Name of the Condition

• Acute Serous Otitis Media, Recurrent, Bilateral
• Also known as: Serous Middle Ear Effusion, Otitis Media with Effusion (OME).

Summary

Acute serous otitis media is an ear condition characterized by the accumulation of a non-infectious fluid in the middle ear, causing hearing difficulties and discomfort. The recurrent and bilateral nature signifies that this condition frequently affects both ears.

Causes

• Eustachian tube dysfunction, often following a cold, allergy, or respiratory infection.
• Fluid from past infections or allergies that did not fully resolve.

Risk Factors

• Young age: More common in children due to smaller, more horizontal eustachian tubes.
• Exposure to secondhand smoke.
• Frequent upper respiratory infections.
• Attendance at daycare or crowded settings.

Symptoms

• A sensation of fullness in the ear.
• Mild hearing impairment.
• Occasional complaints of ear pain, though it may be less severe than acute infections.
• Sometimes tinnitus or balance issues.

Diagnosis

• Physical examination, including an otoscope to visualize the eardrum.
• Tympanometry to assess fluid in the middle ear.
• Audiometry to evaluate the impact on hearing.

Treatment Options

• Observation, as many cases resolve without intervention.
• Nasal decongestants or antihistamines might be recommended for allergy relief.
• In chronic cases, insertion of tympanostomy tubes may help to drain fluid and restore pressure balance.

Prognosis and Follow-Up

• Generally good with appropriate management; many children outgrow the condition.

• Regular follow-up is crucial to monitor hearing and ensure fluid resolution.

  Complications

• Chronic hearing loss if left unmanaged.
• Possible impact on speech and language development in children.
• Rarely progresses to more serious infections.

Lifestyle & Prevention

• Avoid exposure to tobacco smoke.
• Encourage breastfeeding to enhance immune defenses in infants.
• Vaccinations to prevent upper respiratory infections.

When to Seek Professional Help

• If symptoms persist beyond a few weeks.
• Noticeable hearing loss or developmental delays in children.
• Severe ear pain, fever, or discharge from the ear.

Additional Resources

• American Academy of Otolaryngology–Head and Neck Surgery (www.entnet.org)
• National Institute on Deafness and Other Communication Disorders (www.nidcd.nih.gov)

Tips for Medical Coders

• Verify the bilaterality and recurrence history to ensure accurate coding as H65.06.
• Review patient's medical history for eustachian tube dysfunction or previous episodes to confirm coding.
• Common errors include overlooking the bilaterality or recurrent status; ensure specific documentation supports these aspects.