Are diuretics (medications that increase urine production) effective in treating ear effusion (middle ear fluid)?

Diuretics Are Not Recommended for Ear Effusion

Diuretics should not be used for the treatment of ear effusion (middle ear fluid) as there is no evidence supporting their efficacy for this condition. 1, 2

Evidence Against Diuretic Use in Ear Effusion

The American Academy of Otolaryngology-Head and Neck Surgery Foundation's clinical practice guidelines for otitis media with effusion (OME) make strong recommendations against several medication classes for treating middle ear effusion:

• The guidelines specifically recommend against using antihistamines, decongestants, or systemic steroids for treating OME 1, 2
• While diuretics are not explicitly mentioned in these recommendations, they are notably absent from any recommended treatments for OME
• The guidelines emphasize the favorable natural history of most OME cases and the lack of efficacy for medical therapy 1

Appropriate Management of Ear Effusion

Instead of diuretics, the evidence supports the following approach for managing ear effusion:

1. Watchful waiting is recommended for uncomplicated cases:

   • Manage children with OME who are not at risk with watchful waiting for 3 months from the date of effusion onset or diagnosis 1, 2
   • Most cases resolve spontaneously without medical intervention

2. For persistent cases:

   • Obtain age-appropriate hearing tests if OME persists for 3 months or longer 2
   • Consider tympanostomy tubes for surgical intervention when indicated 1, 2
   • In children ≥4 years old, tympanostomy tubes, adenoidectomy, or both may be considered when surgery is performed 2

3. For children at higher risk:

   • Earlier intervention may be warranted for children with speech, language, or learning problems 2
   • More careful monitoring is recommended for these at-risk populations 1

Why Diuretics Don't Work for Ear Effusion

The pathophysiology of middle ear effusion explains why diuretics are ineffective:

• Middle ear effusion involves fluid accumulation in the middle ear space behind the tympanic membrane 3
• The primary mechanisms of hearing loss in OME are:
  • Reduction of the admittance of the middle-ear air space due to displacement of air with fluid (at low frequencies)
  • Increase in tympanic membrane mass by entrained fluid (at high frequencies) 3
• Diuretics work by increasing urinary sodium excretion and reducing fluid retention systemically 1
• There is no direct mechanism by which systemic diuretics would effectively remove fluid from the isolated middle ear compartment

Diuretics in Other Ear Conditions

While diuretics are not indicated for middle ear effusion, they are sometimes used in other ear conditions:

• Diuretics like chlorthalidone, hydrochlorothiazide, and acetazolamide have been used in endolymphatic hydrops (Ménière's disease) 4, 1
• However, even in Ménière's disease, the evidence for diuretic efficacy is limited:
  • A Cochrane systematic review found insufficient good evidence of the effect of diuretics on vertigo, hearing loss, tinnitus or aural fullness in Ménière's disease 5
  • The 2020 clinical practice guideline for Ménière's disease states that diuretics may be offered as an option for maintenance therapy, but notes the balance of benefits and harms 1

Potential Harms of Diuretics

Using diuretics for ear effusion could potentially cause harm:

• Diuretics can cause electrolyte imbalances, particularly hypokalemia 1
• They may lead to dehydration, especially in children
• Some research suggests diuretics might even adversely affect inner ear function through hemodynamic changes 6
• Diuretics rank among drug classes with high rates of medication-related hospital admissions 1

Conclusion

For ear effusion, the evidence-based approach is watchful waiting for most cases, with surgical intervention (tympanostomy tubes) for persistent cases that cause hearing difficulties. Diuretics have no established role in treating middle ear effusion and should be avoided for this indication.