Glue ear (otitis media with effusion)

Behind the eardrum sits a small cavity that should contain nothing but air. Sometimes it fills with a thick clear fluid: the eardrum can no longer vibrate freely and sound arrives muffled, as if the ear had been plugged with cotton wool. That is otitis media with effusion, better known from the stickiness of its contents as glue ear. It does not look like an illness in the usual sense: the ear does not throb, there is no fever, the child runs about as always and simply hears less well. Because it is so quiet, the person who notices it is often not a doctor but a nursery worker or a teacher. It clears by itself, in most children within two or three months. The trouble starts when it drags on, because this is exactly the stage at which a child is learning to speak and to listen.

Where the fluid comes from

The middle ear is joined to the back of the nose by a narrow passage, the Eustachian tube. It opens on swallowing and yawning and does two jobs: it lets fresh air in and drains away whatever collects inside. If the tube stops opening, the air in the cavity is absorbed, a suction builds up inside, and the lining starts producing a fluid that has nowhere to go.

In children that tube is shorter, wider and lies almost flat, so it fails more readily. The usual culprits are:

• one cold after another, with swelling of the lining closing off the mouth of the tube;
• enlarged adenoids, which sit right at its opening;
• allergic rhinitis, with the nose permanently swollen;
• tobacco smoke in the house — one of the few factors that can be dealt with today;
• cleft palate, Down's syndrome and other differences in the shape or the workings of the lining: in these children the fluid drains poorly and rarely clears on its own.

Adults get it less often. In them the fluid usually turns up after a heavy cold or a flight, and as a rule in both ears.

What it looks like from outside

An adult will say the ear feels blocked, that something shifts or clicks inside on swallowing, that their own voice sounds hollow. A child says none of this: either they cannot yet, or they simply do not know it can be otherwise. So it is the behaviour that has to be watched:

• talking louder than usual and turning the cartoons up;
• asking for things to be repeated, not answering to their name unless they can see you;
• not hearing from another room, yet understanding everything close up and face to face;
• becoming irritable and unusually tired by evening, because straining to listen all day is exhausting;
• seeming distracted and away with the fairies in class;
• language coming on more slowly than in other children, or new mistakes appearing in words;
• becoming clumsy and falling more often, since the middle ear plays a part in balance.

Mild ache or a feeling of pressure in the ear and some ringing are sometimes added. The important difference from acute ear infection is that here there is neither a high fever nor the sharp pain that keeps a child awake all night.

What happens at the appointment

The doctor looks into the ear with an otoscope, an instrument with a light and a magnifier. Behind the drum there is amber or greyish fluid, sometimes with air bubbles or a clear fluid level, and the drum itself looks dull and drawn inwards. The examination does not hurt.

The suspicion is confirmed with instruments, and two words are worth knowing here:

• tympanometry, a short painless check of how much the eardrum moves. It takes seconds, requires no answers from the child and is more reliable than any amount of looking;
• a hearing test, matched to the age: play-based methods for the youngest, ordinary audiometry for older children and adults. It shows how much hearing has been lost, and whether any has.

After that the usual course is to watch and wait: since in most cases everything settles on its own within two or three months, there is no reason to rush in. The doctor arranges a repeat examination and a repeat hearing test to see whether things are improving or standing still. If fluid persists beyond three months in both ears and hearing is clearly affected, the child is referred to an ear, nose and throat specialist.

When waiting is wrong

The three-month approach is designed for the ordinary case. There are situations where it does not apply.

• An adult with fluid persisting in one ear only and no obvious reason for it. This is the main case for not delaying: the tube can be blocked by a tumour at the back of the nose, and glue ear can be its only early sign. A lump in the neck, nosebleeds and one side of the nose persistently blocked add to the concern. Examining the back of the nose is essential here, and it is a straightforward test.
• Blood or pus coming from the ear, or pain that prevents sleep.
• Severe pain with a high fever, redness and swelling behind the ear and the ear pushed outwards. With a listless child this is a complication needing help immediately; if the state is severe, call an ambulance, which across Europe is the single number 112.
• A drooping face, severe dizziness with vomiting, a violent headache. Also immediately.
• Foul-smelling discharge going on for months, or a pit, a pocket in the eardrum that the doctor has noticed: that is how cholesteatoma shows itself, a growth that erodes bone. It is treated, not observed.
• Children with cleft palate or Down's syndrome, and any child whose hearing was already reduced. In them the fluid seldom clears by itself, and they are referred without a waiting period.

What helps and what does not

Start with what not to do, because it saves months and money. In glue ear, antibiotics, decongestant nose drops, antihistamines, steroid sprays and tablets and mucus-thinning medicines do not work. An antibiotic is needed only if an acute ear infection has arrived on top, and it treats that infection, not the fluid.

What is worth doing:

• Time. The most effective remedy of all. Most ears clear themselves.
• Autoinflation. The child inflates a special balloon through one nostril, or swallows with the nose pinched, and so opens the tube. The benefit is modest but genuine, no medicine is involved, and it has to be repeated several times a day. The youngest cannot manage it, because it depends on following an instruction, and that comes at about three or four.
• No smoking in the house. Not on the balcony — not at all: the smoke settles in clothes and hair.
• Treating allergic rhinitis where there is any: clearing the swelling in the nose often helps the ear too.

Grommets, adenoids and hearing aids

If three months bring no change and hearing is down far enough to get in the child's way, intervention is discussed.

Grommets are tiny tubes placed in the eardrum under a short anaesthetic. The fluid drains, air returns to the cavity and hearing comes back at once, usually the same day. The tube is not permanent: it works its own way out over six months to a year and the hole closes. Among the consequences are occasional discharge from the ear and, less often, a small hole that fails to close on its own and scarring of the drum. The old ban on water is no longer strict: ordinary bathing and swimming in a pool are generally allowed, though about diving and depth it is worth asking the surgeon.

Removal of the adenoids is added to grommets when the nose is permanently blocked, the child mouth-breathes and snores, or when fluid returns once the tubes have come out. Doing both at once markedly reduces the chance of a second operation.

Hearing aids are a full alternative, not a fallback. They are chosen when anaesthetic is unwelcome, when the family would rather not operate, or when the problem is bound to return anyway, as with a cleft palate. They are worn temporarily, until the ear recovers.

While the child hears poorly

A handful of habits at home and in the classroom change matters more than one would think.

• Before speaking, get the child's attention and turn to face them: lips and expression carry half the meaning.
• Speak in a normal voice, clearly and not too fast. Shouting distorts sounds rather than clarifying them.
• Take away the background: switch off the television and the extractor fan when you are talking.
• Do not make them answer across a room; walk over.
• Tell the teacher and the nursery staff without fail. It helps to seat the child near the front and away from the window and the corridor; inattentiveness in lessons turns out, in these cases, to be an instruction that was never heard.
• If speech is already behind, do not wait for the hearing to sort itself out — ask about speech and language therapy.

And the reassuring part: in the great majority of children hearing returns in full and language catches up with their peers. With age the tube changes shape, the adenoids shrink, and glue ear stops coming back.

Online consultation

Remotely it is easy to settle the main question: whether this is what you think it is, and whether an appointment is needed or watching will do. The doctor goes through how the child behaves and what exactly you have noticed, explains how this differs from an acute ear infection and from a plug of wax, looks at any tympanogram and audiogram already done, and says how long to wait until the next check and on what signs waiting must stop. An online appointment also suits the period after surgery, for talking through care of an ear with a grommet, bathing and the return of symptoms. Looking inside the ear and measuring hearing cannot be done through a screen, so an examination will still be needed; and the signs in the urgent section are not discussed remotely at all.

This material is for information only and does not replace medical advice.