CKS Clinical solutions - Glue ear

The case: A mother presents with her four-year-old child worried about his hearing. She explains he had 'a cold' six weeks ago and his hearing may have been affected.

A glue ear typically occurs following an episode of inflammation (Photograph: SPL)
A glue ear typically occurs following an episode of inflammation (Photograph: SPL)

On examination, you notice a fluid level behind the right tympanic membrane, suggesting a middle ear effusion.

What should I do next?
Gather more information about the hearing loss and ask if there are any concerns about development, such as delayed speech or behaviour problems. Observe the child's response to spoken language in the surgery.

CKS suggests this practical approach as it will help you decide whether a referral to ENT is needed.

What should I advise?
Explain that the child may have a glue ear, which is a collection of fluid in the middle ear and is a common condition.

Explain that glue ear typically occurs following an episode of inflammation, for example, 50 per cent of children with acute otitis media will develop glue ear.1

Should I treat?
No, there is no proven medical treatment for glue ear.

CKS based this recommendation on SIGN guidelines,2 and an appraisal of the evidence which shows no benefit in medical treatments (such as antibiotics or antihistamines) for glue ear.

Should I refer for a hearing test?
Yes, as there are concerns about hearing loss, which is difficult to assess in primary care.

An accurate level of hearing loss is needed to decide whether an immediate referral to ENT is needed, or whether watchful waiting in primary care is appropriate. CKS has based this recommendation on expert opinion and it is consistent with the NICE guidelines on referral to ENT. At present, there is no national guideline on when to refer a child with glue ear for a hearing test.3

Is watchful waiting safe?
Yes, as more than 50 per cent of glue ear episodes will resolve within three months. However, a child will need follow up to assess concerns about hearing.

Organise a hearing test at any stage if there are concerns over hearing.

It is important not to miss deteriorating hearing loss in children with glue ear. This recommendation is consistent with the NICE guideline on referral to ENT.

References

1. Robb PJ. Childhood otitis media with effusion. Clin Otolaryngol 2006; 31(6): 535-7.

2. SIGN. Diagnosis and management of childhood otitis media in primary care. Scottish Intercollegiate Guidelines Network, 2003. www.sign.ac.uk

3. NICE. Referral advice - a guide to appropriate referral from general to specialist services. National Institute for Health and Clinical Excellence, 2001. www.nice.org.uk

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