What are the treatment options for middle ear effusion?

Treatment of Middle Ear Effusion

The primary treatment for middle ear effusion (OME) is watchful waiting for 3 months from the date of diagnosis, with surgical intervention (tympanostomy tubes) considered only after this period if the effusion persists. 1, 2

Diagnosis and Initial Management

• Pneumatic otoscopy is the primary diagnostic method for OME, which should be used to document the presence of middle ear fluid 2
• For uncertain diagnoses, tympanometry can be used to confirm the presence of middle ear effusion 2
• Document the laterality (unilateral/bilateral), duration, and associated symptoms at each assessment 2

Treatment Algorithm

First-Line Approach (0-3 months)

• Watchful waiting for 3 months from the date of effusion onset (if known) or from diagnosis (if onset unknown) 2, 1
• Patient education about the natural history of OME, need for follow-up, and possible sequelae 2
• Regular follow-up examinations during this period

Medications to AVOID

• Do NOT use the following medications as they are ineffective for OME:
  • Antihistamines
  • Decongestants
  • Systemic antibiotics
  • Intranasal or systemic corticosteroids 2, 1

After 3 Months of Persistent OME

1. Obtain age-appropriate hearing test if OME persists for ≥3 months 2, 1
2. Re-examine at 3-6 month intervals until the effusion resolves, significant hearing loss is identified, or structural abnormalities are suspected 2
3. Consider surgical intervention if OME persists with documented hearing loss or speech/language concerns:
   • For children <4 years: Tympanostomy tubes alone 2, 1
   • For children ≥4 years: Tympanostomy tubes, adenoidectomy, or both 2, 1

Special Considerations

At-Risk Children

• Children at risk for speech, language, or learning problems require more prompt evaluation 2
• Evaluate at-risk children at the time of diagnosis and at 12-18 months of age 2
• Consider earlier intervention for these children if OME is affecting development 1

Hearing and Language Assessment

• Counsel families of children with bilateral OME and documented hearing loss about potential impact on speech and language development 2, 1
• Language testing should be conducted for children with hearing loss 1

Surgical Options

• Tympanostomy tube insertion is the preferred initial surgical procedure 2
• Adenoidectomy alone or myringotomy alone should not be used to treat OME 2
• For children ≥4 years with recurrent OME, adenoidectomy plus tympanostomy tubes reduces the need for repeat tube placement by approximately 50% 1

Follow-Up After Treatment

• Document resolution of OME, improved hearing, or improved quality of life 2, 1
• Assess hearing before and after treatment to ensure improvement 1
• Monitor for potential tympanic membrane abnormalities following tube insertion, which occur in approximately 80% of children who receive tubes 3

The evidence strongly supports watchful waiting as the initial approach for most children with OME, as many cases resolve spontaneously within 3 months. Surgical intervention should be reserved for persistent cases that fail to resolve after the observation period, especially when associated with hearing loss or developmental concerns.