After one cold follows another in winter, some children are slow to turn when called, turn up the television or keep asking "what did you say?". One of the most common reasons is fluid building up in the middle ear. Known medically as otitis media with effusion and commonly as glue ear, it is often painless and can easily go unnoticed. In this article we explain why the fluid collects, how it is recognised and when treatment is needed.

What is fluid in the ear?

The middle ear is a small space behind the eardrum that is normally filled with air and connected to the back of the nose by the Eustachian tube. When a cold, allergy or enlarged adenoids stop this tube working properly, the middle ear cannot be ventilated and fluid collects inside it. Fluid can also remain after a middle ear infection. Unlike an acute ear infection, there is usually no fever or severe pain. The NHS notes that it is much more common in children.

What are the signs?

The main signs listed by the NHS are:

  • Temporary hearing loss, often in both ears at once
  • Ear pain or a feeling of fullness in the ear
  • Ringing or buzzing in the ear
  • Balance problems; clumsiness and frequent falls in a small child

The clues parents notice are usually in behaviour: turning the volume up, not turning when called, speaking loudly, struggling to understand someone further away, seeming inattentive in class. The hearing loss can come and go with colds. For more detail, see our article on hearing loss in children.

Who gets it more often?

The risk factors summarised in the NICE guideline are:

  • A recent upper respiratory infection or ear infection
  • Asthma, wheezing and allergic conditions
  • Snoring, often together with enlarged adenoids
  • Exposure to cigarette smoke
  • Dummy use or thumb sucking
  • Differences in the structure of the face and skull, such as cleft palate

How is it diagnosed?

The doctor can usually see the fluid behind the eardrum by looking with an otoscope; the examination is painless. Tympanometry, which measures how the eardrum moves, and an age-appropriate hearing test support the diagnosis. NICE recommends that hearing is also assessed when fluid is found.

Treatment: usually watchful waiting

The NHS states that there is no effective medicine for glue ear, so the first approach is usually watchful waiting. NICE also stresses that antibiotics, steroids, decongestants and mucus-thinning medicines do not help fluid in the ear and are not recommended. What can be done during this time:

  • Facing the child when speaking and reducing background noise
  • Telling the teacher and seating the child near the front of the class
  • Nobody smoking at home; keeping the nose clear with saline during colds
  • In children over 3, autoinflation if the doctor recommends it: as described by the NHS, a special balloon is blown up through one nostril, or the child swallows while holding the nose closed; the aim is to open the Eustachian tube and help the fluid drain

If the fluid lasts more than 3 months and affects hearing, the child is referred to an ear, nose and throat specialist. Options include a temporary ventilation tube in the eardrum, removal of the adenoids if needed, or a temporary hearing aid.

What are grommets?

A grommet (ventilation tube) is a very small tube placed in the eardrum. It lets air into the middle ear, stops fluid building up and can improve hearing quickly. In children the procedure is done under general anaesthetic and takes a short time. According to the NHS, grommets usually fall out on their own within 6 to 12 months and the eardrum heals. The decision is not based on a single examination but on how long the fluid has lasted, whether both ears are affected and the result of the hearing test.

When to see a doctor

  • Behaviour suggesting reduced hearing: turning the volume up, often asking "what did you say?"
  • Speech falling behind children of the same age, or going backwards (speech delay)
  • Fullness in the ear or hearing problems lasting more than 3 months
  • Severe ear pain with fever, or discharge from the ear
  • Marked problems with balance

Children who have a long-lasting green runny nose through the winter, snore and seem to hear less should always have their ears examined. For monitoring language and speech development, see our developmental assessments page. You can book an appointment at Özel Düztepe Yaşam Hospital in Şahinbey, Gaziantep.