Otitis media with effusion ( Part 2 ) – Treatment options

Otitis media with effusion, (OME) describes an inflammatory condition of the middle ear cavity where a fluid effusion that fills the middle ear space and dampens the movement of the eardrum; hence hearing is reduced.

This occurs due to a dysfunction of the naturally venting Eustachian tube that connects the middle ear space with the back of our nose. This Eustachian tube normally allows air to enter the middle ear space during swallowing. Hence the eardrum vibrates freely, and normal hearing is maintained. When this fails to take place, the middle ear pressure drops, and a fluid effusion fills the middle ear space.

What are the treatment possibilities? If OME persists, the discomfort and hearing impairment may need treatment. This is especially so for children who need to hear well to speak well, and especially so when the OME condition is affecting both ears at the same time. Hearing aid/s are a possibility but most children and adults do not find them practical for the treatment of OME.

The best treatment is to ventilate the middle ear through another route i.e. via the eardrum. A small surgical cut in the eardrum is first made, and then the fluid effusion is suction out of the middle ear space. A ventilation tube is then placed through the man-made eardrum hole. This ventilating tube is very small and no larger than the tip of a large ballpoint pen. It is made usually of inert silicone and designed to allow passive air entry from outside into the middle ear space. Hence the pressure is equilibrated, the fluid effusion no longer apparent, and the eardrum vibrates as usual with almost minimal hearing loss.

In a cooperative adult with OME, the tube can be placed under local anaesthesia with an operating microscope. In children who are more likely to move or easily frightened, these ventilation tubes are best placed under a quick short general anaesthesia.

The average tube stays in 6-18 months and fall out by themselves without the patients even realising. Longer stay tubes are available which remain until the doctor removes them. These longer stay special tubes are designed for patients who have ear conditions that require repeated reinsertions.

Otitis media with effusion causes hearing loss similar to having water in your ears after a shower. Ventilating tubes are simple solutions to improve the hearing especially if OME persists and is affecting hearing and speech development and learning.

The Chinese version of this article was published in Hong Kong Economic Journal on June 20, 2013.

A good friend of mine was recently treated by me for sleep apnea last year. He is happy to share his personal experience so I thought it would be an educational thing for my blog visitors to understand his experience and recount... from the most important person ever...the patient! Here goes......

James (not his real name), Caucasian, 47 years old, obese 102 kg, hypertension 140/95.  Below is his reported experience.

Q: How did you become aware of your sleep apnea?

A: I started waking around five times a night in a hot sweat after a bad dream that involved a near death experience. At first I thought I was suffering from stress but then did some googling and remember I had heard about sleep apnea from a friend. After reading about it on the Internet, I made an appointment with my family doctor who referred me to Dr Gordon Soo. He was the same ENT Specialist who had removed some nasal polyps from my nose and sinuses a few years earlier.

The consultation in the clinic confirmed I had obstructive sleep apnea which was compounded by my current weight. Dr Soo found I had enlarged turbinates and my septum (the nose bone) was crooked. I could relate to the enlarged turbinates but could not see how bent my septum was inside as my nose looked straight outside. Dr Soo used a nasal spray to reduce the size of the turbinates before scoping my nose to show me. With also a little stretching of the skin on either side of my nose to widen the nasal passages, I breathed better than I could ever remember.

Dr Soo suggested surgery to reduce the size of the turbinates, straighten my nasal septum and to widen the nasal passages. He said the lower extent of any airway obstruction could be further diagnosed by conducting a sleep endoscopy prior to the surgery.

Q: So how did the surgery go?

A: The worst thing you can do is read too much about this or any procedure on the Internet J. A lot of the discussions tend to highlight problems or mention procedures that involved old technology. I had my operation done at the Union Hospital and it is like a hotel. I actually looked forward to it as I knew I would have a couple of days being taken care of and was interested to know how I would recover.

On the day of the surgery, I checked in the morning of the operation after fasting overnight. The sleep endoscopy and the rest of the procedure went smoothly and I awoke a few hours later. I was eating the same evening and able to walk around without assistance.

Q: What was the recovery like?

A: Here’s where it gets interesting. Forget the horror stories about black eyes and pain. Firstly, my eyes were fine and I was watching TV and using my iPad within hours. Secondly, there was little or no pain. That was taken care of with the pharmaceuticals J. Also forget about a blocked nose, difficulty breathing and the painful removal of any nasal packs. Yes, my nose was blocked, but it had been so prior to the operation anyways. Since I only stayed in hospital for one night, I was douching my nose within 24 hours of the operation. Coupled with the nose drops, the special nasal packing I had, started to dissolve and the stitches tightened. The more I douched, the more I started to breathe.

On the third day, with some gentle blowing, big red boogers started to flow out of my nose. This continued for a couple more days and before I knew it, the remaining packing came out, and I was breathing like never before.

Q: It’s been two months, so what’s new?

A: Well, I resumed daily walks within a week of the operation and returned to the pool a fortnight later. As time went by, I felt more energetic. It was a strange feeling of wanting to conquer the world. I have resumed my swimming and walking schedule with vigour. Coupled with Xenical, I have lost about four kilos. I am also sleeping much better and wake only once in the middle of the night. I do not suffer from the urge to wake and pee.

Q: Do you have any other comments?

A: One thing that surprised me was the effect of air pollution in Hong Kong. A couple of weeks after the operation, I traveled to rural Australia where I continued to douche and walk. I slept through the whole night there. When I returned to Hong Kong, I had a blocked nose and I was worried. I kept douching and exercising and found that my sinuses adjusted to the change in weather. I had the same experience when I made trip a few weeks later. In my opinion, I think it’s the pollution, but we’ll have to leave that to the experts.

The other thing I want to say is that if you are suffering from sleeplessness and you have a blocked nose – do something about it. Don’t put up with it. Have the life you deserve. Don’t let sleeplessness endanger you or the people around you….

p.s. I forgot to add that since my surgery, my trough blood pressure is now 120/62 and even lower at other times of the day. I will probably have to revise my hypertension medication.

At our last record, James’ bodyweight had dropped to 92 kg. He has had to change his wardrobe several times and never felt fitter. Probably a good thing, as he recently became a father once again.

Gordon

Otitis media with effusion ( Part 1 )

Otitis media with effusion (OME) describes perfectly the pathology. It describes an inflammatory condition of the middle ear cavity caused by a negative middle ear cavity pressure. This results in fluid being drawn out from the inflamed mucosal lining, into the middle ear space as an effusion.

So how this comes about? What are the symptoms? Our middle ear space cavity connects with the back of our nose by the Eustachian tube. This tube is usually closed, to prevent bacteria from entering the sterile middle ear. However during swallowing, tiny muscles open this tube for a fraction of a second, and air is pushed up the tube, into the middle ear space. This maintains a middle ear air pressure that is the same as the atmospheric pressure outside the eardrum. When the air pressures on either side of our eardrums are the same, our eardrums are at their most flexible and responsive to sounds, and our hearing is at its best.

Normal Eardrum

When middle ear pressure drops, the eardrum is drawn inward and cannot vibrate easily to sounds; hence our hearing becomes impaired. As the inflammation increases, effusion fluid fills the middle ear space. When this fluid contacts the eardrum from within, it prevents it from moving. Now our hearing gets even worse. Hence patients with partial or complete OME suffer with the following symptoms:

• ear pressure sensations  during the descent in an aeroplane,

• bubbling noises during swallowing,

• hearing loss like having water in the ears after a shower,

• ringing noises called tinnitus from within their ears and

• sometimes pain in the ear.

Otitis media with effusion

Any condition that can cause obstruction of the Eustachian tube can cause OME in one or both ears. So what conditions would make the tube less easier to open during swallowing, or cannot open at all. Common causes are nose allergies, viral infection of the upper nasal airway and middle ear infections. Less commonly are tumours like cancers of the naso-pharynx. Of these, treating your nose allergy and taking precautions not to catch a cold, may help in preventing OME.

OME is quite common in children. A Chinese University of Hong Kong study by MCF Tong et al shows that OME in Hong Kong is present in one/both ears of 9% of children aged 2-10 years. This prevalence is no different from similar studies in the West. OME in children can causes hearing difficulties, and therefore speech delay, inattention, poor behaviour and poor school performance as they cannot hear well.  As middle ear infection is the commonest infection of childhood, it is naturally a major cause of OME in kids. A child’s nose is small and narrow, and the immunity of the child remains underdeveloped against the challenge of viruses and bacteria. In addition the rising trend of nasal and food allergies is thought also to be a factor.

In teenagers to adulthood in Hong Kong, middle ear infections are less common. So for adults, when OME is noted, cancer of the nasopharynx is a possible cause and should be excluded by an ENT examination. The south China region has the highest incidence of nasopharyngeal cancer in the world, with about 30 new cases per 100,000 population diagnosed each year. Early diagnosis is vital to good prognosis.

In summary, otitis media with effusion causes blocked ears and hearing loss. It is usually temporary and lasts a few weeks especially after a cold. If it persists, an ear and/or nasopharynx examination is recommended with your doctor. In children, it can cause speech delay whilst in aduts, cancer of the nasopharynx has to be excluded.

The Chinese version of this article was published in Hong Kong Economic Journal on June 6, 2013 and Part 2 will be published in Hong Kong Economic Journal on June 20, 2013.