Otitis media with effusion (fluid in the ears)

Fluids in the ears or in other words and more correctly – otitis media with effusion, is a very common condition in pediatrics. I think a parent who understands the essential differences between acute otitis media and otitis media with effusion (fluid in the ears) can help his child get more accurate advice and treatment from the pediatrician.

What is otitis media with effusion (fluid in the ears) and how does the fluid get to the ears?

See in the following drawing the structure of the ear which consists of three parts, the outer ear, the middle ear and the inner ear.
The middle ear is actually a cavity that begins in the eardrum and ends in another small membrane called the oval window where the inner ear begins. From the same cavity of the middle ear emerges another canal whose end is in the area behind the nose.
Anyone who first hears the phrase fluid in the ears imagines a puddle of water coming in from the nose or through the ear canal. But the real process is an inflammatory reaction in which different triggers cause a liquid secretion which accumulates in the same middle ear cavity. That cavity is lined with mucus and inflammatory cells. Children have a number of different risk factors and triggers that lead to fluid accumulating in the ears, including heredity, secondhand smoke and recurrent viral infections.
But the most important is the anatomy – in cases where the same canal that connects the middle ear to the nose is obstructed (for example due to recurrent viral infections, adenoid tonsil, etc.) or functions less well anatomically (short, narrow or at a too horizontal angle) – the ventilation of the inner ear is damaged and the same inflammatory fluid accumulates in it.

What is the connection between fluid in the ears and an adenoid tonsil?

The adenoid tonsil (or sometimes mistakenly called polyp) is a tissue located behind the nose in young children. The location of the adenoid tonsil is close to the opening of the same canal that connects the middle ear to the nasal cavity. If the adenoid tonsil is large and interferes with the drainage and ventilation of the same canal then a process of otitis media with effusion may begin. Therefore, as we will see below, the treatment is often combined (ventilation tubes insertion + adenoid tonsil removal).

What is the connection between otitis media with effusion (fluid) and acute otitis media?

On the one hand two completely different processes taking place in the same place. On the other hand, a spectrum of the same process, when sometimes the end of one is the beginning of the other. Complex.
Fluids in the ears – a chronic inflammatory (non-infectious) process. Ostensibly if we sample the liquid it will be sterile (this is not accurate, but it is more easy to simply). So for example, antibiotic treatment will not help.
Acute otitis media – an infectious process for which an acute pathogen (usually a bacteria) is responsible. Therefore, antibiotic treatment can be helpful.
In practice, the relationship between the two is a bit more complicated because there are those who will say that it is actually a spectrum of the same condition. The onset of acute otitis media is often the end of otitis media with effusion.
Let’s summarize the connection as follows: Fluids in the ears are a very convenient ground for bacteria to thrive, although in most cases they do not cause any damage and do not lead to acute otitis media.


How do you differentiate between otitis media with effusion and acute otitis media?

Sometimes it is difficult to distinguish between the two and only a skilled eye can help. In both cases, when looking at the eardrum, fluids can be identified behind the eardrum and a slight bulging of the tympanic membrane may occur. But fluid in the ears is a chronic and painless process while acute otitis media is a process that often includes fever, the presence of earache, and local findings on examination of the eardrum such as redness, bulging of the tympanic membrane and significant turbidity.

Is otitis media with effusion (fluid in the ears) a contagious disease?

Fluids in the ears are not contagious and therefore should not interfere with the child in routine activities in kindergarten or school.

Do fluid in the ears cause hearing loss and who are the children who needs to be examined?

In most cases fluid in the ears causes a slight and not prolonged conductive decrease in hearing. This hearing loss in children is insignificant.
However, there are cases where fluid in the ears can lead to hearing loss, even to values of up to 50 decibels, which considers a moderate hearing loss. If the hearing loss is unilateral, usually no one (including the child) will feel at all that there is a hearing loss. If the decline is bilateral, to a considerable degree and in a prolonged manner then there may be impairment in hearing and language acquisition.
Keep in mind that in children who have some other developmental problem (verbal, behavioral, or developmental), even a slight hearing loss can exacerbate the initial problem, and these children need appropriate follow-up and counseling.
Therefore, in children who may have a hearing loss that leads to a problem on a daily basis or in those who have fluid in their ears for a period of more than 3 months, there is a place to perform an age-appropriate hearing test with a skilled professional. A good hearing test, is a hearing test at an institute has experience with small children. The test will be able to distinguish and isolate the hearing in each ear separately, including separating the degree of hearing loss with and without fluids.
There are those who account to fluids in the ears (with or without hearing loss) all the troubles in the world. For example, a child with a behavioral or ADHD problem. Potentially and according to the textbooks, fluid in the ears, especially for an extended period of time, can also cause these problems as well as posture disorders and more. But keep in mind, that in most cases ear fluids comes and go, over a period of months, and do no cause any harm to children.

What are the possible treatments in cases of ear fluids in children?

Again, most of the millions of children who have fluid in their ears do not need any follow-up or treatment.
Any investigation or treatment should be performed only in those cases where there is evidence of the presence of fluids for a prolonged period of more than 3 months, in cases of hearing loss leading to a additional problems or recurrent otitis media.
Possible treatments are:
Different types of nasal sprays that usually contain salt water – can be slightly relieving but are mainly acceptable for use in adults.
Antibiotics – absolutely not. Antibiotics are not a treatment for otitis media with effusion!
Antihistamines (anti-allergy) – in most cases in children there is no value in this treatment.
Steroids (in a systemic use or as a nasal spray) – in the short term steroids can relieve symptoms but in the long term, they do not change the course of this medical condition. This is also not an acceptable treatment for young children.
Anti congestion drugs – not acceptable for the treatment of children, especially those under the age of two. In addition, have not been proven to be helpful.
Nasal drops such as Dathemycin – do not really change in the long run.
Inflating balloons, salt rooms and all sorts of other inventions – does not work.
This is the time to mention, that it is most difficult for an attending physician to stand in front of the parents and say that there is no real solution that works over time.
The only treatment that resolves fluid in the ears is ventilation tubes surgery.

What are the factors to consider when deciding on ventilation tube surgery?

Before coming to surgery, two important points must be considered:
1. The vast majority of the many children who have fluid in their ears do not need any follow-up or treatment. The fluids do not cause any short- or long-term problem and do not warrant intervention. The fluids will decrease and be gone within weeks or months.
2. Ventilation tubes surgery is the most common surgery in the State of Israel in children and is therefore a type of business. Therefore, consult with your pediatrician on this subject and at the same time with an ear, nose and throat specialist in pediatrics for whom you have received warm recommendations and who are in no hurry to operate without a clear indication.
Together with the surgeon, consider a number of variables that affect the need for surgery, including: age of the child, season (there is a difference between pre-winter and pre-summer counseling, for example, when the number of viral infections decreases), number and intensity of acute otitis media incidence (if there were any), the presence of fluids in one or both ears, the duration of fluids if known and most importantly the extent of their impairment in the child’s hearing and developmental problems associated with hearing loss.

What is Ventilation tubes surgery and what does it have to do with the adenoid tonsil?

Ventilation tubes surgery is a surgery in which a small incision is made in the eardrum and through which ventilation tubes (one on each side) are inserted. Since now the middle ear cavity is open to the auditory canal, then there is ventilation of that cavity, the fluids evaporate, the hearing loss disappears and often also the tendency for acute middle ear infections decreases.
There are two types of ventilation tubes. There are short-term (usually emitted alone in a period of between six months and a year) or long-term. In the vast majority of cases in children short-term tubes will be inserted.
In many cases, surgery will be performed at the same time to remove the adenoid tonsil that caused the nasal blockage.
But more about that in a separate chapter that will be devoted entirely to the adenoid tonsil.