Paeds · ent-hearing-and-oral-health
Otitis media with effusion and grommet decisions
Also known as Otitis media with effusion · OME · Glue ear · Serous otitis media · Secretory otitis media · Tympanostomy tube · Ventilation tube · Grommet · Middle ear effusion
Fellowship topic on otitis media with effusion (glue ear) and grommet (tympanostomy tube) decisions in children: the definition of OME as non-purulent fluid behind an intact tympanic membrane without acute infective signs, distinct from acute otitis media; the Eustachian tube dysfunction pathophysiology amplified by the short, horizontal, compliant paediatric tube; the natural-history principle that most effusions resolve within three months and that watchful waiting is the first and default management; the tympanogram (type A normal, type B flat effusion, type C negative pressure) and the typical 20 to 30 dB HL conductive hearing loss; the grommet criterion of bilateral OME persisting three months or longer with documented hearing difficulty, and the rule against inserting tubes for a single episode under three months; the at-risk child (Down syndrome, cleft palate, permanent hearing loss, developmental delay) needing earlier referral; the Paradise developmental trials showing no long-term advantage of early tubes and the Cochrane hearing evidence; autoinflation and the limited role of antibiotics, steroids and adenoidectomy; and culturally safe, region-aware care including the high-burden early-severe disease of Aboriginal and Torres Strait Islander children.
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Target exams
Red flags
- Persistent bilateral otitis media with effusion for three months or longer with documented hearing difficulty in a young child — refer for ENT assessment and consideration of bilateral grommets, because the conductive hearing loss affects speech, language and schooling
- An at-risk child with OME — Down syndrome, cleft palate, permanent sensorineural hearing loss, developmental delay, autistic spectrum or blindness — needs early audiology and ENT referral, because even a mild additive conductive loss has a higher developmental cost
- Unilateral persistent OME in an older child that fails to resolve or is associated with attic or pars-tensa abnormality — reassess and consider specialist review to exclude underlying middle-ear pathology such as cholesteatoma
- A child with OME who develops acute ear pain, fever or a bulging red drum — a superimposed acute otitis media that needs separate assessment and treatment
- An Aboriginal or Torres Strait Islander, Maori or Pasifika child with persistent ear disease — early, culturally safe assessment and a lower threshold to treat, given the high burden of early, persistent and severe otitis media and its long-term developmental and educational cost
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Care settings
Clinical exam formats
Board mappings
- General Paediatrics and Otolaryngology: otitis media with effusion (glue ear) — definition, the watchful-waiting stance, tympanometry and audiometry, and the grommet criteria
- Growth, development and behaviour: the impact of persistent conductive hearing loss on speech, language and schooling
- Renewed curriculum — Ear, nose and throat and hearing: persistent bilateral OME, the three-month duration threshold, the hearing-difficulty criterion and the at-risk child
- Evidence and guidelines: the Paradise developmental trials and the Cochrane grommet review
- General Paediatrics: the assessment of the child with suspected hearing difficulty, the tympanogram, and the watchful-waiting-to-grommet pathway
- Communication: explaining glue ear and the watchful-waiting plan to a family, with a clear safety-net
- Long Case / Structured discussion: a child with persistent bilateral OME and hearing difficulty — watchful waiting versus grommets, the evidence, and the at-risk and Indigenous child
- Communication station: counselling a family on the grommet decision and the natural history of glue ear
- Level 2 / 3 — ENT and audiology and developmental: otitis media with effusion, tympanometry and audiometry, watchful waiting and the surgical decision
- Communication and Safeguarding: culturally safe care for Indigenous and migrant families with high-burden otitis media
- Foundation of Practice (FOP): the definition of OME, the tympanogram types and the natural history of resolution
- Applied Knowledge in Practice (AKP): the grommet criteria, the Paradise developmental evidence and the management of the at-risk child
- History-taking and management: the child with hearing difficulty and persistent OME — the watchful-waiting plan and the grommet decision
- Communication: explaining glue ear and the natural history to a family, with reassurance and a safety-net
- General Pediatrics Content Outline — otitis media with effusion: diagnosis, tympanometry, watchful waiting and tympanostomy tube indications
- Developmental and behavioral pediatrics: the effect of conductive hearing loss on speech, language and learning
- Patient Care: recognition and stepwise management of OME, applying the watchful-waiting stance and the grommet criteria with audiological documentation
- Systems-Based Practice: equitable, culturally safe access to audiology and ENT, including for Indigenous and rural children
- Medical Knowledge: Eustachian tube pathophysiology, tympanogram interpretation and the evidence on tympanostomy tubes
- Medical Expert: OME diagnosis, tympanometry and audiometry interpretation, watchful waiting and tympanostomy tube indications
- Collaborator: multidisciplinary management with audiology, ENT, speech-language and primary care
- Communicator: explaining the natural history and the grommet decision to a family
The two diseases a swollen dull drum can be
Otitis media with effusion (glue ear)
Acute otitis media
Overview & Definition
Picture a three-year-old whose parents bring her in because she turns the television up loud, does not always answer when called, and has fallen behind at preschool with her speech. She has had a string of winter colds but is not unwell, has no ear pain and no fever. Looking in her ears you find a dull, slightly retracted, amber-coloured eardrum with a faint fluid level behind it. This is the classic face of glue ear — fluid sitting in the middle ear, conducting sound poorly, but without any of the acute infective signs that would make you think of an acute ear infection. The question is not whether she has fluid — she plainly does — but whether it will clear on its own, how much it is affecting her hearing and development, and whether and when a grommet would help. [2] [8]
Otitis media with effusion (OME) is defined as the presence of non-purulent fluid in the middle ear behind an intact tympanic membrane, without the acute infective features of acute otitis media. The older names — serous otitis media, secretory otitis media, and the everyday "glue ear" — all describe the same thing. The fluid may be thin and straw-coloured, or thick and tenacious (the true "glue"). It is one of the commonest problems of early childhood: most children have at least one episode by their third birthday, and prevalence peaks between six months and four years of age. [5] [2]
The clinician's task runs in three layers. The first is recognition — separating glue ear from acute otitis media, which changes both the urgency and the treatment. The second is documentation — confirming the effusion with tympanometry and measuring the hearing with age-appropriate audiometry, because the surgical decision depends on the hearing level, not on the look of the drum alone. The third is timing — understanding that most effusions resolve within three months, so the default first step is watchful waiting, and that grommets are reserved for the child whose effusion persists and whose hearing or development is affected. [3] [10]
References11ShowHide
- [1]Paradise JL; Feldman HM; Campbell TF; et al Tympanostomy tubes and developmental outcomes at 9 to 11 years of age. N Engl J Med, 2007.PMID 17229952
- [2]MacKeith S; Mulvaney CA; Galbraith K; et al Ventilation tubes (grommets) for otitis media with effusion (OME) in children. Cochrane Database Syst Rev, 2023.PMID 37965944
- [3]Rosenfeld RM; Tunkel DE; Schwartz SR; et al Clinical Practice Guideline: Tympanostomy Tubes in Children (Update). Otolaryngol Head Neck Surg, 2022.PMID 35138954
- [4]Leach AJ; Morris PS; Coates HL; et al Otitis media guidelines for Australian Aboriginal and Torres Strait Islander children: summary of recommendations. Med J Aust, 2021.PMID 33641192
- [5]Paradise JL; Rockette HE; Colborn DK; et al Otitis media in 2253 Pittsburgh-area infants: prevalence and risk factors during the first two years of life. Pediatrics, 1997.PMID 9041282
- [6]Boonacker CW; Rovers MM; Browning GG; et al Adenoidectomy with or without grommets for children with otitis media: an individual patient data meta-analysis. Health Technol Assess, 2014.PMID 24438691
- [7]Venekamp RP; Burton MJ; van Dongen TM; et al Antibiotics for otitis media with effusion in children. Cochrane Database Syst Rev, 2016.PMID 27290722
- [8]Roberts JE; Burchinal MR; Zeisel SA; et al Otitis media, the caregiving environment, and language and cognitive outcomes at 2 years. Pediatrics, 1998.PMID 9685437
- [9]Johnston LC; Feldman HM; Paradise JL; et al Tympanic membrane abnormalities and hearing levels at the ages of 5 and 6 years in relation to persistent otitis media and tympanostomy tube insertion in the first 3 years of life: a prospective study incorporating a randomized clinical trial. Pediatrics, 2004.PMID 15231974
- [10]Browning GG; Rovers MM; Williamson I; et al Grommets (ventilation tubes) for hearing loss associated with otitis media with effusion in children. Cochrane Database Syst Rev, 2010.PMID 20927726
- [11]Paradise JL; Campbell TF; Dollaghan CA; et al Developmental outcomes after early or delayed insertion of tympanostomy tubes. N Engl J Med, 2005.PMID 16093466