What to do if otitis media with effusion (OME) persists after treatment?

Management of Persistent Otitis Media with Effusion

For persistent otitis media with effusion (OME) after initial treatment, watchful waiting for 3 months is recommended as the first approach, followed by hearing evaluation and consideration of surgical intervention if the condition persists beyond this period. 1, 2

Initial Assessment and Monitoring

• When OME persists after initial treatment, continue watchful waiting for a total of 3 months from diagnosis or onset (if known) 1
• Re-examine children with persistent OME at 3-6 month intervals until:
  • The effusion resolves
  • Significant hearing loss is identified
  • Structural abnormalities of the eardrum or middle ear are suspected 1

Hearing Evaluation

• Perform age-appropriate hearing testing if:
  • OME persists for ≥3 months
  • Language delay, learning problems, or significant hearing loss is suspected 1, 2
• For children ≥4 years: Initial hearing testing can be conducted in primary care setting
• For children <4 years: Comprehensive audiologic examination is recommended 1

Intervention Decision Algorithm

When to Continue Watchful Waiting:

• Asymptomatic OME even if persisting >3 months
• No significant hearing loss
• No structural abnormalities
• Child not at risk for developmental delays

When to Consider Surgical Intervention:

1. OME persisting ≥4 months with documented hearing loss
2. OME with significant impact on quality of life or school performance
3. Presence of structural concerns (posterosuperior retraction pockets, ossicular erosion, adhesive atelectasis)
4. Child at risk for speech, language, or learning problems

Surgical Options

• First-line surgical option: Tympanostomy tube insertion 1, 2
• For children ≥4 years: Consider tympanostomy tubes, adenoidectomy, or both 2, 3
• For children <4 years: Tympanostomy tubes alone are recommended 2
• Adenoidectomy as an adjunct reduces need for repeat tube placement by ~50% in children ≥4 years 2, 4

Important Cautions

• Do not use medications for persistent OME:

  • Antibiotics, steroids (intranasal or systemic), antihistamines, and decongestants are ineffective for long-term management and may cause adverse effects 1, 2, 4
  • Despite FDA approval for other conditions, azithromycin has not shown long-term effectiveness for OME 5

• Avoid common pitfalls:

  • Failing to document effusion duration and laterality when referring to specialists
  • Not performing hearing evaluation before and after treatment
  • Repeating ineffective medical therapies instead of proceeding to appropriate surgical evaluation
  • Overlooking structural changes to the tympanic membrane that may require intervention

Patient Education and Environmental Optimization

• Educate families about:

  • Natural history of OME
  • Need for follow-up
  • Potential impact on speech and language development 1, 2

• Suggest strategies to optimize listening environment:

  • Speak within 3 feet of the child
  • Face the child and speak clearly
  • Reduce background noise
  • Use visual cues when speaking
  • Consider preferential classroom seating 1, 2

Follow-up After Intervention

• Document resolution of OME, improved hearing, or improved quality of life
• Assess hearing before and after treatment to ensure improvement
• Continue monitoring until complete resolution to prevent missing complications 1, 6