Otitis Media with Effusion

A 2-year-old presents to the emergency department (ED) for evaluation of ear discomfort after his mom noticed him sticking his finger into his right ear. The mom states the child has had several ear infections, the most recent infection being 2 months ago that was treated with antibiotics. Mom reports some concern about his hearing—she notes her son puts his fingers in his ears “a lot” and is lagging behind in his expressive language development. The child has nasal congestion and a low-grade fever but is otherwise well-appearing. The WiscMed Wispr digital otoscope exam is shown.

Which of the following is the most appropriate course of action now?

1. The ear is normal, no management is necessary.
2. Antibiotics should be prescribed.
3. Refer the child to otolaryngology (ENT) for tympanostomy tubes.
4. Provide symptomatic relief suggestions and have the child follow up with his pediatrician.

Answer: D. Provide symptomatic relief suggestions and have the child follow up with his pediatrician.

This child has Otitis Media with Effusion (OME) which is defined as middle ear effusion (MEE) without signs of infection of the fluid or inflammation of the tympanic membrane (TM). The hallmarks of OME are air-fluid levels behind a tympanic membrane that is not bulging. Because the TM is not bulging, the malleus ossicle is clearly distinguishable. The fluid is located in the middle-ear space. The lack of bulging and the presence of air along with the fluid suggests that the Eustachian tube is functioning properly.

OME most often occurs as a result of resolving AOM or in association with a viral upper respiratory infection. While typically requiring only supportive care, it should be noted that OME is also at the intersection between resolving AOM, evolving AOM, or Chronic Otitis Media with Effusion (COME), see Diagram 1.