A 16-year-old male with complaints of muffled hearing and ear pain?
A 16-year-old boy was brought to the clinic with complaints of muffled hearing and occasional pain in his left ear. He recently had a cold and had recovered with the exception of the ear symptoms.
On examination, what physical findings might suggest a diagnosis?
Muffled hearing with ear pain could be caused by a foreign body or cerumenosis. Infections, such as otitis externa, suppurative otitis media, otitis media with effusion (also called serous otitis media), and even shingles can cause pain and decreased hearing. In addition, illnesses that can cause dysfunction in the eustacian tube, such as pharyngitis and sinusitis, also can result in ear pain. Trauma (e.g., from a cotton-tipped swab) and barotrauma can cause muffled or complete loss of hearing and variable degrees of pain.
Referred pain from the sinuses, throat, or teeth would not be expected to affect hearing.
On examination, note the condition of the tympanic membrane. Decreased movement with pneumatic insufflation suggests effusion. Determine whether the membrane is intact, bulging, retracted, or discolored and whether an air-fluid level or bubbles are visible through the membrane. Look for the presence of foreign bodies, bleeding, or swelling in the canal as well as signs of infection or trauma outside the ear. Note sinus congestion, throat redness or swelling, adenopathy, masses, facial swelling, or tenderness.
In this patient, air bubbles behind the ear drum and decreased mobility of the tympanic membrane are noted. No other abnormalities are found. What can cause this?
A finding of bubbles and/or an air-fluid level with decreased mobility of the tympanic membrane is clear evidence of a middle ear effusion. Inflammation and local swelling cause the eustacian tube to collapse; this is particularly common after a viral illness. Pressure in the middle ear is usually equalized nearly instantly by a patent eustacian tube. If the tube is not open, the closed system quickly develops a vacuum as the oxygen is absorbed out of the trapped air. This vacuum causes a transudate to develop and may also cause retraction of the membrane.
What can be done to treat the symptoms?
In most cases, the effusion is transient, and no treatment is required. If treatment is indicated, the recommendations are different for children and adults. Children often have persistent effusions because of the relatively horizontal positioning of the eustacian tube. Adults are more likely to have another cause for the effusion, such as recurrent allergies or chronic sinusitis.
The American Academy of Otolaryngology?Head and Neck Surgery and others suggest that in children who are not at risk for language delay, observation is the most appropriate approach. If the effusion is still present after 3 months, hearing tests should be done. The child should be referred to an otolaryngologist if any abnormalities of the ear develop or if indications exist of hearing loss or impairment of language development.
Treating children with antihistamines during acute otitis media actually may prolong the duration of the effusion.
Some recent studies by Tasker et al. and Suskin et al. have suggested the possibility that gastroesophageal reflux may cause otitis media with effusion in children. In the future, antireflux treatment may be a consideration for children with chronic effusion and reflux.
No clearly superior methods of treatment exist for a persistent, acute transudate in adults. Most patients do not need to be treated, but if symptoms are problematic, a short course of oral steroids may provide relief. Treatment with oral antibiotics also has been suggested because findings have shown that about one third of patients have bacteria present in the fluid.
In milder cases in adults, treatment with systemic decongestants and nasal spray decongestants for a few days may be helpful. Longer treatment will cause reactive mucosal edema and prolong the symptoms. These decongestants may be useful for effusion that develops in conjunction with viral illness or seasonal allergies. Patients who are prone to developing effusions and persistent pain after airplane travel might also find some relief using a nasal decongestant spray during the flight.
For patients with allergies, treatment with intranasal steroids and antihistamines may be helpful.
Chronic effusions should be fully evaluated, and the cause should be treated. In most cases, there is good response to placement of a tympanostomy tube to allow ventilation of the middle ear. Laser eustachian tuboplasty, a form of laser surgery to enlarge the nasopharyngeal opening of the eustacian tube, is a new procedure that is being investigated; it shows promise for some patients.
What more serious conditions might cause effusion?
In adults, an effusion should resolve within 2 to 3 months with the treatment described. If it does not, further evaluation for an obstructing lesion is indicated.
A nasopharyngeal tumor can obstruct the eustacian tube and cause chronic effusion. This should be ruled out in adults with chronic effusion, even though it is uncommon. Dysfunction of the palate, hypertrophy of adenoid tissue, and chronic sinusitis may cause chronic effusion and may require surgery for correction.
What are some complications of chronic effusion?
The membrane can develop retraction pockets and scarring. The effusion fluid thickens to the consistency of glue, resulting in poor hearing, chronic inflammation, and possibly damage to the ossicles. If chronic infection is present as well, mastoiditis and abscesses in the bone or epidural space can result.
Cholesteatoma, a collection of squamous epithelial cells that are trapped in a sac of tissue formed by retraction of the pars flaccida, may result from the chronic inflammation. This can cause obstructive hearing loss and can destroy the ossicles, produce a labyrinthine fistula, or erode into cranial bone. Treatment for cholesteatoma is surgical removal and reconstruction of the ear drum.
Adhesive otitis media can develop. In this condition, the tympanic membrane retracts completely into the middle ear, obliterating the space and becoming adherent to the ossicles.
Most, if not all, complications can be prevented by noting the duration of the effusion and its response to treatment. If the effusion is chronic, the patient should have an evaluation by an otolaryngologist.