What is the treatment for otitis media with effusion (OME)?

Treatment of Otitis Media with Effusion (OME)

Watchful waiting for 3 months is the recommended first-line approach for children with OME who are not at risk for speech, language, or learning problems. 1

Initial Management Algorithm

1. Document and assess:

   • Laterality (unilateral vs. bilateral)
   • Duration of effusion
   • Presence and severity of associated symptoms 1

2. Risk stratification:

   • Determine if the child is at risk for speech, language, or learning problems
   • At-risk children include those with:
     • Visual impairments
     • Permanent hearing loss independent of OME
     • Speech/language delays
     • Craniofacial disorders
     • Developmental disorders 1

3. Management based on risk:

   • For children NOT at risk:

     • Watchful waiting for 3 months from date of effusion onset or diagnosis
     • During this period, 75-90% of OME cases will resolve spontaneously 1

   • For children AT risk:

     • More prompt evaluation of hearing, speech, and language
     • Consider earlier intervention 1

Medication

Antihistamines, decongestants, antimicrobials, and corticosteroids are ineffective for long-term management of OME and are not recommended. 1, 2

Common pitfalls with medication use:

• Antimicrobials may show initial benefits but become non-significant within 2 weeks of stopping
• Adverse effects include rashes, diarrhea, bacterial resistance
• Oral steroids can cause behavioral changes, increased appetite, and weight gain
• No evidence supports the use of mucolytics or nasal decongestants 1

Monitoring and Follow-up

1. Re-examination schedule:

   • Children with persistent OME who are not at risk should be re-examined at 3-6 month intervals
   • Continue monitoring until:
     • Effusion resolves
     • Significant hearing loss is identified
     • Structural abnormalities are suspected 1

2. Hearing evaluation:

   • Recommended when OME persists for 3+ months
   • Also indicated if language delay, learning problems, or significant hearing loss is suspected
   • Children who fail primary care hearing testing or are younger than 4 years should have comprehensive audiologic examination 1

3. Language testing:

   • Should be conducted for children with hearing loss 1

Surgical Management

When a child becomes a surgical candidate, the algorithm is:

1. Tympanostomy tube insertion is the preferred initial surgical procedure when:

   • OME persists for 4+ months with persistent hearing loss or other symptoms
   • Recurrent or persistent OME occurs in at-risk children regardless of hearing status
   • OME with structural damage to the tympanic membrane or middle ear is present 1, 3

2. Adenoidectomy:

   • Should NOT be performed as initial surgery unless a distinct indication exists (nasal obstruction, chronic adenoiditis)
   • Consider as an adjunct in children over 4 years of age 1, 2
   • For repeat surgery, adenoidectomy plus myringotomy with or without tube insertion is recommended 1

3. Procedures NOT recommended:

   • Tonsillectomy alone
   • Myringotomy alone 1

Patient Education During Watchful Waiting

During the observation period, clinicians should:

• Inform parents that the child may experience reduced hearing until effusion resolves
• Suggest strategies to optimize the listening environment:
  • Speaking in close proximity to the child
  • Facing the child and speaking clearly
  • Repeating phrases when misunderstood
  • Providing preferential classroom seating 1

Outcomes of Surgical Intervention

Tympanostomy tubes:

• Improve hearing levels by approximately 9 dB during the first 6 months and 6 dB after 12 months
• Reduce time with effusion by about 32% during the first year
• May cause tympanosclerosis as a potential adverse effect 4

The benefits of early surgical intervention on language development in otherwise healthy children with OME appear small, but may be more significant for children with pre-existing speech, language, or developmental issues 4.