Otitis media with effusion and grommet decisions — formative SAQs

SAQ 1 (10 marks)

A 4-year-old girl is brought to the general paediatric clinic because her preschool teacher reports she is falling behind, sits very close at story time and often does not respond when called. She has had recurrent winter colds but is otherwise well, with no ear pain and no fever. Otoscopy shows dull, retracted, amber-coloured tympanic membranes bilaterally with fluid levels, and reduced mobility on pneumatic otoscopy. Tympanometry shows flat type B traces bilaterally, and audiometry confirms a bilateral conductive hearing loss of 28 dB HL. The effusion has been present for at least four months. [3]

Question: Outline the diagnosis, the relevant investigations, and the stepwise management of this child, including the grommet decision and the evidence you would cite to the family. (10 marks) [3]

Model answer

Diagnosis and recognition (2 marks). The diagnosis is persistent bilateral otitis media with effusion (glue ear). The well, afebrile child with dull, retracted, amber tympanic membranes, fluid levels and reduced mobility, presenting with hearing and educational difficulty rather than pain or fever, is the classic picture of OME, here persisting for four months with a documented conductive hearing loss of 28 dB HL. This is distinct from acute otitis media, which would have pain, fever and a bulging red drum. [2] [3]

Investigations (2 marks). The diagnosis is already appropriately documented with the two investigations that drive every grommet decision: tympanometry confirming the effusion (flat type B traces bilaterally) and age-appropriate audiometry documenting the degree and type of hearing loss (a 28 dB HL bilateral conductive loss with an air-bone gap). No imaging or blood tests are required for typical OME. The duration of four months places this child beyond the three-month threshold at which intervention is considered. [2] [3]

The grommet decision (2 marks). This child meets the AAO-HNS 2022 criterion for surgery: clinicians should offer bilateral tympanostomy tube insertion to children with bilateral OME persisting three months or longer and documented hearing difficulties. She has bilateral OME for four months, a 28 dB HL conductive loss, and clear educational impact. She is therefore referred to ENT for consideration of bilateral grommets. Tubes are not indicated for a single episode under three months, and operating on otoscopy alone without audiometry is the classic error — neither applies here. [3]

The evidence to cite to the family (2 marks). Counsel the family honestly with the two pieces of evidence that shape expectations. The 2023 Cochrane review shows that grommets deliver a real but time-limited hearing benefit that narrows by around twelve months as the non-operated ear also resolves. The Paradise randomised trials, following children to age nine to eleven years, found no difference in developmental, language, academic or behavioural outcomes between early and delayed insertion. So the operation is justified by her current hearing and educational impact, not by fear of long-term developmental harm. [2] [1]

Disposition, follow-up and safety-netting (2 marks). Refer to ENT for bilateral grommet insertion. After surgery, review the ears within three months, advise on water precautions and the management of tube otorrhoea (topical antibiotic drops, not oral antibiotics, for uncomplicated discharge), and arrange periodic review until the tubes extrude and hearing is confirmed normal. Give a safety-net for any acute ear pain or fever (a superimposed acute otitis media). The prognosis is good: the tubes will restore hearing while patent, and the natural maturation of the Eustachian tube makes recurrence increasingly unlikely. [3]

SAQ 2 (10 marks)

Question: A 2-year-old boy is brought to the general practitioner two weeks after an upper respiratory infection. His mother reports he has been turning the television up but is otherwise well, afebrile and eating normally. Otoscopy shows a dull, slightly retracted right tympanic membrane with a faint fluid level; the left ear is normal. (a) What is the diagnosis and how does it differ from acute otitis media? (b) Outline the management and follow-up. (c) What feature would prompt earlier referral rather than a full three months of watchful waiting? (10 marks) [2]

Model answer

(a) Diagnosis and distinction from acute otitis media (4 marks). The diagnosis is otitis media with effusion (glue ear) — non-purulent fluid behind an intact, dull, retracted tympanic membrane, presenting with hearing difficulty two weeks after a cold, in a well, afebrile child. It differs from acute otitis media, which presents with acute ear pain, fever and a systemically unwell child, and a bulging, opaque, red or yellow tympanic membrane with loss of landmarks. OME is the dull, retracted, painless drum; acute otitis media is the bulging, red, painful drum. OME often appears as residual fluid after an acute infection has settled, which is the likely sequence here. [2] [3]

(b) Management and follow-up (3 marks). The first and default management is watchful waiting for three months, because most effusions resolve as the Eustachian tube recovers and the cold settles. Reassure the family, give hearing and speech advice, and provide a safety-net. Reassess at three months: if the effusion has persisted, perform tympanometry to confirm it and age-appropriate audiometry to document the hearing level before any surgical decision. Neither antibiotics nor steroids have a lasting role in OME and should not be prescribed routinely. Autoinflation with a nasal balloon device is a low-harm option with modest benefit in a child old enough to use it. [2] [7]

(c) The feature prompting earlier referral (3 marks). The standard three-month threshold is adjusted for the at-risk child, in whom even a mild additive conductive hearing loss has a higher developmental cost. Earlier audiology and ENT referral is warranted for a child with Down syndrome, cleft palate (overt or submucous), a permanent sensorineural hearing loss, developmental delay or autistic spectrum disorder, or blindness, and for an Aboriginal or Torres Strait Islander child with persistent disease, in whom early, culturally safe assessment and a lower threshold to treat are recommended. A child developing acute ear pain, fever or a bulging red drum has a superimposed acute otitis media needing separate assessment. [3] [4]