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Don McFerran FRCS Consultant Otolaryngologist Essex County Hospital, Colchester
What is glue ear? Glue ear is a common cause of hearing impairment caused by a build up of fluid in the middle ear.
The middle ear is a small space underneath the ear drum which is normally filled with air. This space contains the three little bones of hearing - the hammer, anvil and stirrup (or malleus, incus and stapes) - that conduct sound vibrations from the ear drum to the inner ear. When the space is full of fluid the ear drum and bones cannot vibrate properly and the sound is not transmitted as efficiently as before. The fluid that accumulates in glue ear is sometimes thin and watery but is more often thick and sticky, hence the term ‘glue’.
Confusingly the condition can also be known as secretory otitis (SOM) or otitis media with effusion (OME).
What causes glue ear? The air that is normally in the middle ear reaches this site from the back of the nose via a small tube called the eustachian tube. Most of us are aware that if we swallow or yawn our ears pop. This is because the action of the swallowing or yawning opens our eustachian tubes and allows the air up the tube and into the middle ear. In patients with glue ear the fundamental problem is that the eustachian tubes are not working properly and air is unable to reach the middle ear. Initially this causes a negative pressure in the middle ear which pulls the ear drum inwards. If this negative pressure persists the lining of the middle ear changes and produces the fluid that results in glue ear.
Glue ear can occur at any age but is especially common in children because their eustachian tubes are immature and do not function properly. Another reason why glue ear is common in childhood is that the adenoids tend to enlarge around the age of three or four: adenoid tissue resembles a single tonsil and is situated above and behind the uvula (“the dangly thing at the back of the throat”), where the back of the nose joins the back of the throat. The function of adenoids is to help to fight infection and their presence is generally beneficial. However, if the adenoids become significantly enlarged they can block the eustachian tubes.
Smoking, whether active or passive, damages the eustachian tubes and increases the risk of developing glue ear. Repeated ear infections can cause glue ear but usually there is no history of ear infection. Colds and sinus infections can cause swelling around the eustachian tube and predispose to glue ear. In a few patients allergy seems to be involved in the development of glue ear.
What are the effects of glue ear? A person with glue ear has muffled hearing. Even if the fluid is very thick and the middle ears are completely full, some sound will still reach the inner ear and therefore total deafness does not result.
An adult or older child will report this hearing loss directly. Smaller children and babies do not volunteer this information and diagnosis is more difficult. Often they seem to be not paying attention or concentrating. They may appear to be in a different world of their own. School work may be poor and the child may show behavioural problems due to the frustration of not being able to hear adequately. In very young children and babies there may be delay in the development of speech. In older children, development of other language skills such as reading and writing may be delayed.
Sufferers frequently want the television louder than other people. Ear ache sometimes occurs especially in the initial phases when there is negative middle ear pressure. When the fluid is established the condition is usually pain free. People with glue ear sometimes seem clumsier than normal.
How is glue ear diagnosed? Screening of Children’s hearing is changing in the UK. Previously hearing was tested at approximately seven months and again at three years old. Now the health service is moving over to performing the first test immediately after birth. Parents are still questioned about their child’s hearing at the three year developmental check and a hearing test is generally done when a child starts school. Any of these tests may detect hearing loss due to glue ear.
If any person is concerned about their own hearing or if a parent or school teacher is worried about a child's hearing the first port of call should be the general practitioner. The GP will look in the ears to make the diagnosis. Most GPs will then wait for a period and reassess the patient. If the glue ear persists the GP will refer the person to a specialist. Hearing tests are available for all age groups but the exact nature of the test does depend on the age of the patient. There is also a test which shows up negative pressure or fluid in the middle ear. This is called tympanometry or acoustic impedance audiometry. All the tests are painless, non-invasive and easy to perform.
What can be done about glue ear?
Glue ear is very common and generally is a mild and temporary condition. Therefore the first thing to do is to wait and retest in three to four months. Doctors sometimes refer to this as “watchful waiting”. Teachers should be told that the child’s hearing is reduced so that special allowances can be made at school. Active treatment is only needed if the condition causes significant hearing loss for a prolonged time.
Sometimes it is difficult to distinguish glue ear from an acute ear infection. A course of antibiotics may be appropriate. Other medication such as nasal decongestants and anti histamines have been tried but there is little evidence that these help in the majority of cases. Patients with glue ear should be kept away from smokers.
An Otovent® device can be used by older children and adults. This is a special balloon that is inflated using the nose. This encourages the eustachian tubes to work again. Otovents® are available at good pharmacies without prescription and come with full instructions – check with your GP or ENT department first. This is a slightly controversial treatment: some doctors believe it to be helpful whereas others feel it offers no benefit.
Hearing aids are very effective at dealing with the hearing deficit and some patients prefer this approach to surgery.
The middle ear fluid can be drained out by making a tiny incision (approximately 2mm) in the ear drum. Children require a short general anaesthetic for this procedure but adults can often be treated under local anaesthetic. Sometimes simply draining the fluid is all that is required.
However, often the surgeon then puts a grommet (also known as a ventilation tube) into the incision in the ear drum. This is a tiny plastic or metal tube that sits in the ear drum and allows air to reach the middle ear. This bypasses the patient's own blocked eustachian tube and allows the ear to return to normal.
The grommet is gradually pushed out by the ear drum as it grows. This process is very variable but usually takes nine to twelve months.
If the glue ear is associated with symptoms of enlarged adenoids, the surgeon may suggest removing the adenoids under the same anaesthetic as the grommet insertion.
Care of grommets
Instructions vary according to the patient and the surgeon who performed the operation. Most surgeons suggest that the ears should be kept dry for a short while after the operation, usually a matter of a few weeks. It is then usually possible to go swimming again though it may be necessary to wear waterproof ear plugs. Diving and swimming under water should be avoided. It is a good idea to keep soapy water out of the ears while the grommets are in situ.
Occasionally an ear with a grommet in place starts discharging. This is abnormal and the GP should be contacted. Antibiotics and ear drops usually control the problem quickly. Very rarely the discharge continues and in these circumstances it may be necessary to remove the grommet.
There is no restriction on air travel for patients who have grommets. Indeed, grommets allow air pressure in the ear to equalise and prevent pain on take-off and landing.
Long term outcome of glue ear
Most people who develop glue ear eventually recover. Active treatment is aimed at allowing normal hearing for social and educational requirements until this recovery has occurred. The majority of children with glue ear have grown out of the condition by the age of eight or nine.
Of the patients who require grommets, the majority need only one set: by the time these have come out, the eustachian tubes have returned to normal and the problem does not recur.
A few people do need several sets of grommets and a few of these do need to remain under specialist review. Minor scarring of the ear drum is not uncommon after grommet insertion but this seldom causes any problem. Rarely a small hole or perforation of the ear drum persists after the grommet comes out and a further small operation may be needed to close the hole.
Latest developments and the future
Recently a new device for the treatment of glue ear has come on the market. The EarPopperTM is a small device that is held against one nostril. The other nostril is blocked by pressing with a finger and the patient is instructed to swallow. The device increases the air pressure in the nose which in turn causes the eustachian tubes to open and air to reach the middle ear. Although the developers of this device have reported very good outcomes there are no independent trials as yet. As with all new devices, the BTA advises waiting for independent trials before recommending the technique.
Over the years there have been various attempts at trying to improve eustachian tube function by operating directly on the tubes. These have generally tended to make the condition worse rather than better. Recently some doctors have revisited this idea using more modern surgical equipment and have used lasers under endoscopic control to widen the tubes. Some optimistic reports have been published. However, this is still very much at the experimental stage and the technique has only been tried on patients who have had very severe eustachian tube problems over many years.
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January 2006 - © British Tinnitus Association
This information is not a substitute for medical advice. You should always see your GP / medical professional.
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