What tests or criteria are used to differentiate between fluid in the middle ear versus other diagnosis such as conductive hearing loss due to fusion of the bones? The patient is a 3 1/2 year old with significant hearing loss in the left ear, and only mild fluid as shown on the tympanogram. Three hearing tests generated almost identical responses.
Reply: --------------------------
Generally speaking, a tympanogram cannot reliably be used to differentiate "mild" middle ear fluid from more significant middle ear fluid. If the tympanogram is completely flat, this is the best evidence of middle ear fluid. If the tympanogram reveals some ear drum mobility with normal or negative middle ear pressures, then usually there is no fluid but rather a eustachian tube problem exists. An otolaryngologist typically relies on otoscopy including pneumatic otoscopy to diagnose middle ear fluid in children and in most cases uses a tympanogram mainly as a confirmatory test in selected cases. It is very difficult to definitively prove that a conductive hearing loss is due to an ossicular problem such as "bone fusion" without surgically exploring the ear, although in some cases a high resolution CT scan may be of assistance. However the presence of any fluid in the middle ear confounds the assessment.
Most cases of unilateral otitis media with effusion whether or not they are associated with significant conductive hearing loss will resolve on their own, although it may take several months. If any middle ear fluid is present in the presence of a significant conductive hearing loss in a single ear, the best advice would be to observe it over a 3-6 month period of time as long as the problem was otherwise asymptomatic, there is relatively normal hearing in the other ear, and an examination of the nose, and throat has been performed. Then if after 6 mos. the fluid and conductive hearing loss are still present, a myringotomy and possibly a tube insertion should be performed with an audiogram obtained post-operatively to re-measure the hearing. If the conductive hearing loss persists then one would suspect an ossicular abnormality. Treatment of unilateral conductive hearing loss due to ossicular abnormalities in young children with normal hearing in the other ear are usually deferred until the patient is an adult. If unilateral hearing loss of this nature is felt to contribute to poor performance in school that is not remedied by preferential seating (up front with better ear towards the teacher), then temporary amplification (hearing aid) would be an option until the child is old enough to consider surgical repair of the problem.
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Steve Dankle, MD
Otolaryngology-Head and Neck Surgery
Milwaukee, Wis
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