3.06 Serous Otitis Media

agk’s Library of Common Simple Emergencies

Presentation

Following an upper respiratory infection or an airplane flight, an adult may complain of a feeling of fullness in the ears, inability to equalize middle ear pressure, decreased hearing, and clicking, popping, or crackling sounds, especially when the head is moved. There is little pain or tenderness. Through the otoscope, the tympanic membrane appears retracted, with a dull to normal light reflex, minimal if any injection, and poor motion on insufflation. You may see an air-fluid level or bubbles through the ear drum. Hearing will be decreased and the Rinne test will show decreased air conduction (i.e., a tuning fork will be heard no better through air than through bone).

What to do:

• Tell the patient to lie supine with head tilted back and toward the affected side and then instill vasoconstrictor nose drops like phenylephrine 1% (Neo-Synephrine) or oxymetazoline 0.05% (Afrin), wait two minutes for the nasal mucosa to shrink, reinstill nose drops, and wait an additional 2 minutes for the medicine to seep down to the posterior pharyngeal wall, around the opening of the eustachian tube. Have him repeat this procedure with drops (not spray) every 4 hours during the day for no more than 3 days.
• After each treatment with nose drops, instruct the patient to insufflate his middle ear via his eustachian tube by closing his mouth, pinching his nose shut, and blowing until his ears “pop.”
• Unless contraindicated by hypertension or other medical conditions, add a systemic vasoconstrictor (pseudoephedrine 60mg qid).
• Instruct the patient to seek otolaryngologic followup if not better in a week.

What not to do:

• Do not allow the patient to become habituated to vasoconstrictor nose drops. After a few days, they become ineffective, and then the nasal mucosa develop a rebound swelling known as “rhinitis medicamentosa” when the medicine is withdrawn.
• Do not prescribe antihistamines (which dry out secretions) unless clearly indicated by an allergy.

Discussion

Acute serous otitis media is probably caused by obstruction of the eustachian tube, creating negative pressure in the middle ear, which then draws a fluid transudate out of the middle ear epithelium. The treatment above is directed solely at reestablishing the patency of the eustachian tube, but further treatment includes insufflation of the eustachian tube or myringotomy. Fluid in the middle ear is more common in children, because of frequent viral upper respiratory infections and an underdeveloped eustachian tube. Children are also more prone to bacterial superinfection of the fluid in the middle ear, and, when accompanied by fever and pain, merit treatment with analgesics and antibiotics (e.g., ibuprofen and amoxicillin) (see above). Repeated bouts of serous otitis in an adult, especially if unilateral, should raise the question of obstruction of the eustachian tube by tumor or lymphatic hypertrophy.

References:

• Csortan E, Jones J, Haan M, et al: Efficacy of pseudoephedrine for the prevention of barotrauma during air travel. Ann Emerg Med 1994; 23:1324-1327.

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