3.06 Serous Otitis Media
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agk's Library of Common Simple Emergencies

Presentation
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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:
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- 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:
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- 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   medicine is withdrawn.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
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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 [Otitis 
media]). 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:
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- 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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