Introduction
Otitis media with effusion (OME) occurring in adult life may be a manifestation of underlying conditions or may be idiopathic.Reference Mills and Hathorn1 In particular, OME is associated with nasopharyngeal carcinoma (NPC) and its treatment with radiotherapy. Otitis media with effusion is frequently an intractable, chronic condition and its management presents the otologist with significant challenges.
Method
A review of the scientific literature from 1970 to the 2024 has been carried out. Several articles in Chinese with abstracts in English have been included because otherwise an important body of literature featuring otitis media with effusion in patients with nasopharyngeal carcinoma would have been excluded. The author was unable to read these papers and has relied entirely on the information provided in their abstracts.
The PubMed database was searched using the terms ‘management of otitis media with effusion in adults’, ‘management of otitis media with effusion in adult life’, ‘adult otitis media with effusion’ and ‘hearing aids for adults with otitis media with effusion’. Additional bibliographic referencing was undertaken. Only papers dealing with the management of OME in adults were included. Some of those reported below included children and adults. A significant proportion of the studies identified concerned only OME associated with nasopharyngeal carcinoma or the relatively recently recognised entity of eosinophilic otitis media and the specific management of these conditions has been highlighted.
Watchful waiting
This strategy plays an important part in the management of OME in children. Mills and Vaughan-Jones studied adults with OME referred to a hospital ENT clinic and found that spontaneous resolution of the effusions occurred in 37 per cent of them during a two-month observation period.Reference Mills and Vaughan-Jones2 This was significantly more likely to occur it there was a history of upper respiratory infection at the onset of the hearing loss (p <0.02).
Medical treatment
Treatments for nasal allergy
There have been isolated reports of the efficacy of an antihistamine (e.g. azelastine hydrochloride) and intranasal steroids (e.g. triamcinolone) for treating OME in adults.Reference Suzuki, Kawauchi and Mogi3, Reference Gluth, McDonald, Weaver, Bauch, Beatty and Ovidas4 The latter study was a prospective randomised, controlled trial but included patients with Eustachian tube dysfunction, as well as those with OME. Neither treatment was found to be effective.
Steroids and mucolytics
Dong et al. divided 86 patients with adult OME into two groups, one treated with ambroxal hydrochloride (a mucolytic) and dexamethasone (study group) and one with ambroxal hydrochloride alone (controls).Reference Dong, Ma, Liu and He5 Post-treatment hearing thresholds were significantly lower in the treatment group than in the controls. Zasadzińska-Stempniak et al. reported a pilot study in which adult patients with OME were administered inhaled mucolytics and steroids using an automatic manosonic aerosol generator, which is a type of nebulising system incorporating a pump that delivers temporary adjustable overpressure.Reference Zasadzińska-Stempniak, Karwat, Jarmołowicz-Aniołkowska and Zajączkiewicz6 Short-term improvement was noted in 81 per cent of the patients, but complete resolution of the effusions occurred in only 39 per cent.
Intratympanic steroids
Yang et al. compared intratympanic budesonide and dexamethasone, with normal saline acting as a control, in 90 children over 12 years old and adults (112 ears).Reference Yang, Zhao, An, Zheng, Yu and Gu7 Injections were given once a week. Dexamethasone treatment was associated with greater improvement in subjective symptoms than normal saline, but budesonide was more effective than dexamethasone. Kuo et al. treated patients (27 patients, 44 ears) with post-irradiation OME with nasopharyngeal carcinoma with weekly administration of dexamethasone administered through a laser myringotomy.Reference Kuo, Wang, Chu and Shiao8 The mean follow-up period was 37 weeks. Half of the ears developed persistent eardrum perforations, 78 per cent of which were dry; 40 per cent of ears developed recurrent middle-ear effusions.
Intratympanic steroid therapy also has been used in patients with eosinophilic otitis media.Reference Yukiko, Nagamine, Kakizaki, Komiya, Katano and Saruya9, Reference Esu, Iino, Masuda, Kanazawa and Yoshida10 One instillation of triamcinolone rendered 81 per cent of ears free of effusion for more than three weeks, as compared with 26 per cent in controls.Reference Kuo, Wang, Chu and Shiao8 In a study of 68 patients with eosinophilic otitis media (136 ears), Esu et al. classified the cases into three grades, based on middle-ear mucosal thickness.Reference Esu, Iino, Masuda, Kanazawa and Yoshida10 Fourteen patients with very thick (grade 3) mucosa underwent surgical removal of mucosa in addition to steroid therapy. Grade 1 cases received intratympanic triamcinolone alone, while grade 2 cases had systemic steroid therapy as well.
Other treatments for eosinophilic otitis media
Three case reports describe the use of novel treatments for eosinophilic otitis media: ramatroban (a thromboxane A2 receptor),Reference Wada, Uemaetomari, Murashita, Tobita, Tsuji and Tabuchi11 mepolizumab (an anti-IL-5 monoclonal antibody)Reference Suzaki, Kimura, Tanaka, Hirano, Ishibashi and Mizuyoshi12 and pegylated interferon-alpha 2a and b).Reference Neff, Voss, Carlson, O’Brien and Butterfield13 In each case positive responses were obtained. However, no follow-up reports with larger numbers have been published yet.
Auto-inflation
Auto-inflation by the Valsalva manoeuvre can produce improvement in hearing lasting up to thirty days,Reference Han, Park, Kim, Park and Park14 but is unlikely to be a permanent solution in most patients. The use of a balloon on a tube inserted into the nose was investigated by Ogawa in 21 adults over a 16-month period.Reference Ogawa15 In adults with a short history of adult OME (n = 16; 23 ears), the tympanograms for 12 ears were converted from type B to type A and three from type B to type C1. Lesinskas divided 198 patients with adult OME into three treatment groups: middle-ear inflation alone, a combination of inflation and antibiotics (amoxicillin), or no treatment.Reference Lesinskas16 After six weeks, half of the patients in both treatment groups had improved, as compared to only 11 per cent of the control group (p <0.001). No long-term follow-up data were available. Zhong et al.Reference Zhong, Zhang, Ren, Liu, Zhen and Xiao17 treated 107 adult patients with OME using either auto-inflation alone or in combination with medication. They reported that a successful outcome was more likely in younger patients, those with smaller air–bone gaps and those who received the combined treatment rather than auto-inflation alone.Reference Zhong, Zhang, Ren, Liu, Zhen and Xiao17 Perera et al.Reference Perera, Glasziou, Heneghan, McLellan and Williamson18 reviewed eight studies including 702 patients (a mixture of adults and children). They commented: ‘all of the studies were small, of limited treatment duration and had short follow-up’.Reference Perera, Glasziou, Heneghan, McLellan and Williamson18
Surgical treatment
Myringotomy
Several studies have examined the use of laser myringotomy, without other interventions such as tube placement, in patients with OME associated with nasopharyngeal carcinomaReference Hwang, Chien, Lin, Peng, Chang and Su19 and in other cases of adult OME.Reference Zanetti, Piccioni, Nassif, Campovecchi and Redaelli de Zinis20–Reference Prokopakis, Lachanas, Christodoulou, Bizakis, Karatzanis and Velegrakis23 Zanetti et al. compared laser myringotomy (39 ears) with knife myringotomy and ventilation tubes (34 ears).Reference Zanetti, Piccioni, Nassif, Campovecchi and Redaelli de Zinis20 Hearing improved immediately after the procedures in all the patients in both groups. In the laser myringotomy group, effusions recurred within a month of healing of the drum in 92 per cent of ears, whereas recurrence was only noted in 24 per cent of ears with ventilation tubes (p <0.001).Reference Zanetti, Piccioni, Nassif, Campovecchi and Redaelli de Zinis20 Hwang et al. reported that 40 per cent of 68 ears in patients with nasopharyngeal carcinoma developed persistent perforations following laser myringotomy.Reference Hwang, Chien, Lin, Peng, Chang and Su19 Of the remainder, 37 per cent had recurrence of OME and 23 per cent were disease free with intact drums. Persistent perforations were found in only 3 per cent of 37 ears in non-NPC patients, while 43 per cent of these ears were disease free. Chang et al. compared the outcome of laser myringotomy in 96 adults (108 ears) and 130 children (160 ears).Reference Chang, Yang, Fu and Shiao21 Cure rates at six months were similar in both groups (64 per cent and 58 per cent, respectively). Cohen et al. carried out a similar study but with a two-year post-operative observation period.Reference Cohen, Schechter, Slatkine, Gatt and Perez22 Perforations remained open for a mean duration of 22 days in adults. Prokopakis et al. investigated the results of laser myringotomy at two months in 108 adults (142 ears) with a variety of middle-ear disorders, including OME.Reference Prokopakis, Lachanas, Christodoulou, Bizakis, Karatzanis and Velegrakis23 They reported that 48 per cent of patients were free of middle-ear effusion following closure of the perforations.
Ventilation tubes
The efficacy of ventilation-tube insertion and its complications have been studied in patients with nasopharyngeal carcinoma,Reference Wei, Engzell, Lam and Lau24–Reference Charusripan and Khattiyawittayakun33 sinonasal tumoursReference Miller, Hall and Ahsan34 and those without.Reference Heaton and Mills36–Reference McCluney and Mills40 Charusripan and Khattiyawittayakun reported hearing air-conduction thresholds in patients who were irradiated for NCP and who had ventilation tubes inserted and those who did not.Reference Charusripan and Khattiyawittayakun33 The mean air-conduction threshold for the ventilation tube group was 38 dB, as compared with 52 dB in the non-ventilation tube group (p <0.001). However, Miller et al. found that only 54 per cent of the patients treated with ventilation tubes for nasopharyngeal or sinonasal cancers experienced hearing improvement.Reference Miller, Hall and Ahsan34 Xu et al.Reference Xu, Ou, Zheng, Chen and Ji31 found that only 51 per cent of ears treated with ventilation tubes were free of middle-ear effusion at the end of a two-year observation period; 29 percent of them had persistent perforations and 7 per cent of the group had active discharge. They compared outcomes in this group of patients with those in patients treated with myringotomy and aspiration of effusion (group 1) and those in whom this was combined with cauterisation (group 3). The proportion of patients who were effusion free after two years was 38 per cent in group 1 and 46.7 per cent in group 2.Reference Xu, Ou, Zheng, Chen and Ji31
Liang et al. reported recurrent OME in 53 per cent of patients two years after completion of radiotherapy.Reference Liang, Su, Twu, Jiang, Lin and Shiao32 Eight patients still had ventilation tubes in situ and one had a dry perforation. Dry perforations were present in 8 per cent of ears and discharging perforations in a further 7 per cent.Reference Liang, Su, Twu, Jiang, Lin and Shiao32 Morton et al. found no difference in the rate of resolution of OME in patients treated with ventilation tubes and those who did not receive them.Reference Wei, Engzell, Lam and Lau24 Lau et al. compared the outcomes of ventilation-tube placement in patients with and without NPC.Reference Lau, Wei, Sham, Hui and Choy26 Tympanic membrane defects took longer to heal in the patients who had been irradiated (p <0.04) and there were more persistent perforations in this group (p <0.03). Discharge via ventilation tubes was reported in 28–68 per cent of cases.Reference Morton, Woollons and McIvor27, Reference Liang, Su, Twu, Jiang, Lin and Shiao32, Reference Charusripan and Khattiyawittayakun33 Aural discharge was found to be significantly more frequent in patients who received ventilation tubes than in those who did not (p <0.05).Reference Morton, Woollons and McIvor27
In the study reported by McLuney and Mills, 97 per cent percent of 42 ears with adult OME not associated with nasopharyngeal carcinoma had audiometric improvement immediately following ventilation tube placement.Reference McCluney and Mills40 However, Dempster and Swann found that only two of 50 ears maintained their improvement in hearing two months after the extrusion of the ventilation tube.Reference Dempster and Swan35 Recurrence of adult OME following extrusion of ventilation tubes in 61 per cent of 31 patients was reported by Yung and Arasaratnam,Reference Yung and Arasaratnam38 in 62 per cent of 89 patients by Jiang and LiuReference Jiang and Y-h39 and in 59 per cent of 335 ears by Tu et al.Reference Tu, Chen, Lien and Chang37 The most commonly reported complication of ventilation tube placement is otorrhoea, which occurred in 27 per cent of cases in the study reported by Heaton and Mills.Reference Heaton and Mills36
Eustachian tube surgery
A number of studies have examined the benefits of balloon dilatation Eustachian tuboplasty in otitis media with effusion.Reference Poe, Silvola and Pyykkö41–Reference Sun, Cao, Qui, Hu and Zhang51 Poe et al.Reference Poe, Silvola and Pyykkö41 studied 11 patients with adult OME who were unable to auto-inflate their ears using the Valsalva manoeuvre, swallowing or yawning. Following the procedure all of them were able to perform a successful Valsalva and there were no complications.Reference Poe, Silvola and Pyykkö41 Four studies have compared balloon dilatation Eustachian tuboplasty with paracentesis.Reference Si, Chen, Chu, Chen, Xiong and Chen43, Reference Liang, Xiong, Cai, Chen, Zhang and Chen45, Reference Li, Jiang, Tian, Li and Li46, Reference Formánková, Formánek, Skoloudík, Zeleník, Tomášková and Chrobok48 Formánková et al. found that paracentesis plus balloon dilatation Eustachian tuboplasty was no more effective than balloon dilatation Eustachian tuboplasty alone.Reference Formánková, Formánek, Skoloudík, Zeleník, Tomášková and Chrobok48 Liang et al. reported that balloon dilatation Eustachian tuboplasty produced better outcomes than paracentesis alone at one month, but by three months this difference had disappeared.Reference Liang, Xiong, Cai, Chen, Zhang and Chen45 Yu et al. divided their patients into four groups: paracentesis alone, balloon dilatation Eustachian tuboplasty alone, balloon dilatation Eustachian tuboplasty plus paracentesis and balloon dilatation Eustachian tuboplasty plus paracentesis plus steroids.Reference Yu, Sun, Diao, Xia and Zhang47 The group that received steroids had better outcomes at six months but by a year there was no difference. Li et al. reported that the group that underwent balloon dilatation of the Eustachian tube had significantly better outcomes than the controls (p <0.05).Reference Li, Jiang, Tian, Li and Li46 Yu et al. used hypothermy plasma ablation therapy to remove hypertrophic tissue around the Eustachian tube orifice in 31 cases (39 ears) and compared the results with the findings in a control group of 17 cases (22 ears).Reference Yu, Sun, Diao, Xia and Zhang47 At one year the recurrence rate was 14 per cent in the treatment group, but 65 per cent in the control group (p <0.01). Miller and ElhassanReference Li, Tang, Xu, Chen and Mao50 reviewed the results of Eustachian tube dilatation in 235 patients. They concluded that short-term improvement (less than six months) was clearly demonstrated in these studies.Reference Li, Tang, Xu, Chen and Mao50
Two studies have investigated the benefit of Eustachian tube dilatation in patients with nasopharyngeal carcinoma.Reference Li, Tang, Xu, Chen and Mao50, Reference Sun, Cao, Qui, Hu and Zhang51 Li et al. used a Swan–Gans catheter to dilate the Eustachian tubes of 21 patients (37 ears).Reference Li, Tang, Xu, Chen and Mao50 Effusions resolved in 43 per cent of them. Sun et al. treated 58 patients (74 ears) by balloon dilatation Eustachian tuboplasty.Reference Sun, Cao, Qui, Hu and Zhang51 The improvement in the results of tympanometry was greatest at six months, but thereafter they deteriorated. After two years only one patient was effusion free.
Cortical mastoidectomy
Two papers describing the use of cortical mastoidectomy in the management of adult OME were identified.Reference X-h, X-b, Wang, Y-t and X-q52, Reference Long, Feng, Zhang and Xie53 Feng et al. carried out mastoidectomy with ventilation tube placement in 32 ears.Reference X-h, X-b, Wang, Y-t and X-q52 The mean air-conduction threshold for the group was 25 dB 1–2 years after surgery. The ears were free of effusion after removal of the ventilation tubes. Long et al. carried out mastoid operations with ventilation tube placement in 22 patients (33 ears).Reference Long, Feng, Zhang and Xie53 The ventilation tubes were removed after 3–6 months. Twenty-one ears had type A tympanograms after surgery.
Discussion
All the studies identified in this review featured relatively few patients. The largest study of cases associated with nasopharyngeal carcinoma included 163 patients (206 ears)Reference Ho, Wei, Yuen and Wong28 but most cohorts had fewer than 100 cases. The largest series of cases without NPC (198 patients)Reference Lesinskas16 was a study of patients undergoing daily inflation of the middle ear with a balloon device, combined with antibiotic therapy. These small numbers are not surprising, as adult OME is not a common condition. Examination of the author’s adult OME database revealed that 196 patients were added over a 22-year period (9 patients per year; R Mills, unpublished data). The only solution appears to be a multicentre study similar to the Trial of Alternative Regimens in Glue Ear Treatment for childhood OME (TARGET Trial).
Adult OME is a chronic condition lasting for years in many cases. Despite this, many of the studies only reported early results. Follow up was generally longer in patients with associated NPC, the longest being 10 years.Reference Chen, Young, Hsu and Hsu29 The longest follow up reported for cases without NPC was four years.Reference Silvola, Kivekäs and Poe42
Many of the studies were retrospective and/or lacked controls, only seven of them being randomised, controlled trials.Reference Suzuki, Kawauchi and Mogi3–Reference Dong, Ma, Liu and He5, Reference Yang, Zhao, An, Zheng, Yu and Gu7, Reference Lesinskas16, Reference Ho, Wei, Kwong, Sham, Au and Chua30, Reference Xu, Ou, Zheng, Chen and Ji31 Four of these studies were trials of medical treatments. In one study patients with OME secondary to NPC were randomised to receive either ventilation tubes before radiotherapy or no treatment.Reference Ho, Wei, Kwong, Sham, Au and Chua30 Follow up was continued for four years. In another study older children and adults with adult OME were randomised to receive intratympanic steroids or normal saline.Reference Yang, Zhao, An, Zheng, Yu and Gu7 Evaluation was by a visual analogue for symptoms. Two studies compared balloon dilatation Eustachian tuboplasty alone with balloon dilatation Eustachian tuboplasty and paracentesis.Reference Liang, Xiong, Cai, Chen, Zhang and Chen45, Reference Miller and Elhassan49
Despite the limitations of the papers described in this article, some conclusions can be drawn concerning the management of adult OME and priorities for future research can be identified. In the past the standard treatment of adult OME has been ventilation tubes, including those designed to remain in situ for long periods. It is clear that hearing does not always improve following this intervention, especially in patients with associated NPC.Reference Ho, Wei, Yuen and Wong28 One reason for this is that these patients frequently experience discharge via their ventilation tubes and via persistent perforations when the ventilation tubes are extruded.Reference Skinner and van Hasselt25–Reference Morton, Woollons and McIvor27, Reference Liang, Su, Twu, Jiang, Lin and Shiao32 Persistent perforations are more common in patients who have been treated with radiotherapy.Reference Chen, Young, Hsu and Hsu29 Following the extrusion of ventilation tubes, 49–53 per cent of cases developed recurrent effusions.Reference Lau, Wei, Sham, Hui and Choy26, Reference Ho, Wei, Yuen and Wong28
In these circumstances it seems to be imperative to consider whether there are viable alternatives to ventilation tubes in patients with NPC. There are only two reports of the use of Eustachian tube dilatation in this patient group.Reference Li, Tang, Xu, Chen and Mao50, Reference Sun, Cao, Qui, Hu and Zhang51 The results were no worse than for ventilation tubes in the short term and the risk of complications appears to be lower. These two studies included only 79 patients in total. This therapeutic approach is a logical one if the underlying pathology of adult OME following radiation is a post-radiation stricture of the cartilaginous portion of the Eustachian tube. Experience from the treatment of post-radiation strictures suggests that repeated dilatations would be necessary, but as the procedure is quick and relatively non-invasive, this would be acceptable. However, the cartilaginous portion of the Eustachian tube is closed much of the times and is opened by the veli palatine muscles, which are sometimes destroyed in cases with NPC. Further research is surely indicated.
In cases of adult OME not associated with NPC, ventilation tubes are more likely to be associated with hearing improvement in the short term and less likely to be complicated by aural discharge. Nonetheless, a significant proportion of effusions recur following extrusion of a ventilation tube.Reference Tu, Chen, Lien and Chang37–Reference Jiang and Y-h39 This may be because the underlying pathology in the middle-ear mucosa and/or the Eustachian tube remains unresolved. Middle-ear mucosal pathology could potentially be improved by intratympanic steroid therapy. This approach has been tried mainly in cases with eosinophilic otitis media.Reference Yukiko, Nagamine, Kakizaki, Komiya, Katano and Saruya9, Reference Esu, Iino, Masuda, Kanazawa and Yoshida10 In one of these cases, de-bulking of middle-ear mucosa was carried out in severe cases.Reference Esu, Iino, Masuda, Kanazawa and Yoshida10 If the efficacy of intratympanic steroid therapy is to be investigated further, routine collection and analysis of middle-ear effusions needs to be carried out to establish which cases have eosinophilic otitis media and which have another form of adult OME. It is possible that the way in which steroids are introduced into the middle ear is important, as medication in liquid form may be rapidly lost from the middle ear. Esu et al.Reference Esu, Iino, Masuda, Kanazawa and Yoshida10 de-bulked thick mucosa and then applied a steroid-soaked gelatin sponge. This may have prolonged the action of the medication. The use of a gelatin sponge or ointment in the middle ear might impair hearing in the short term but this would be justified if the long-term outcomes were favourable. Another approach would be to introduce steroids over a period of time using a device such as a Silverstein MicroWick or Pfleiderer intratympanic catheter system. Middle-ear mucosal biopsies taken before and after steroid treatment would be of interest.
Eustachian tube pathology can be targeted with balloon dilatation Eustachian tuboplasty. Three studies suggest that this approach is more effective than medical treatmentReference Yu, Sun, Diao, Xia and Zhang47 or paracentesis alone.Reference Li, Jiang, Tian, Li and Li46 Balloon dilatation Eustachian tuboplasty combined with methylprednisolone was more effective than balloon dilatation Eustachian tuboplasty alone.Reference Si, Chen, Chu, Chen, Xiong and Chen43 This appears to make sense, as the underlying pathology of OME is a change of the middle-ear mucosa from one with a predominance of inactive cuboidal cells to one that secretes serous or mucoid fluid.Reference Lim54–Reference Sade58 It appears reasonable to suggest that mucosal changes might be reversed by steroid therapy, but it is hard to see how balloon dilatation Eustachian tuboplasty would have this effect. Larger studies with longer follow up are needed.
Two studies investigated the use of cortical mastoidectomy to treat adult OME and reported positive results.Reference X-h, X-b, Wang, Y-t and X-q52, Reference Long, Feng, Zhang and Xie53 The longest follow up was two years. The generally accepted rational for this form of surgery was that a large air-containing cavity was created, which limited variations in middle-ear pressure. All too often cortical mastoid cavities fill up with soft tissue post-operatively, undermining this hypothesis. A second possibility is that the mucosa of mastoid air cells is an important source of middle-ear fluid and that its ablation is therefore beneficial. This hypothesis also lacks an evidence base. The question of whether or not cortical mastoidectomy is beneficial in adult OME may be resolved by a controlled trial.
The author was unable to find any publications investigating the value of hearing aids in the management of adult OME, despite indications that they have a place. Two studies mentioned the use of hearing aids without providing any outcome data.Reference Skinner and van Hasselt25, Reference Liang, Su, Twu, Jiang, Lin and Shiao32 A study using quality-of-life measures, such as the Glasgow Benefit Inventory, would be welcome.
• There is no good evidence that medical treatment is effective in OME in adults
• The use of ventilation tubes in adults with OME is associated with an unacceptable prevalence of aural discharge, particularly in cases associated with nasopharyngeal carcinoma
• The evidence supporting the use of balloon dilatation of the Eustachian tube to treat OME in adults is inconclusive
• Two very small studies suggest that cortical mastoidectomy may result in resolution intractable OME in adults
• There is some evidence that intratympanic steroids may be of value in treating OME in adults, especially in cases of eosinophilic otitis media
• Further research should focus on the role of balloon dilatation Eustachian tuboplasty, intratympanic steroids and cortical mastoidectomy
Conclusion
There is a need for rethinking management strategies for otitis media with effusion in adults, particularly those with associated nasopharyngeal carcinoma. Further research should focus on the role of hearing aids, baloon dilatation of the Eustachian tube, intratympanic steroids and cortical mastoidectomy. Of these, intratympanic steroid therapy appears to be the most promising option.
