The patient’s unmet needs (PUNs)
A five-year-old girl presents with her mother who has concerns about the girl’s hearing. She has to turn the TV up loud, tends to shout and sometimes misses what her teacher says at school – although her mother thinks that, at times, she simply isn’t concentrating. On examination, the child is a mouth breather and both tympanic membranes look dull and grey. You diagnose likely glue ear. The mother is keen for you to ‘test her hearing’, and wonders whether her daughter should be referred because her older sibling required grommets.
The doctor’s educational needs (DENs)
Can the GP realistically perform a valid screening hearing test in the surgery? Or should all such children be referred for formal audiology?
It is difficult to perform a valid hearing assessment in a small child during a busy GP surgery. While there is now universal neonatal hearing screening in the UK, a child may pass the screening and then develop sensorineural hearing loss, either because of intrauterine infection, or acquired postnatal infection.
If the parents are concerned and there are positive clinical findings of glue ear, formal audiology would be warranted. Depending on local access, this will normally be to a local children’s ENT clinic for pure tone audiometry.
Children younger than four years should initially be referred to the local second tier paediatric community audiology clinic as it will not be possible to perform reliable pure tone audiometry in an ENT clinic.
What is the natural history of this condition?
Glue ear (otitis media with effusion) is the most common cause of hearing loss in childhood. Prevalence peaks at around two years, and again at around five years of age. By the age of 10, about 80% of children will have had glue ear.
Glue ear may be asymptomatic and parents may not notice hearing loss. In young children, poor balance, and speech and language delay are common presenting features. In school-age children, teachers may note inattention or poor social behaviour where background noise is a problem. When asked, older children may be aware that they cannot hear well. Untreated, most cases resolve within three months and 90% within six months.
What conservative measures can be tried, and for how long?
The initial management of glue ear is hearing assessment and active monitoring. This depends on timely referral for hearing testing, repeated three months later to assess resolution or the need for intervention. Reassure parents that resolution is common and medical treatment is not helpful. There is no evidence that antibiotics, decongestants, antihistamines or intranasal steroids are beneficial. And there is no evidence for alternative or complementary remedies. Nasal autoinflation of the Eustachian tubes with a balloon may be helpful during the period when natural resolution can occur, but the need to use the balloon three or more times daily is often a drawback for children.
Which children should be referred, and when?
A child with a history and new diagnosis of glue ear should be referred for hearing assessment and active monitoring. Most children will have to wait about three months to be seen. Referral does not imply the need for surgical treatment, but to document the hearing thresholds and middle ear tympanometry, repeating these over a three-month period, after which persistent glue ear might require intervention.
Are there ‘special groups’ who warrant more urgent action – and is the family history of any relevance?
Children with some conditions, such as Down’s syndrome and cleft palate, are more likely to develop persistent, recurrent glue ear. These children are usually under surveillance by a developmental paediatrician or in a regional cleft service. If not, early referral is recommended. For children where persistent glue ear is predictable, hearing aids are a helpful option to avoid repeated operations.
The genetics of otitis media with effusion are currently being studied, and it is likely that a familial disposition will be shown.
How effective is surgical treatment? What are the currently favoured procedures?
NICE guidance1 advises that after three months of bilateral hearing loss, confirmed on audiometry and tympanometry, the effective treatment is ventilation of the middle ear with grommets. In addition to improvement in hearing, there are small benefits in speech, language and behaviour in children after grommet insertion. The benefits are statistically small after 12 months, but 12 months of poor hearing for a three-year old is a significant proportion of their life, at a time when speech, language and social behaviour are developing rapidly.
Grommet insertion is a short procedure under general anaesthetic routinely performed as a day-case, with return to school or nursery the following day. The grommets typically extrude with natural epithelial growth in about nine months. The risk of permanent perforation with standard pattern grommets is around 2% or less. During this period, the child will be reviewed and a hearing assessment performed following extrusion of the grommets to confirm normal hearing. Recurrent, infected discharge from the ears can be prevented by keeping water out of the ears when bathing, hair-washing and swimming.
Hyponasal speech and a poor nasal airway may point to adenoidal hyperplasia, although the size of the adenoid is not necessarily relevant to the biofilm activity. It is no longer believed that glue ear is the result of physical obstruction of the Eustachian tube by the adenoid causing middle ear vacuum. Consider rhinitis as a differential diagnosis of the nasal symptoms, particularly in an atopic child, or one with a family history of atopy.
The adenoid can be examined during the same procedure as grommet insertion and removed if necessary. In older children, the adenoid may have already naturally involuted and not require removal. Day case adenoidectomy performed with suction coagulation causes little post-operative pain and the post-operative bleeding rate for adenoidectomy is about 1:200, usually on the day of surgery while the child is still in hospital.
Mr Peter Robb is a consultant ENT surgeon at Epsom Hospital and Surrey Children’s ENT Clinic, Ashtead Hospital.
Produced in collaboration with ENT UK – to apply for membership, get professional or patient information, and details about education, training and conferences, go to entuk.org
1 National Institute for Health and Clinical Excellence. Surgical management of children with otitis media with effusion. NICE CG60. 2008
- MRC Multicentre Otitis Media Study Group. Adjuvant adenoidectomy in persistent bilateral otitis media with effusion: hearing and revision surgery outcomes through two years in the TARGET randomised trial. Clin Otolaryngol, 2012;37:107–16
- Robb PJ and Williamson IG. Otitis media with effusion in children: Current management. Paediatrics and Child Health, 2012;22:(1)9-12
- Robb PJ. Childhood otitis media with effusion. Clin Otolaryngol, 2006;31: 535-37
- Kubba H, Pearson JP and Birchall JP. The aetiology of otitis media with effusion: a review. Clin Otolaryngol, 2000;25:181–94