Patient: [Patient Name]
MRN: [Medical Record Number]
Date: [Date of Encounter]
Chief Complaint:
Hearing loss (may be mild and noticed by parents in children)
Ear fullness or pressure sensation
Earache (less common than in acute otitis media)
Difficulty understanding speech (especially in children)
Balance problems (less common)
History of Present Illness:
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Onset, duration, and severity of symptoms.
Recent upper respiratory infections (URIs) or allergies (common
triggers for OME).
Previous episodes of ear infections (otitis media).
History of ear tubes (if applicable).
Past Medical History:
Underlying medical conditions that may contribute to OME (e.g.,
cystic fibrosis, Down syndrome, cleft palate).
Allergies (allergic rhinitis can contribute to OME).
Previous surgeries (e.g., adenoidectomy, tonsillectomy).
Family History:
Family history of OME or other ear problems.
Social History:
Exposure to secondhand smoke (increases risk of OME).
Childcare attendance (increased risk in group settings).
Physical Examination:
General examination: Assess for signs of upper respiratory infection
(URI).
Ear examination: Otoscopy to visualize the tympanic membranes
(eardrums).
Look for signs of fluid behind the eardrum (cloudy, immobile
tympanic membrane).
Assess for pneumatic otoscopy findings (reduced or absent
pneumatic movement of the eardrum).
Diagnostic Tests (if indicated):
Tympanometry: Measures the movement (compliance) of the tympanic membrane in response to changes in air pressure. Abnormal tympanometry
findings can suggest OME.
Audiometry (may be performed if hearing loss is suspected):
Evaluates hearing acuity.
Assessment:
Otitis media with effusion (OME): Based on clinical presentation
(symptoms and otoscopy findings) and may be supported by tympanometry
results.
Severity of hearing loss (if present): Consider the degree of
hearing impairment based on audiometry results (if performed).
Duration of OME: Acute (less than 3 months), subacute (3-6 months),
or chronic (greater than 6 months).
Differential Diagnoses:
Consider other conditions that may mimic OME:
Acute otitis media (presence of earache and fever is more
suggestive)
Cerumen impaction (wax buildup in the ear canal)
Eustachian tube dysfunction (may coexist with OME)
Plan:
Treatment approach: Depends on the severity and duration of OME,
symptoms, and patient age. Options may include:
Watchful waiting: Spontaneous resolution is common, especially
in young children. Follow-up appointments are necessary to monitor
symptoms.
Nasal decongestants and/or antihistamines: To improve Eustachian
tube function and drainage (may be helpful for short-term symptomatic
relief).
Antibiotics: May be considered for specific situations (e.g.,
recurrent episodes, severe symptoms).
Ear tubes (tympanostomy tubes): Surgical insertion of tubes
through the eardrum to drain fluid and improve ventilation. May be
considered for persistent or recurrent OME with significant hearing loss
or developmental delays.
Hearing evaluation (if necessary): Audiometry testing to assess
hearing acuity, especially if concerns persist or worsen.
Speech therapy (if indicated): May be helpful for children
experiencing language delays due to hearing loss from OME.
Patient education: Educate the patient (or parents/caregivers)
about OME, causes, treatment options, and potential complications.
Prognosis:
Most cases of OME resolve spontaneously within a few months.
Early diagnosis and appropriate management can help minimize complications
such as hearing loss and developmental delays.