Assessment of Bilateral OME

1. History
   • How long is the hearing loss history?
     • Document parental/caregiver and educational concerns and the duration of these.
     • Include any collateral history from vision and hearing testers or community ear nurses.
   • Additional history
     • Delayed speech and language development
     • Information on the normal developmental range
     • Episodes of acute OM/earache.
     • Family history of OME or "grommets".
     • Is there a history of chronic "snotty" nose or snoring?
     • Some children may have OME and undiagnosed pre-existing hearing loss. Look for history or signs of longer-term hearing loss. 
     • OME that resolves then rapidly recurs is effectively chronic OME and should be managed as such.
     • Any child with suspected pre-existing hearing loss, language or developmental delay needs immediate referral - see pathway -  complicating factors

       Pre-existing hearing loss or relevant disability.

       Cholesteatoma, Retraction pocket need immediate referral to ENT.

       Drum retraction	Cholesteotoma

       
       Risk factors for hearing related developmental/learning difficulties:

       • Permanent hearing loss independent of otitis media with effusion.
       • Cleft palate with or without an associated syndrome.
       • Syndrome (eg Down Syndrome) or craniofacial disorders that include cognitive speech language delays.
       • Suspected or diagnosed speech and language delay.

       If any of the above risk factors present with OME the child needs immediate referral to ENT with audiology results. If audiology has not been previously performed please arrange this too:

       • Autism spectrum disorder or other pervasive developmental disorders.
       • Blindness or un-correctable visual impairment.
       • Developmental delay.

       The children with the above plus OME may need early referral once audiology results available.

     • Children may have been seen by or referred to GP by other agencies, notably  Vision and Hearing technicians and Community Ear nurses

       Vision & Hearing Screening

       Vision and Hearing Technicians (VHTs)
       Bay of Plenty District Health Board

       We will contact the child’s caregiver and arrange the most suitable venue to see the child at.

       It is helpful for us to have as much information about the child and their family as possible but particularly:

       1. The school or preschool that they attend.
       2. Current details and phone contact.
       3. What you want done about the issue.
       4. What has already been prescribed or done.
       5. What instructions the child/family have been given.
          
          

       Tauranga Office: 510 Cameron road Tauranga 3140 PO Box 2121 Tauranga Tel: 07 577 3383 Fax: 07 578 5485	Whakatane Office: Whakatane Hospital Stewart Street Whakatane 3120 PO Box 241 Whakatane Tel: 07 306 0944 Fax: 07 306 0987
       Tauranga Office: PO Box 2121 Tauranga 3110 Tel: 07 578 5485 Fax: 577 3386	Whakatane Office: PO Box 241 Whakatane 3120 Tel: 07 306 0944 Fax: 07 306 0987

       and Audiology.
2. Examination
   • Tympanic membrane appearance e.g.
     • Normal Eardrum
     • Secretory OME
     • Mucoid OME
     • Drum retraction pocket - indication for immediate referral
     • Cholesteatoma - indication for immediate referral

     • Normal Eardrum	Secretory OME	Serous OME

   • Pneumatic otoscopy-a useful clinical skill worth developing
   • Tympanogram provides information about:
     • Mobility of the tympanic membrane (TM)
     • Presence of fluid in the middle ear
     • Results must be correlated with history and examination.
     • Is not essential if examination and history confirm OME.
     • Can be obtained from VHTs and Community ear nurses (see above)
   • Tympanogram Results
     • Type A- In a normal tympanogram (Type A) the peak pressure (TPP) should fall close to zero and the compliance should be between 0.3 and 1.5.  Both should be within the normal range
     • Type B- there is a flat line due to reduced mobility of the TM
       • indicates effusion However, it is 100% sensitive but only 75% specific, i.e. one in four patients with Type B do not have effusion.
     • Type C- shows a highly negative pressure in the middle ear, indicated by a negative TPP.  The peak falls outside the normal range.
     • May indicate either partial effusion or Eustachian tube dysfunction

       

Management of Bilateral OME

1. 12 weeks uncomplicated
   • Medical management surveillance - 3 Monthly Review
     • Consider a single course of antibiotics of 10-14 days if the child has not had a course in the last month.
     • See Antibiotic profile for likely pathogens and sensitivities.
     • Cefaclor or Co-trimoxazole are preferable to Amoxycillin / Clavulanic Acid.
     • There is limited evidence for the use of decongestants, antihistamines or systemic steriods in OME.
     • Intranasal steriods may be of use in children over 5 years with a history of allergic rhinitis.
     • Advise more upright nursing for breast and bottle-fed infants with OME.
     • Advise daily nose blowing in older children.
     • Suggest simulated valsalva manoeuvres in older children such as blowing up balloons. 
2. More than 12 weeks with Bilateral OME and a normal hearing history
   • Audiometry (VHT or Audiology depending on age)
     • Audiometry is best reserved for uncomplicated clinical OME without corroborating history of hearing loss.
     • Audiometry is not needed where there is reported hearing loss.
     • Child is <3 years old.  Refer to Audiology (Whakatane or Tauranga Hospital)
     • Child is >3 years old. Refer to VHT
       • The above age is a guideline. Children seeing VHT need to be able to understand and follow instructions.
       • Audiology assessment is much more time intensive, so best kept for very young children or suspicion of pre-existing hearing loss.
     • Clinical Knowledge Summaries (CKS) define hearing loss and expected auditory behaviours in children with otitis media with effusion (OME) within the following thresholds of hearing levels (decibels [dB]) [1]:

     1. 1. threshold more than 40 dB:
           • communication, learning, and socialisation significantly affected
           • child understands conversational speech only within a distance of 1-1.5 metres (face-to-face)
        2. threshold of 25-39 dB:
           • has difficulty with selective hearing and background noise
           • has significant difficulty with faint or distant speakers
           • may mimic attention problems
        3. threshold less than 25 dB:
           • may exhibit fatigue due to listening effort
           • may have difficulty with faint or distant speakers

     References:
     [1] Clinical Knowledge Summaries (CKS). Otitis media with effusion. Version 1.0. Newcastle upon Tyne: CKS; 2007.

   • If Abnormal > 25db, refer to ENT Refer to ENT / Otolaryngology (Head & Neck surgery)
     • Information to be included in referral letter
       • Length of time of OME and if bilateral or unilateral.
       • Reported hearing loss from parents or caregivers including length of that history.
       • Any suspected or diagnosed pre-existing hearing, language or developmental problems. 
       • Family history of middle ear problems.
       • Chronic purulent nasal discharge (may indicate need for adenoidectomy as well).
       • OME that resolves then rapidly recurs is effectively chronic OME and should be managed as such.
       • Episodes of AOM.
       • Please attach any audiometry results and information from other agencies, even if the child has been seen at the hospital.
       • NB: It is imperative that in an uncomplicated case the referral demonstrates that there has been bilateral OME and hearing loss for 12 weeks or unilateral OME and hearing loss for 6 months. 
   • Post-Operative Grommet Care information
     • Grommets usually remain in the eardrum for 6-18 months (depending on type) and normally extrude spontaneously.
       
       
     • Surgical removal is rarely required – usually after 2 years if the patient has had no further problems. Occasionally, persistent discharge not responsive to ear drops develops due to the formation of biofilms and this necessitates grommet removal.
       
       
     • There are not any problems flying with grommets if the tubes are open, as the ears do not need to equalise.
       
       
     • Showering is preferable to bathing.
       
       
     • Bathing – avoid ear immersion. Prevent soapy water entering ears. Use ear plugs made of blu-tak, ready made ear plugs, and cotton wool with Vaseline.
       
       
     • Spa pools – no immersion of the head under water.
       
       
     • Treated swimming pool water and sea water – no precautions necessary except in a small group of patients who develop ear infections easily.

     If grommets discharge persistently post operatively aural toileting is required and topical ear drops. Sofradex is considered to be safe for 4-5 days treatment when used in the presence of inflammation. Ciproxin is probably a safer choice but is considerably more expensive. Oral antibiotics are significantly less effective.

3. More than 12 weeks with Bilateral OME and hearing loss history (unilateral threshold > 6 months)
   • Refer to ENT Refer to ENT / Otolaryngology (Head & Neck surgery)
     • Information to be included in referral letter
       • Length of time of OME and if bilateral or unilateral.
       • Reported hearing loss from parents or caregivers including length of that history.
       • Any suspected or diagnosed pre-existing hearing, language or developmental problems. 
       • Family history of middle ear problems.
       • Chronic purulent nasal discharge (may indicate need for adenoidectomy as well).
       • OME that resolves then rapidly recurs is effectively chronic OME and should be managed as such.
       • Episodes of AOM.
       • Please attach any audiometry results and information from other agencies, even if the child has been seen at the hospital.
       • NB: It is imperative that in an uncomplicated case the referral demonstrates that there has been bilateral OME and hearing loss for 12 weeks or unilateral OME and hearing loss for 6 months. 
   • Post-Operative Grommet Care information
     • Grommets usually remain in the eardrum for 6-18 months (depending on type) and normally extrude spontaneously.
       
       
     • Surgical removal is rarely required – usually after 2 years if the patient has had no further problems. Occasionally, persistent discharge not responsive to ear drops develops due to the formation of biofilms and this necessitates grommet removal.
       
       
     • There are not any problems flying with grommets if the tubes are open, as the ears do not need to equalise.
       
       
     • Showering is preferable to bathing.
       
       
     • Bathing – avoid ear immersion. Prevent soapy water entering ears. Use ear plugs made of blu-tak, ready made ear plugs, and cotton wool with Vaseline.
       
       
     • Spa pools – no immersion of the head under water.
       
       
     • Treated swimming pool water and sea water – no precautions necessary except in a small group of patients who develop ear infections easily.

     If grommets discharge persistently post operatively aural toileting is required and topical ear drops. Sofradex is considered to be safe for 4-5 days treatment when used in the presence of inflammation. Ciproxin is probably a safer choice but is considerably more expensive. Oral antibiotics are significantly less effective.

4. Pre-existing Hearing Loss or Relevant Disability
   • Cholesteatoma, Retraction pocket need immediate referral to ENT.

     Drum retraction	Cholesteotoma

     • Risk factors for hearing related developmental/learning difficulties
       • Permanent hearing loss independent of otitis media with effusion.
       • Cleft palate with or without an associated syndrome.
       • Syndrome (eg Down Syndrome) or craniofacial disorders that include cognitive speech language delays.
       • Suspected or diagnosed speech and language delay.
     • If any of the above risk factors present with OME the child needs immediate referral to ENT with audiology results. If audiology has not been previously performed, please arrange this too:
       • Autism spectrum disorder or other pervasive developmental disorders.
       • Blindness or un-correctable visual impairment.
       • Developmental delay.
     • The children with the above plus OME may need early referral once audiology results available.
   • Refer to ENT Refer to ENT / Otolaryngology (Head & Neck surgery)
     • Information to be included in referral letter
       • Length of time of OME and if bilateral or unilateral.
       • Reported hearing loss from parents or caregivers including length of that history.
       • Any suspected or diagnosed pre-existing hearing, language or developmental problems. 
       • Family history of middle ear problems.
       • Chronic purulent nasal discharge (may indicate need for adenoidectomy as well).
       • OME that resolves then rapidly recurs is effectively chronic OME and should be managed as such.
       • Episodes of AOM.
       • Please attach any audiometry results and information from other agencies, even if the child has been seen at the hospital.
       • NB: It is imperative that in an uncomplicated case the referral demonstrates that there has been bilateral OME and hearing loss for 12 weeks or unilateral OME and hearing loss for 6 months. 
     • Post-Operative Grommet Care information
       • Grommets usually remain in the eardrum for 6-18 months (depending on type) and normally extrude spontaneously.
         
         
       • Surgical removal is rarely required – usually after 2 years if the patient has had no further problems. Occasionally, persistent discharge not responsive to ear drops develops due to the formation of biofilms and this necessitates grommet removal.
         
         
       • There are not any problems flying with grommets if the tubes are open, as the ears do not need to equalise.
         
         
       • Showering is preferable to bathing.
         
         
       • Bathing – avoid ear immersion. Prevent soapy water entering ears. Use ear plugs made of blu-tak, ready made ear plugs, and cotton wool with Vaseline.
         
         
       • Spa pools – no immersion of the head under water.
         
         
       • Treated swimming pool water and sea water – no precautions necessary except in a small group of patients who develop ear infections easily.

       If grommets discharge persistently post operatively aural toileting is required and topical ear drops. Sofradex is considered to be safe for 4-5 days treatment when used in the presence of inflammation. Ciproxin is probably a safer choice but is considerably more expensive. Oral antibiotics are significantly less effective.

Unilateral OME Surveillance– 3-month review

1. If OME is unilateral monitor and review with tympanometry/pneumatic otoscopy.
2. Consider moving the child's position in the classroom with the unaffected ear closest to the teacher.  
3. Consider referral to ENT if unilateral OME persists for 6 months but note that with current thresholds child is unlikely to be seen. 
4. Earlier referral may be needed if there are complicating factors

   Pre-existing hearing loss or relevant disability.

   Cholesteatoma, Retraction pocket need immediate referral to ENT.

   Drum retraction	Cholesteotoma

   
   Risk factors for hearing related developmental/learning difficulties:

   • Permanent hearing loss independent of otitis media with effusion.
   • Cleft palate with or without an associated syndrome.
   • Syndrome (eg Down Syndrome) or craniofacial disorders that include cognitive speech language delays.
   • Suspected or diagnosed speech and language delay.

   If any of the above risk factors present with OME the child needs immediate referral to ENT with audiology results. If audiology has not been previously performed please arrange this too:

   • Autism spectrum disorder or other pervasive developmental disorders.
   • Blindness or un-correctable visual impairment.
   • Developmental delay.

   The children with the above plus OME may need early referral once audiology results available.

Information

• For Patients
  • Ministry of Health glue ear leaflet
  • Kidshealth - Glue ear
  • Post-Operative Grommet Care information
    • Grommets usually remain in the eardrum for 6-18 months (depending on type) and normally extrude spontaneously.
      
      
    • Surgical removal is rarely required – usually after 2 years if the patient has had no further problems. Occasionally, persistent discharge not responsive to ear drops develops due to the formation of biofilms and this necessitates grommet removal.
      
      
    • There are not any problems flying with grommets if the tubes are open, as the ears do not need to equalise.
      
      
    • Showering is preferable to bathing.
      
      
    • Bathing – avoid ear immersion. Prevent soapy water entering ears. Use ear plugs made of blu-tak, ready made ear plugs, and cotton wool with Vaseline.
      
      
    • Spa pools – no immersion of the head under water.
      
      
    • Treated swimming pool water and sea water – no precautions necessary except in a small group of patients who develop ear infections easily.

    If grommets discharge persistently post operatively aural toileting is required and topical ear drops. Sofradex is considered to be safe for 4-5 days treatment when used in the presence of inflammation. Ciproxin is probably a safer choice but is considerably more expensive. Oral antibiotics are significantly less effective.

  • Glue Ear information

    What can parents do for their child with otitis media with effusion (glue ear)?

    • Do NOT give the baby or child a bottle to drink in it’s cot or bed.
      
      
    • Babies should be breast or bottle-fed in a 'head up' position and not lying flat. Breast-feeding helps to protect against ear infections. Breast-feed for as long as possible.
      
      
    • Although not proven to work, it makes good sense to get your child to blow his or her nose frequently to clear mucus from the nose. It may also force air bubbles up the eustachian tube into the middle ear.
      
      
    • Cigarette smoking has been shown to cause OME (Glue Ear) and other respiratory problems as well. Don't smoke in the house, car, or near children.
      
      
    • If the child has other evidence of a cow's milk allergy then a 4 - 8 week trial of a dairy food free diet is worth trying.
      
      
    • If the child has Hay Fever, try and find the source of the allergy and get rid of it if possible (house dust, cats and other pets, plants etc) and treat the Hay Fever.
      
      
    • Attract your child's attention before you speak. Look directly at your child and raise your voice slightly. Talk to your child a lot and read lots of stories in a quiet area.
      
      
    • Ask the teacher to put your child at the front of the classroom and always speak directly to the child. Lip reading helps to reinforce what the child is hearing.
      
      
    • Tilting the head of the bed up by 200 – 300 mm (8 - 12 inches) may improve drainage from the middle ear. A pillow may be necessary in the bottom of the bed to stop the child from sliding down the bed.
  • Video explaining OME/grommets (3:21mins long)
• Acknowledgements

  NICE Guidelines
  Starship

  Pathway developed by the following people:

  Name	Title
  Dr Todd Hulbert	GP (Lead)
  Dr Hugh Lees	Paediatrician (Lead)
  Dr Chris Moyes*	Paediatrician
  Dr Claire McNally	GP
  Dr Tracy Momsen	Paediatrician
  Dr Evelyn Gerrish*	GP
  Dr Mark Haywood*	GP
  Dr Geoff Esterman	GP
  Dr Jeremy Armishaw	Paediatrician
  Dr John Malcolm	Paediatrician
  Dr Justin Wilde	Paediatrician
  Dr Richard Forster	Paediatrician
  Dr Joanne Simson*	GP Liaison
  Jacky Maaka	Admin Support
  Kerrie Freeman	Facilitator
  Richard Harrison	IT Analyst
  Trevor Richardson	DSA Manager

  *core group contributor

  Additional Contributors:
  Dr Brandon Hitchcock, Jeannie Bruning, Cassandra Kerr, Karen Thomas, Noeline White, Scott McLay

Disclaimer: These pathways, for the care and management of patients within Bay of Plenty, have been developed jointly by primary and secondary care clinicians. They provide guidance for General Practice teams to diagnose and manage patients suffering from a number of different conditions, and contain patient information resources. The pathways are maps of publicly-funded services accessed by referral from the community, and are strongly evidence based, but are not full clinical guidelines. As the pathways are suggested guidance only, while using them you must exercise your own clinical judgement and pertinent clinical data when treating your patient. This site is intended to be flexible and frequently updated. While every effort has been made to ensure accuracy, all information should be verified.