Otitis media with effusion (glue ear): symptoms and treatment

The middle ear is the air-filled space behind the eardrum, linked to the back of the nose by the eustachian tube. In glue ear this space fills with fluid. NICE Clinical Knowledge Summaries describe otitis media with effusion as fluid in the middle ear without signs of acute inflammation, which separates it from an acute ear infection with pain and fever.

The practical consequence is that sound is conducted less efficiently, so hearing is dulled. The NHS describes the most common symptom as temporary hearing loss, which can affect both ears at the same time. It is much more common in children, although adults can have it too, with the same symptoms.

According to CKS, glue ear may occur during an upper respiratory infection, as an inflammatory response after acute otitis media, or spontaneously because the eustachian tube is working poorly. The underlying mechanism is complex, and infection, genetics and environment may all contribute.

CKS lists conditions that make it more common:

• cleft palate and Down's syndrome

• primary ciliary dyskinesia

• allergies, chronic rhinitis, asthma, urticaria and eczema

• enlarged adenoids (adenoidal hypertrophy)

Apart from hearing loss, the NHS lists earache, ringing or buzzing sounds (tinnitus) and problems with balance as possible symptoms. Because children often do not say they cannot hear, the NHS gives behavioural clues that should prompt a visit to a GP:

• speaking loudly or being difficult to understand

• asking people to repeat what they say

• asking for the TV or music to be turned up loud

• struggling to hear people who are far away

• becoming easily distracted when people are talking

• finding it hard to concentrate, or seeming tired and irritable because listening takes more effort

The NHS says a GP should be able to tell whether it is glue ear by looking for fluid with a small scope that has a light and magnifying glass. This should not be painful. If the child has had glue ear for more than 3 months, referral for hearing tests may follow, because testing shows how severe any hearing loss is and what is causing it.

CKS advises that children with suspected glue ear are referred for formal assessment, which includes specialist examination, tympanometry (a test of how the eardrum moves) and hearing tests. Depending on the local pathway, this is done by paediatric audiology, ear, nose and throat services, or both. The same pathway aims to rule out other causes such as acute otitis media, a foreign body, impacted wax, asthma or balance disorders.

Glue ear is not always treated. The NHS explains that the GP will usually wait to see if symptoms improve on their own, because there is no effective medicine for it and it often clears within 3 months. A child may be monitored for up to a year in case symptoms change or get worse. NICE CKS notes the hearing loss usually resolves over several weeks or months, although it can be more persistent and, if it affects both ears, may lead to developmental problems.

While waiting, the GP may suggest autoinflation, which can help fluid drain. It involves either blowing up a special balloon with one nostril at a time or swallowing while holding the nostrils closed. Because it has to be done several times a day, the NHS says it is not usually recommended for children under 3. Antibiotics are only prescribed if the glue ear causes an infection.

The NHS says a child may be referred to a hospital specialist if glue ear is affecting learning and development, if they already had severe hearing loss before glue ear, or if they have Down's syndrome or a cleft lip and palate, because glue ear is less likely to get better by itself in these children.

The two main treatments are temporary hearing aids and grommets. A grommet is a small tube placed in the eardrum during surgery that drains fluid and keeps the eardrum open; the NHS says it should fall out naturally within 6 to 12 months as the ear gets better. Occasionally, surgery to remove adenoids (adenoidectomy) is also recommended. CKS lists the specialist options as reassurance and discharge if no hearing loss is found, non-surgical management with monitoring, support, autoinflation or hearing aids, and surgery with grommets with or without adenoidectomy.

Glue ear is much more common in children, but the NHS says adults who have it get the same symptoms, chiefly temporary hearing loss. An adult with persistent hearing loss or fluid in the ear should see a GP, who can look in the ear and arrange referral if needed.

On the NHS, the pathway for children runs from the GP to paediatric audiology or ENT services, depending on the local arrangement, as NICE CKS describes. A private paediatric ENT or audiology service can offer the same hearing tests and tympanometry; the options for monitoring, hearing aids and grommets are the same wherever assessment takes place. Services and waiting times vary, so confirm what a provider offers before attending.