Eustachian tube dysfunction is not the primary causative mechanism in "glue ear"
Farboud et al (1) present a commendable summary of issues in the
management of otitis media with effusion (OME or "glue ear") in primary
care. Although they recognise that the cause is poorly understood they go
on to state "it arises from eustachian tube dysfunction, causing
chronically low pressure in the middle ear". This "hydrops ex-vacuo"
theory was formulated by Politzer nearly 150 years ago (2), and although
stated sometimes even in contemporary literature (3), it is unsubstantiated4.
Abnormal opening or closing pressure ("function") of the eustachian
tube is demonstrated in some children when OME is present (5), but probably
reflects a narrowing of the lumen of the eustachian tube by mucosal
inflammation: an effect rather than a cause of OME. The ideal study, to
measure eustachian tube function in a cohort of children as a prospective
predictor of first episode of OME, seems infeasible. However, in children
who have had a first episode of OME, eustachian tube function does not
correlate to disease recurrence (6), nor explain the success of surgical
treatment (7) (8).
Empirically, eustachian tube function may be important in the
aetiology of OME in special circumstances such as craniofacial
malformation (unverified), but in non-syndromic cases present evidence
does not support this as a dominant aetiological factor. Instead onset of
OME reflects a complex interplay between the nasopharyngeal microbiome and
mucosal immunology, and with poorly understood factors that cause
progression from acute to chronic inflammatory signaling. However, the
duration of effusion in OME is known to have high heritability (9), and so
future dissection of host genetics (10) may prove a fruitful strategy in
Nuffield Department of Surgical Sciences, University of Oxford
1. Farboud A, Skinner R, Pratap R. Otitis media with effusion ("glue
ear"). BMJ (Clinical research ed 2011;343:d3770.
2. Politzer A. Diseases of the Ear. 5th edition ed. Philadelphia: Lea
and Febiger, 1869.
3. Bluestone CD, Bluestone, M.B., Coulter, J. The Eustachian Tube:
Structure, Function, Role in Otitis Media. Hamilton: B C Decker, 2005.
4. de Ru JA, Grote JJ. Otitis media with effusion: disease or
defense? A review of the literature. International journal of pediatric
5. Takahashi H, Hayashi M, Sato H, Honjo I. Primary deficits in
eustachian tube function in patients with otitis media with effusion.
Archives of otolaryngology--head & neck surgery 1989;115(5):581-4.
6. Straetemans M, van Heerbeek N, Schilder AG, Feuth T, Rijkers GT,
Zielhuis GA. Eustachian tube function before recurrence of otitis media
with effusion. Archives of otolaryngology--head & neck surgery
7. Knight LC, Hilger A. The effects of grommet insertion on
Eustachian tube function. Clinical otolaryngology and allied sciences
8. van der Avoort SJ, van Heerbeek N, Zielhuis GA, Cremers CW.
Sonotubometry in children with otitis media with effusion before and after
insertion of ventilation tubes. Archives of otolaryngology--head &
neck surgery 2009;135(5):448-52.
9. Casselbrant ML, Mandel EM, Rockette HE, Kurs-Lasky M, Fall PA,
Bluestone CD, et al. The genetic component of middle ear disease in the
first 5 years of life. Archives of otolaryngology--head & neck surgery
10. Rye MS, Bhutta MF, Cheeseman MT, Burgner D, Blackwell JM, Brown
SD, et al. Unraveling the genetics of otitis media: from mouse to human
and back again. Mamm Genome 2011;22(1-2):66-82.
Competing interests: No competing interests