Otitis media with effusion and grommet decisions — formative SAQs

SAQ 1 (10 marks)

A 4-year-old girl is brought to the general paediatric clinic because her preschool teacher reports she is falling behind, sits very close at story time and often does not respond when called. She has had recurrent winter colds but is otherwise well, with no ear pain and no fever. Otoscopy shows dull, retracted, amber-coloured tympanic membranes bilaterally with fluid levels, and reduced mobility on pneumatic otoscopy. Tympanometry shows flat type B traces bilaterally, and audiometry confirms a bilateral conductive hearing loss of 28 dB HL. The effusion has been present for at least four months. [3]

Question: Outline the diagnosis, the relevant investigations, and the stepwise management of this child, including the grommet decision and the evidence you would cite to the family. (10 marks) [3]

Model answer

Diagnosis and recognition (2 marks). The diagnosis is persistent bilateral otitis media with effusion (glue ear). The well, afebrile child with dull, retracted, amber tympanic membranes, fluid levels and reduced mobility, presenting with hearing and educational difficulty rather than pain or fever, is the classic picture of OME, here persisting for four months with a documented conductive hearing loss of 28 dB HL. This is distinct from acute otitis media, which would have pain, fever and a bulging red drum. [2] [3]

Investigations (2 marks). The diagnosis is already appropriately documented with the two investigations that drive every grommet decision: tympanometry confirming the effusion (flat type B traces bilaterally) and age-appropriate audiometry documenting the degree and type of hearing loss (a 28 dB HL bilateral conductive loss with an air-bone gap). No imaging or blood tests are required for typical OME. The duration of four months places this child beyond the three-month threshold at which intervention is considered. [2] [3]

The grommet decision (2 marks). This child meets the AAO-HNS 2022 criterion for surgery: clinicians should offer bilateral tympanostomy tube insertion to children with bilateral OME persisting three months or longer and documented hearing difficulties. She has bilateral OME for four months, a 28 dB HL conductive loss, and clear educational impact. She is therefore referred to ENT for consideration of bilateral grommets. Tubes are not indicated for a single episode under three months, and operating on otoscopy alone without audiometry is the classic error — neither applies here. [3]

The evidence to cite to the family (2 marks). Counsel the family honestly with the two pieces of evidence that shape expectations. The 2023 Cochrane review shows that grommets deliver a real but time-limited hearing benefit that narrows by around twelve months as the non-operated ear also resolves. The Paradise randomised trials, following children to age nine to eleven years, found no difference in developmental, language, academic or behavioural outcomes between early and delayed insertion. So the operation is justified by her current hearing and educational impact, not by fear of long-term developmental harm. [2] [1]

Disposition, follow-up and safety-netting (2 marks). Refer to ENT for bilateral grommet insertion. After surgery, review the ears within three months, advise on water precautions and the management of tube otorrhoea (topical antibiotic drops, not oral antibiotics, for uncomplicated discharge), and arrange periodic review until the tubes extrude and hearing is confirmed normal. Give a safety-net for any acute ear pain or fever (a superimposed acute otitis media). The prognosis is good: the tubes will restore hearing while patent, and the natural maturation of the Eustachian tube makes recurrence increasingly unlikely. [3]