Otitis media can be classified into two different types. Secretory otitis media is characterized by the presence of middle ear effusion behind an intact tympanic membrane; the tympanic membrane is retracted, immobile, dark yellowish, bluish, or it may be transparent with a hairline (liquid level) or air bubbles visible through it. It is usually caused by Eustachian tube dysfunction. In case of unilateral disease, the nasopharynx has to be explored to exclude the presence of a tumor. Acute otitis media is the consequence of an upper airway infection with blockage of the Eustachian tube and effusion in the middle ear, when the fluid in the middle ear gets additionally infected with bacteria. The tympanic membrane is bulged, and shows signs of cloudiness and redness. In severe or untreated cases, the tympanic membrane may rupture, allowing the pus in the middle ear space to drain into the ear canal. A simple medical treatment is required in most of the cases. Secretory otitis media is characterized by the presence of middle ear effusion composed of a transudate/exudate of the mucosa of the middle ear cleft that is formed behind an intact tympanic membrane. Classically, the tympanic membrane is retracted, immobile, dark yellowish or bluish, and thickened. At times, it may be transparent with a hairline (liquid level) or air bubbles visible through it. The causes are generally: Eustachian tube obstruction secondary to mucosal edema due to infection (sinusitis, nasopharyngitis) or allergy; extrinsic pressure on the cartilaginous portion of the Eustachian tube due to hyperplasia of glandular or lymphoid tissue or, rarely, due to tumors; and malfunction of the tubal muscles, as in children with cleft palate, or malformation of the tube itself, as in Down syndrome. Other factors that may contribute include: bacteriologic, immunologic, genetic, socioeconomic status, seasonal variation, as well as lack of transmission of specific immunoglobulins in nonbreast-fed infants. All these factors cause tubal dysfunction or occlusion, leading to negative middle ear pressure due to oxygen absorption by the mucosa of the middle ear cleft. Normally, the tendency of the tubal walls to collapse at the level of the isthmus can be overcome by an increase in the nasopharyngeal pressure. A negative middle ear pressure up to –25 mm Hg can be thus corrected. On the other hand, with edema of the tubal mucosa, the same increase in the nasopharyngeal pressure cannot overcome a negative middle ear pressure less than –5 mm Hg. In children, hyperplasia of the adenoid tissue is the most common predisposing factor, and nasopharyngitis is the most frequent cause of secretory otitis media. In adults, the condition is much less common and the presence of persistent unilateral otitis media with effusion can be due to a nasopharyngeal tumor that occludes the tubal opening, or a neoplasm that compresses or infiltrates the tube along its course. In cases that do not resolve despite proper medical treatment (nasal and systemic decongestants, mucolytics, and antibiotics) or in cases with persistent conductive hearing loss (see ▶ Fig. 4.1, ▶ Fig. 4.2), the insertion of a ventilation tube is indicated. In children, adenoidectomy is also performed. Surgery aims at alleviating the conductive hearing loss, avoiding the sequelae of otitis media with effusion. Sequelae include recurrent otitis media, tympanosclerosis, adhesive otitis media, retraction pockets with eventual cholesteatoma formation, and, in some long-standing cases, the formation of cholesterol granuloma (see Chapter ▶ 5). In this chapter, some typical cases of otitis media with effusion are shown. Refer to ▶ Fig. 4.3, ▶ Fig. 4.4, ▶ Fig. 4.5, ▶ Fig. 4.6, ▶ Fig. 4.7, ▶ Fig. 4.8, ▶ Fig. 4.9, ▶ Fig. 4.10, ▶ Fig. 4.11, ▶ Fig. 4.12. For the surgical treatment (myringotomy and ventilation tube insertion), the reader is referred to Chapter ▶ 14 on postsurgical conditions. Fig. 4.1 Conductive hearing loss. Bone conduction is normal. Air conduction is on average of 35 dB. Fig. 4.2 Tympanogram type B, typical of middle ear effusion. Fig. 4.3 Right ear. Secretory otitis media. Air bubbles can be seen anterior to the handle of the malleus and also in the posteroinferior quadrant. Fig. 4.4 Left ear. Secretory otitis media. Middle ear effusion having a reddish color inferiorly and a yellowish color superiorly. In this case, the differential diagnosis includes glomus tympanicum. If doubts still exist after microscopic examination, medical treatment is administered for several weeks and the patient is reexamined. Fig. 4.5 Right ear. Secretory otitis media with middle ear effusion and air bubbles visible in the anterosuperior quadrant. The tympanic membrane is retracted toward the promontorium. This case reflects usually a chronic condition that should be managed with the insertion of a ventilation tube. Fig. 4.6 Right ear. Secretory otitis media with middle ear effusion and air bubbles visible in the posterior quadrants. The patient has also a cholesteatoma in the contralateral ear (see Fig. 8.22). The CT scan shows the presence of fluid trapped in the mastoid (see ▶ Fig. 4.7). Fig. 4.7 CT scan, axial view of case in ▶ Fig. 4.6. The fluid is trapped in the mastoid air cells. The septa between the pneumatized cells are preserved. Fig. 4.8 Right ear. The presence of glue in the middle ear leads to bulging of the tympanic membrane. In the posterior quadrant, a thinned area of the drum is visualized, through which the yellowish color of the effusion is visible. The area would probably be the site of a future perforation. Fig. 4.9 Left ear. Secretory otitis media. The tympanic membrane is thickened. Catarrhal fluid can be seen through the relatively thinner anteroinferior quadrant.
4.1 Secretory Otitis Media (Otitis Media with Effusion)
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