What is the treatment for persistent bilateral middle ear effusions in a child?

Treatment for Persistent Bilateral Middle Ear Effusions in Children

For children with bilateral otitis media with effusion (OME) persisting for 3 months or longer with documented hearing difficulties, bilateral tympanostomy tube insertion should be offered as the primary treatment. 1

Diagnostic Assessment

• Confirm the presence of middle ear effusion using pneumatic otoscopy
• Obtain tympanometry when diagnosis is uncertain after pneumatic otoscopy
• Perform age-appropriate hearing testing for children with OME persisting ≥3 months
  • Visual reinforcement audiometry for ages 6-24 months
  • Play audiometry for ages 24-48 months
  • Conventional screening audiometry for children ≥4 years old

Treatment Algorithm

Step 1: Watchful Waiting (Initial 3 Months)

• Watchful waiting is recommended for the first 3 months from onset or diagnosis of OME
• During this period:
  • Avoid ineffective treatments including:
    • Antihistamines
    • Decongestants
    • Systemic antibiotics
    • Oral or topical steroids 2
  • Consider autoinflation devices as a low-risk option during watchful waiting 2

Step 2: After 3 Months of Persistent OME

• Obtain hearing evaluation if not done previously
• Treatment decision based on hearing status and symptoms:

If Hearing Loss Present (16-40 dB HL):

• Offer bilateral tympanostomy tube insertion 1
• Benefits include:
  • Rapid normalization of hearing
  • Clearing of middle ear effusion for up to 2 years 2
  • Improved quality of life

If Normal Hearing (<15 dB HL):

• Consider tympanostomy tubes if child has symptoms attributable to OME:
  • Vestibular problems
  • Poor school performance
  • Behavioral problems
  • Ear discomfort
  • Reduced quality of life 1
• Otherwise, continue watchful waiting with reevaluation every 3-6 months

Step 3: Age-Specific Surgical Considerations

• For children <4 years: Tympanostomy tubes alone 3
• For children ≥4 years: Consider tympanostomy tubes with adjuvant adenoidectomy 1, 2
  • Adenoidectomy reduces need for repeat tube placement by approximately 50% 2

Special Considerations

At-Risk Children

• More prompt evaluation and earlier intervention for children with:
  • Permanent hearing loss
  • Speech/language delay
  • Autism spectrum disorders
  • Craniofacial disorders (including cleft palate)
  • Down syndrome
  • Developmental delays 1

Structural Tympanic Membrane Changes

• Immediate tympanostomy tube insertion (regardless of duration) for:
  • Posterosuperior retraction pockets
  • Ossicular erosion
  • Adhesive atelectasis
  • Retraction pockets with keratin debris 1

Post-Treatment Management

• For children with tubes:

  • Routine prophylactic water precautions are not necessary 1
  • Treat acute tube otorrhea with topical antibiotic eardrops only (not oral antibiotics) 1
  • Educate caregivers about expected tube duration and follow-up schedule 1

• For children without tubes:

  • Optimize listening-learning environment:
    • Get within 3 feet of child before speaking
    • Reduce background noise
    • Use visual cues when speaking
    • Consider preferential classroom seating 1

Pitfalls and Caveats

• Avoid unnecessary surgery in children with OME of less than 3 months' duration 1
• Do not perform tympanostomy tube insertion in children with recurrent acute otitis media who do not have middle ear effusion at assessment 1
• Recognize that 70% of children with chronic OME have mild-to-moderate hearing loss that can impact language development 4
• Tonsillectomy alone or myringotomy alone should not be used to treat OME 5
• Hearing aids may be considered as an alternative to surgery in children with persistent bilateral OME and hearing loss 1, 2

The management of persistent bilateral middle ear effusions requires careful assessment of duration, hearing status, and associated symptoms to determine the optimal treatment approach, with tympanostomy tubes being the primary intervention for those with documented hearing difficulties or persistent symptoms.