Serous Otitis Media in Children — Symptoms, Diagnosis and Treatment

What is serous otitis?

Serous otitis (otitis media with effusion, secretory otitis media) refers to the presence of fluid (effusion) in the middle ear cavity, behind an intact tympanic membrane, in the absence of signs of acute infection. It is the most common cause of hearing loss in preschool-aged children.

Approximately 90% of children will have at least one episode of serous otitis before school age. In most cases, it resolves spontaneously, but persistent forms require intervention to prevent consequences on hearing and speech development.

Symptoms

Serous otitis is often "silent" — the child does not experience pain and has no fever:

• Hearing loss — the child does not hear well, does not respond when called, turns up the television volume
• Sensation of blocked ear — in older children who can express the symptom
• Delayed speech development — in young children with persistent bilateral serous otitis
• Inattention and learning difficulties — due to undetected hearing loss
• Balance instability — rarely, through vestibular function impairment
• Behavioral changes — irritability, social withdrawal

Often, serous otitis is discovered incidentally during a routine ENT check-up or following an episode of acute otitis media.

Causes

• Eustachian tube dysfunction — the main cause; the tube does not properly ventilate and drain the middle ear
• Adenoid hypertrophy — enlarged adenoids mechanically block the pharyngeal opening of the tube
• Post-acute otitis media — residual fluid may persist for weeks to months after the acute episode
• Allergic rhinitis — allergic edema of the tubal mucosa
• Recurrent upper respiratory tract infections
• Cleft palate — tubal dysfunction due to palatal muscle anomaly
• Exposure to cigarette smoke

Risk factors include attending group settings (daycare, kindergarten), age between 6 months and 4 years, and the cold season.

Diagnosis

• Otoscopy — retracted tympanic membrane, yellow-amber or bluish in color, with visible fluid level or air bubbles
• Otomicroscopy — microscope examination, more precise
• Tympanometry — the reference test: type B (flat) curve confirms the presence of fluid
• Audiometry — reveals conductive hearing loss (usually 20-40 dB)
• Nasopharyngeal endoscopy — evaluates the adenoid vegetations and the tubal orifice

Tympanometry is a quick, painless, and extremely useful test for diagnosing serous otitis. Any child with suspected hearing loss should undergo tympanometric evaluation.

Treatment

Active monitoring (watchful waiting)

Most effusions resolve spontaneously within 3 months. Otoscopic and tympanometric reassessment is recommended at 4-6 week intervals.

Medical treatment

• Nasal corticosteroids — may improve tubal function
• Treatment of associated allergic rhinitis
• Oral antibiotics and antihistamines are not routinely recommended for serous otitis
• Valsalva maneuver and balloon autoinflation — in cooperative children

Surgical treatment

Surgical intervention is indicated when the effusion persists for more than 3 months with documented hearing loss:

• Myringotomy with tympanic ventilation tube insertion — the procedure of choice, allowing ventilation of the middle ear and fluid evacuation
• Adenoidectomy — frequently associated, especially if adenoid hypertrophy is present or serous otitis recurs after tube extrusion

Ventilation tubes are usually maintained for 6-12 months and are spontaneously extruded. During this period, hearing normalizes.

When to see a doctor

• The child does not seem to hear well or does not respond when called
• Delayed speech or language development
• Recurrent acute otitis media
• Sensation of blocked ear persisting after a cold
• Attention difficulties and poor school performance

Complications

• Persistent conductive hearing loss — with impact on language and learning
• Delayed speech development — especially in prolonged bilateral forms
• Tympanic retraction — due to chronic negative pressure, with risk of cholesteatoma
• Middle ear atelectasis — collapse of the tympanic membrane onto the middle ear structures
• Recurrent acute otitis media
• Cholesteatoma — a rare but serious complication requiring surgical intervention