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The Distress of Middle Ear Infection and Fluid


As a Speech-Language Pathologist (SLP) with extensive training in auditory processing-language disorders and as a mother of a child who had recurrent ear infections, I have a lot of advice on the implications of fluid in a child’s ear and the steps to take if your child is in a similar situation.

To warn you, this is a heavy piece!

First, it is important to know the medical terminology so you are better versed when speaking to a professional:

What is Otitis Media?

Acute Otitis Media is a type of ear infection. It is the most common bacterial infection in children. Many times this is accompanied with fluid build up in the middle ear – Acute Otitis Media with Effusion (AOM). Typically your child would experience discomfort and fever and therefore this diagnosis would take place at the pediatrician’s office where your child would be examined with an otoscope and then the findings would be linked to the symptomology experienced by your child.

Otitis Media with effusion (OME) is when fluid builds in the middle ear without an infection. This is important to be aware of as there may be no signs or symptoms, so as a parent you may be unaware.

Fluid build up can occur due to allergies, exposure to irritants, respiratory infections, post ear-infections when fluid build-up during the infection doesn’t drain. Fluid can collect also when your child drinks while lying down or due to changes in ear pressure (on a plane).

Get it checked out if your child complains of having full ears, if you feel as if your child is not hearing as well, or If your child has had recurrent upper respiratory infections, allergy reactions etc.,

OME can be preliminarily diagnosed at a regular doctor’s visit when the doctor uses an otoscope to look in the ear. At times, a tympanogram by an Ear Nose and Throat (ENT) doctor is also recommended to confirm the diagnosis.

Recommendations by Sarah Darwish, Audiogoloist from the Hearing and Balance Centre are that diagnosis of OME should be confirmed by an ENT or Audiologist as they specialize in the ear.

Chronic OME is when there is a persistence of fluid in the ear for a period of 3 months or more.

Persistent AOM (ear infection) occurs when there is a relapse of infection within 1 month of completing antibiotics.

Recurrent AOM (ear infection) is when there have been 3 or more well documented and separate AOM episodes in the past 6 months or at least 3 in the past 12 months with at least 1 in the past 6 months.

For many children, OME will resolve itself. However, it is key and vital for parents to properly document all cases of ear infection and fluid in the ears and follow up with the doctor to ensure that the fluid completely drains.

If the fluid does not drain for a period of 3 months, it becomes a case of Chronic Otitis Media.

How can OME affect my child?

At least 25% of OME’s that persist for greater than or equal to 3 months can result in hearing loss, vestibular difficulties, decreased school performance, and recurring Acute Otitis Media.

Hearing Loss:

All children with AOM or OME have some degree of hearing loss (whilst the fluid is in the ears). OME is the most common cause of Hearing Loss in children in developed nations. The fluid obstructs the auditory pathway and can create a temporary conductive hearing loss. Average hearing loss is 25-28db HL (decibels, hearing loss), or a mild hearing loss, which wouldn’t significantly affect conversational speech. However, 20% of children will experience levels beyond 35db HL, resulting in at least a moderate hearing loss.

This means if you draw a line at 35db on the below diagram, all the sounds above that line, will not be able to be perceived in normal conversation. It does therefore become critical if your child has experienced persistent OME (fluid in the ear with or without infection) for 3 months or longer, that you do obtain a hearing test from an audiologist to gauge how severe the hearing loss is. Only 30% of patients who have otitis media with effusion will clear the effusion after 3 months.

Speech-Language/Auditory Processing Difficulties

Persistent middle ear fluid affects the mobility of the tympanic membrane, becomes a barrier to sound conduction, resulting in difficulty with speech recognition, speech processing, speech perception and localization (difficulty processing auditory information).

The first 8 years of life represent a critical period of language and literacy development. Lois Kam Heymann (http://www.listenlovelearn.com/), a Speech-Language Auditory Therapist, is a specialist in listening-language therapy. In her introductory remarks on her website, she indicates that hindered auditory skills affect language development, communication, and learning skills. Children who have difficulties processing auditory information may have low vocabularies, difficulty following directions, comprehending stories, and expressing themselves.

Vestibular Difficulties:

The auditory and vestibular systems are intimately connected. The receptors for both are located in the temporal bone.

As a result, preschool students with a history of recurrent or persistent otitis media, performed worse on vestibular and balance tests than children who did not suffer from otitis media. The vestibular system includes the parts of the inner ear and brain that help control balance and eye movements. When the vestibular system is affected, it can create clumsiness, difficulty with coordination, difficulty maintaining appropriate posture, hearing loss, sensitivity to loud sounds, difficulty focusing, tracking, and paying attention.

From the many clients I’ve seen over the years who present with auditory- processing difficulties due to fluid in the ears, many benefit greatly from Occupational Therapy services, in order to help manage the vestibular difficulties that also present themselves.

How do you treat persistent Otitis Media?

AOM Treatment: Antibiotics are the main treatment method. Follow up is necessary to ensure fluid in the ears drain effectively.

OME Treatment: Some ENT’s and Pediatricians may attempt decongestants, steroids, antihistamines, antibiotics. But the best treatment for chronic OME is surgery – either a Myringostomy, a hole to drain the fluid, or pressure equalization (PE) tube insertion (tympanomestry tubes or grommets). The surgery would be recommended by and carried out by an ENT (Ear, Nose, Throat) doctor.

Tympanomestry tubes are most often inserted because of persistent middle ear fluid, frequent ear infections, or ear infections that persist despite antibiotic therapy. It is the most common surgery 1/15 children will get this surgery in the USA.This surgery can take place in the case of unilateral or bilateral Chronic OME – that is when fluid persists for 3 months or longer.

Unfortunately, if your child has OME without infection, you may not know how long the fluid has been present in the ears. It is important to write the exact date the fluid was detected. If the fluid persists for 3 months from the suspected start, an age appropriate hearing test should be conducted at this point.

General guidelines for conducting the surgery are in cases of:

  1. Persistent Acute Otitis Media (AOM)

  2. Recurrent Acute Otitis Media (AOM)

  3. Hearing Loss caused by Chronic effusion (OME)

  4. Presentation of symptoms which may be caused by fluid in the middle ear e.g., vestibular problems, poor school performance, behavioral problems, ear discomfort, or reduced quality of life

  5. Children who are at a higher risk of hearing/speech and language difficulties where it is not likely to resolve quickly

  6. Unacceptable antibiotic burden

Please see the decision making tree at the bottom of this blog by Rosenfeld et al. 2013 to help guide the decision making process.

Advantages of tympanomestry tubes

Use of tympanomestry tubes have been linked with significant improvements in hearing, associated symptoms, and the child’s developmental risk. It reduces the risk of recurrent acute otitis media by providing a mechanism for drainage, thereby improving quality of life. Observational studies have resulted in positive parental / caregiver reports in at-risk children for speech, language, learning outcomes.

Personal Insight

Insertion of tympanomestry tubes for our son at 15 months of age following 5 ear infections, was the best decision we made. Dr. John McEwan from the Sohar Clinic was careful and thorough. The surgery was short with no side effects, and we noticed a difference in his focus and listening skills the next day! Since he had the surgery he has had no ear infections to date (knock on wood).

As an SLP, I was not willing to take the risk of hearing being affected, especially with what I know and what you know now! And good ENT’s don’t want to put a child under local anesthesia unless there is cause to do so. So for me, it was

about presenting factual evidence to demonstrate to my ENT that the surgery would benefit my son.

The most important take home is that documentation of all ear infections and cases of fluid in the ears is key. Furthermore, proving that there is an affect on hearing or other aspects of development, is important too. For my son, a hearing test confirmed that with fluid in his ears, he had a mild-moderate hearing loss, (even though developmentally there were no concerns). It was this result that convinced the ENT that surgery needed to be scheduled.

Remember – documentation is key and the advice on the decision making tree is invaluable.

Sources

Apel, Kenn, Masterson, Julie. Be-yond baby talk. 2001.

Denning J, Mayberry W (1987). Vestibular dysfunction in preschool children with a history of otitis-media. Occupational Therapy Journal of Research 7 (6):335-348

Edward Onusko, M.D.,Clinton Memorial Hospital, Wilmington, Ohio

Am Fam Physician. 2004 Nov 1;70(9):1713-1720. Tympanometry. https://www.aafp.org/afp/2004/1101/p1713.html

Hanafin S1, Griffiths P. Does pacifier use cause ear infections in young children?

https://www.ncbi.nlm.nih.gov/pubmed/11979200

Kivi, Rose & Yu, Winnie. https://www.healthline.com/health/ear-infection-acute

Niemela, M. Uhari,M & Mottonen, M (1995). A pacifier increases the risk of recurrent otitis media in children in day care centers. Pediatrics, 96(5), 884-888

Otitis Media with Effusion. https://medlineplus.gov/ency/article/007010.htm

Rosenfeld, Richard M. et al. Clinical Practice Guideline: Tympanostomy Tubes in Children. Otolaryngology – Head and Neck Surgery 2013. http://otojournal.org.

https://www.healthychildren.org/English/health-issues/conditions/ear-nose-throat/Pages/Middle-Ear-Infections.aspx

https://www.duo.uio.no/bitstream/handle/10852/48795/PhD-Aarhus-DUO.pdf?sequence=1

https://vestibular.org/understanding-vestibular-disorder/symptoms

http://www.bioon.com/bioline/neurosci/course/audvest.html

https://patient.info/doctor/otitis-media-with-effusion

https://emedicine.medscape.com/article/858990-treatment

http://www.listenlovelearn.com/

http://www.entnet.org/?q=node/1313


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