What is the treatment for serous otitis media (ear effusion) without infection?

Treatment of Ear Effusion Without Infection

Watchful waiting for 3 months is the recommended first-line approach for otitis media with effusion (OME), avoiding ineffective treatments such as antihistamines, decongestants, antibiotics, and steroids. 1

Diagnosis and Confirmation

• Confirm presence of middle ear effusion using:
  • Pneumatic otoscopy (primary diagnostic tool)
  • Tympanometry when diagnosis is uncertain 1
  • Type B tympanogram (flat curve with no discernible peak) indicates high probability of middle ear effusion 2

Initial Management (0-3 Months)

Recommended:

• Watchful waiting for the first 3 months from onset or diagnosis 1
• Autoinflation devices may provide small positive effects on middle ear function during watchful waiting period 1
• Optimize listening environment for children:
  • Get within 3 feet of child before speaking
  • Reduce background noise
  • Use visual cues when speaking
  • Consider preferential classroom seating 1

Not Recommended:

• Antihistamines
• Decongestants
• Systemic antibiotics
• Oral or topical steroids 1, 2

These medications have not demonstrated long-term effectiveness for OME resolution. Antimicrobials may produce short-term benefits but these become non-significant within 2 weeks of stopping medication, and approximately 7 children would need treatment to achieve one short-term response 2.

Management After 3 Months of Persistence

If OME persists for ≥3 months:

1. Perform hearing testing 1

   • Age-appropriate testing methods:
     • Visual reinforcement audiometry (6-24 months)
     • Play audiometry (24-48 months)
     • Conventional screening audiometry (≥4 years)

2. Treatment decision based on hearing status and symptoms:

   a) For children with documented hearing difficulties or persistent symptoms:

   • Bilateral tympanostomy tube insertion is recommended 1
   • For children <4 years: tympanostomy tubes alone
   • For children ≥4 years: consider tympanostomy tubes with adjuvant adenoidectomy (reduces need for repeat tube placement by ~50%) 1

   b) For children without hearing difficulties:

   • Continue watchful waiting
   • Hearing aids may be considered as an alternative to surgery 1

Special Considerations

• Earlier intervention is recommended for children with:

  • Permanent hearing loss
  • Speech/language delay
  • Autism spectrum disorders
  • Craniofacial disorders
  • Down syndrome
  • Developmental delays 1

• Nasal steroids: While one small study showed potential efficacy similar to systemic steroids 3, larger studies found no significant effect on middle ear effusion 4. Current guidelines do not recommend nasal steroids for routine OME treatment.

Post-Tympanostomy Tube Care

If tubes are placed:

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

Pitfalls to Avoid

1. Using medications with no proven efficacy (antihistamines, decongestants, antibiotics, steroids)
2. Performing unnecessary surgery in children with OME of less than 3 months' duration
3. Placing tympanostomy tubes in children with recurrent acute otitis media who do not have middle ear effusion at assessment
4. Delaying intervention in children at higher risk for developmental sequelae
5. Failing to perform appropriate hearing assessment in children with persistent OME

Remember that about 90% of children will experience at least one episode of OME by age 2, and many cases resolve spontaneously with time 2. The treatment approach should focus on monitoring, hearing assessment, and appropriate surgical intervention when indicated by persistent symptoms or hearing loss.