Otitis Media with Effusion (Glue Ear)

See Recurrent Otitis Media for shared risk factors and prevention.

Condition

Middle ear effusion can persist for several weeks after resolution of acute otitis media — this is otitis media with effusion (OME), characterised by middle ear effusion without the other signs/symptoms of acute otitis media (e.g. acute-onset ear pain, bulging tympanic membrane. OME involves accumulation of non-purulent fluid — thin and serous, or thick and mucoid — in the middle ear space. The dominant mechanism is Eustachian tube dysfunction: negative pressure develops in the middle ear, drawing a sterile transudate from the mucosa; when the fluid is thick and mucin-laden the condition is popularly known as “glue ear.” Elevated adenoid tissue, allergic inflammation, and (in adults) gastro-oesophageal reflux are all recognised contributors.

How common is it? OME is the single most common disease affecting children and the leading cause of acquired childhood hearing loss — up to 80% of children have at least one episode by age 4, with peak incidence between 2 and 4 years and a marked decline after age 6. By 3 months, 90% of effusions resolve spontaneously, but recurrence affects roughly 30–40% of children who have had an episode. It is more common in Aboriginal and Torres Strait Islander communities — detected in over 40% of young children in a Northern Territory survey — and in children from lower socioeconomic backgrounds.

Persistent OME (“glue ear”) is a middle ear effusion lasting longer than 3 months.

Risk factors (shared with recurrent acute otitis media): group child care; allergic rhinitis; adenoid disease; structural anomalies (cleft palate, Down syndrome, craniofacial syndromes); smoke exposure (second-hand or third-hand); bottle-feeding or feeding while supine; socioeconomic disadvantage; a sibling or parent with a history of otitis media. Ensure the child is up to date with Streptococcus pneumoniae vaccination (Prevenar 13).

Clinical features: loss of lucency of the tympanic membrane; visible grey-white or blue fluid; an immobile tympanic membrane with dilated blood vessels on pneumatic otoscopy or tympanometry. A “flat” (type B) tympanogram supports the diagnosis. Where hearing is formally tested, OME produces a conductive hearing loss with an air–bone gap typically greater than 15dB HL; mixed sensorineural loss can occasionally occur, though the mechanism is unclear.

Adults with unilateral OME need a nasopharynx check. OME is uncommon and usually unilateral in adults, and often follows an upper respiratory infection or pressure change (flying, diving) — but persistent unilateral OME in an adult should prompt nasopharyngoscopy to exclude a nasopharyngeal mass (including nasopharyngeal carcinoma) before it is attributed to a benign cause.

Management

Aims to restore hearing and resolve/prevent recurrent effusions. Most children need no active treatment — expectant management with risk-factor modification (avoiding smoke exposure and feeding while supine, breastfeeding where possible) is appropriate while awaiting spontaneous resolution.

Effusion present <3 months: if the child has normal hearing and isn’t at risk of speech/language problems, observation is appropriate — most effusions resolve spontaneously. Refer to an otolaryngologist if the effusion is associated with speech delay, learning problems, or structural tympanic membrane damage (e.g. significant retraction, cholesteatoma).

Effusion present ≥3 months (persistent OME): diagnosis can be difficult — patients may present with conductive hearing loss or behavioural problems. Perform audiometry to detect hearing loss and tympanometry to confirm an effusion. Refer to an otolaryngologist if audiometry shows bilateral hearing loss; children without hearing loss can be managed with a further 3 months of observation before re-assessing.

Medical treatments have not shown durable benefit and are not routinely recommended. A 2023 Cochrane review of antibiotics for OME found the use of antibiotics compared to no treatment “might slightly reduce the number of children who have glue ear at three months of follow-up,” but the evidence for a lasting effect is unclear and antibiotics “may cause unpleasant side effects such as skin rash. “Oral steroids “may reduce the number of children who have glue ear after 6 to 12 months, but we are uncertain how large this reduction might be,” and have “little or no impact on hearing and quality of life”; nasal steroid spray shows even less robust evidence of benefit, and prolonged oral steroid courses carry a risk of harms such as bone loss. Neither antihistamines nor decongestants improve resolution of OME and are not recommended. Nasal balloon autoinflation is a low-cost, low-harm option some children can be taught to use during a period of watchful waiting — trial evidence is mixed, with modest tympanometric improvement at 4 weeks in some studies, though it does not obviate the need for review.

Graded referral by hearing loss (per the high-risk-population management algorithm):

• <20dB, bilateral OME, normal hearing — continue regular review; refer to ENT only if severe retraction is present (retraction pocket or atelectasis).
• 20–35dB, mild hearing loss — continue regular review; recommend strategies to improve communication and classroom/personal amplification; ensure ongoing audiological/educational support; consider ENT referral.
• >35dB, mild-moderate hearing loss — continue regular review; recommend communication strategies; refer to ENT for grommet surgery; refer for hearing aids if surgery is unavailable or unsuccessful; ensure ongoing audiological/educational support.

Consider referral to an otolaryngologist for myringotomy and tympanostomy tube (grommet) insertion for frequent recurrences. The evidence behind grommets is weaker than commonly assumed. A 2023 Cochrane review of 19 trials (2,888 children) found the evidence “very uncertain” about how much ventilation tubes improve hearing — glue ear’s high rate of spontaneous resolution and recurrence makes this hard to study. Tubes “may slightly reduce the number of children who have glue ear after three to six months of follow-up,” but “it is not clear whether they also have an effect over longer periods of time,” and insertion carries a risk of a persistent tympanic membrane perforation, reported at “0% to 12%” across the included studies. This does not change the referral thresholds above — children with significant persistent bilateral hearing loss still benefit from ENT assessment — but families should be counselled that grommets are not a guaranteed fix and carry a real, if modest, complication rate.

Adenoidectomy (with or without concurrent grommet insertion) is considered for persistent or recurrent OME, particularly in children aged 4 years or older, when grommets alone have failed to prevent recurrence, or alongside a distinct indication such as nasal obstruction or chronic adenoiditis. A 2023 Cochrane review found the evidence similarly uncertain: it’s unclear whether adenoidectomy improves hearing, though it “may slightly reduce the number of children who have glue ear after one to two years of follow-up” — with a small but real bleeding risk from the surgery itself. Tonsillectomy alone has not been shown to improve OME outcomes and is not indicated for this purpose.