of snoring and 36% patients had
speech hyponasality, thus suggesting a strong correlation
between adenoid hypertrophy and OME. The Guideline
Development Group, England has also reached a consensus
that the possibility of OME should be considered in children
presenting with recurrent upper respiratory tract infections
since the two conditions are commonly associated.[12]
Clinically, 74% ears had dull and retracted TM, 3% had thin and
retracted TM and only 2% ears showed the characteristic air
bubbles behind the eardrum, whereas the rest 21% were normal
on otoscopy. On pneumatic otoscopy, 57% ears had restricted
TM mobility, 22% had no mobility, and 21% had normal
mobility. The sensitivity and specificity of otoscopy were found to
be 95.52% and 54.55%, respectively. Another study also showed
otoscopy to be having a high sensitivity but poor specificity.[5]
Impedance audiometry was done in all patients. About 34.5%,
50.17%, and 15.33% and ears showed Type A, Type B, and Type
Indian Journal of Otology | July 2015 | Vol 21 | Issue 3 |

C tympanograms, respectively. Asimilar study showed Type

B graph in 66.15% and Type C in 33.85%.[13] On conducting
PTA, majority of cases had a mild conductive hearing loss.
Bluestone stated that the average hearing loss in children with
OME is 27 decibels.[7] This is the reason the diagnosis is often
delayed because the hearing loss is fluctuating and is never
profound. There was a good correlation between PTA findings
and impedance audiometry findings with 89% agreement
between the two.
The adenoid grading as per digital Xray correlated well with
the size of adenoid tissue on digital palpation, which was
done intraoperatively in every case. There was also a good
correlation of PTA findings and impedance audiometry
findings with the radiological findings of adenoid hypertrophy.
Hence, it is stated that a digital lateral radiograph of the
nasopharynx is a very useful tool for assessing the severity of
obstruction of the nasopharyngeal airway. Kurien etal. showed
that lateral Xrays of the neck, besides being a noninvasive
procedure, still remains a very reliable and valid diagnostic
test in the evaluation of hypertrophied adenoids.[14]
Adenoidectomy was done in all the patients. Myringotomy
was done in 78.67% that is, 472 out of 600 ears. Of these, no
secretions could be aspirated in 107 ears(22.67%). The aspirate
was serous in 136 ears(28.81%) whereas mucoid in 48.52%.
Asimilar study showed serous aspirate in 24% and mucoid
in 76%.[13] Grommets were inserted in 365 ears(77.33%). No
intraoperative and immediate postoperative complications
were observed.
The mean air conduction threshold levels on PTA showed
statistically significant improvement following adenoidectomy
and grommet insertion with about 8 dB improvement in right
ear and 7.5 dB in left ear 2 months postoperative. At 6th month,
postoperative the average improvement from baseline dropped
to about 6.0 dB in right ear and 5.5 dB in the left ear. According
to Black etal., the mean dB gain at 7weeks and 6 months are
4.5 and 3.5 dB, respectively.[15] However, Maw reported that
there was a resolution in 3646% of chronic effusions as a
result of adenoidectomy.[16]
The patients included in the present study had persistent OME
and the chances of spontaneous resolution in our setting would
be extremely low. Furthermore, the anticipated reluctance of
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Sharma, etal.: Clinico-audio-radiological and operative evaluation of otitis media with effusion

patients for constant followup and readmission for second

surgery were the reasons for the surgical approach, which we
had selected. This reiterates the goal of our study that children
having chronic OME with adenoid hypertrophy should be
managed aggressively and timely surgery (adenoidectomy
with myringotomy in a single sitting) can help avoid hearing
loss and developmental delay.

Conclusion
Whenever there is any deviation of the normal anatomy of
TM on otoscopy in a child, the child must be subjected to
pneumatic otoscopy and impedance audiometry. Thereafter,
as per needs an Xray soft tissue nasopharynx lateral view for
adenoid and PTA needs to be performed. After the failure of
medical treatment for 3 months, the child should be subjected
to myringotomy with adenoidectomy in a single sitting.
However, if the situation demands, it can also be combined
with a tonsillectomy. Hence, for the prevention of this silent
hearing impairment, the aim should be peep into the ears of
the child at the earliest available opportunity and proceed
accordingly if one suspects OME. We must keep a close vigil
on this common disease entity causing a silent hearing loss
and the treatment should be very methodical and meticulous.
In this way, we can definitely contribute a lot for the National
Program for Prevention and Control of Deafness in which
OME has been assigned a major contributing factor for hearing
impairment. Furthermore, it will contribute toward the global
mission of SOUND HEARING 2030.

Acknowledgments
We are highly thankful to the Department of Radiology, Anesthesia
and Pediatrics of our institution for their help throughout this study.

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How to cite this article: Sharma K, Mehan R, Arora A.
Clinico-audio-radiological and operative evaluation of otitis media
with effusion. Indian J Otol 2015;21:174-8.
Source of Support: Nil. Conflict of Interest: None declared.

Indian Journal of Otology | July 2015 | Vol 21 | Issue 3 |