What is the role of steroid nasal sprays, such as mometasone furoate (mometasone), in the treatment of acute otitis media with effusion?

Nasal Steroid Sprays Are Not Recommended for Acute Otitis Media with Effusion

Nasal steroid sprays are not recommended for the treatment of acute otitis media with effusion (OME) as they have not demonstrated long-term efficacy in resolving middle ear effusions. 1

Evidence Against Nasal Steroid Use in OME

The American Academy of Otolaryngology-Head and Neck Surgery and the American Academy of Pediatrics strongly discourage the use of nasal steroids for OME management due to:

• Lack of evidence for long-term effectiveness
• No significant benefit for middle ear effusion resolution (RR 0.99) 2
• Clinical practice guidelines specifically state that "corticosteroids do not have long-term efficacy and are not recommended for routine management" 1

A high-quality randomized controlled trial by Williamson et al. found that mometasone furoate nasal spray was unlikely to be an effective treatment for OME in primary care, with 41% of the steroid group and 45% of the placebo group showing resolution at one month (adjusted relative risk 0.97,95% CI 0.74 to 1.26) 3

Natural History and Management of OME

OME is characterized by fluid in the middle ear without signs or symptoms of acute ear infection 2. The condition has a high rate of spontaneous resolution:

• 75-90% of cases resolve spontaneously within three months 2
• Watchful waiting for 3 months from the date of effusion onset or diagnosis is the recommended first-line approach 2

Appropriate Management Algorithm for OME

1. Initial Diagnosis and Assessment

   • Confirm diagnosis using pneumatic otoscopy to assess tympanic membrane mobility
   • Consider tympanometry when diagnosis is uncertain (Type B tympanogram indicates high probability of middle ear effusion) 2

2. Watchful Waiting (First 3 Months)

   • Implement watchful waiting for 3 months from onset/diagnosis 2
   • Optimize listening environment: speak in close proximity to child, face the child when speaking, reduce background noise 1
   • Consider autoinflation devices as a low-cost, low-risk option during this period 2

3. After 3 Months of Persistent OME

   • Perform hearing assessment if OME persists for ≥3 months 2
   • Age-appropriate testing: visual reinforcement audiometry (6-24 months), play audiometry (24-48 months), conventional screening audiometry (≥4 years) 2

4. Intervention for Persistent OME

   • If hearing difficulties are documented or symptoms persist, consider referral to an otolaryngologist for possible surgical intervention 2
   • Tympanostomy tube insertion is the preferred initial procedure when surgery is indicated 2
   • For children ≥4 years, consider adenoidectomy along with tympanostomy tubes to reduce the need for repeat tube placement 2

Special Considerations

• Earlier intervention may be warranted for children with:
  • Permanent hearing loss
  • Speech/language delay
  • Autism spectrum disorders
  • Craniofacial disorders
  • Down syndrome
  • Developmental delays 2

Treatments to Avoid

Several treatments have been studied but are not recommended due to lack of efficacy:

• Oral steroids alone or with antibiotics may show short-term benefits but lack long-term efficacy 1
• Antihistamines and decongestants are ineffective for OME 1
• Antimicrobials do not have long-term efficacy 1

Conclusion on Nasal Steroids

While some smaller studies have suggested potential benefits of nasal steroids in specific populations (such as children with adenoid hypertrophy) 4, 5, the highest quality evidence and clinical guidelines do not support their use for routine management of OME. The systematic review by Griffin et al. concluded that there is no evidence for long-term benefit from treating hearing loss associated with OME with either oral or topical nasal steroids 6.

The focus of treatment should remain on watchful waiting for the first three months, with surgical intervention considered for persistent cases with documented hearing difficulties or other risk factors.