What are the treatment options for otitis effusion (middle ear effusion)?

Treatment of Otitis Media with Effusion (OME)

Watchful waiting for 3 months is the recommended first-line approach for otitis media with effusion, as 75-90% of cases resolve spontaneously within this timeframe. 1

Initial Management Approach

• Watchful waiting (3 months): The American Academy of Family Physicians recommends monitoring for 3 months from effusion onset or diagnosis before considering interventions 1
• Regular follow-up: Schedule visits every 3-6 months until effusion resolves 1
• Autoinflation devices: Can be used during the watchful waiting period as they show small but positive effects on middle ear function and are low-cost and low-risk 1
• Avoid ineffective medications: Oral/topical steroids, antihistamines, and decongestants are strongly discouraged as they show no evidence of long-term effectiveness for middle ear effusion resolution 1

Assessment After 3 Months of Persistent OME

If OME persists beyond 3 months, the following steps should be taken:

1. Hearing assessment: Age-appropriate hearing testing should be performed 1

   • 6-24 months: Visual reinforcement audiometry
   • 24-48 months: Play audiometry
   • ≥4 years: Conventional screening audiometry

2. Optimize listening environment: For children without surgical intervention 1

   • Get within 3 feet of child before speaking
   • Reduce background noise
   • Use visual cues when speaking
   • Consider preferential classroom seating

Surgical Intervention Criteria

Referral to an otolaryngologist is recommended if OME persists for ≥3 months with any of the following:

• Documented hearing difficulties
• Suspected structural abnormalities of eardrum/middle ear
• Language delay or learning problems 1

Surgical Options Based on Age

• Children <4 years: Bilateral tympanostomy tube insertion alone 1
• Children ≥4 years: Tympanostomy tubes with consideration of adjuvant adenoidectomy (reduces need for repeat tube placement by approximately 50%) 1
• Immediate tympanostomy tube insertion is indicated for children with:
  • Posterosuperior retraction pockets
  • Ossicular erosion
  • Adhesive atelectasis
  • Retraction pockets with keratin debris 1

Risk Factors for Persistent OME

Special attention should be given to children with:

• No history of adenoidectomy
• Episode of acute otitis media in the first year of life
• Bilateral OME occurring between June and November 2
• Presence of upper respiratory tract infection at follow-up visits 2

Special Considerations

• Children requiring earlier intervention: More prompt evaluation and earlier intervention are recommended for children with:

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

• Alternative to surgery: Hearing aids may be considered as an alternative to surgery in children with persistent bilateral OME and hearing loss 1

Post-Surgical Care

• Water precautions: Routine prophylactic water precautions are not necessary for children with tubes 1
• Tube otorrhea treatment: Acute tube otorrhea should be treated with topical antibiotic eardrops only, not oral antibiotics 1
• Education: Caregivers should be informed about expected tube duration and follow-up schedule 1

Common Pitfalls to Avoid

1. Premature intervention: Avoid surgical intervention before the recommended 3-month watchful waiting period
2. Ineffective medication use: Avoid prescribing antihistamines, decongestants, antibiotics, or steroids for OME as they show no long-term benefit 1, 3
3. Inadequate follow-up: Failing to monitor children until complete resolution of OME may result in missed complications 4
4. Missing underlying causes: Ensure evaluation for craniofacial dysmorphism, respiratory allergy, and gastro-esophageal reflux, which can contribute to OME development 4