What is the best treatment for otitis media with effusion (OME) or fluid in the middle ear?

Best Treatment for Otitis Media with Effusion (OME)

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

Initial Management (0-3 months)

Watchful Waiting

• Monitor for 3 months from the date of effusion onset or diagnosis 1
• Schedule regular follow-up every 3-6 months until effusion resolves 1
• During this period, optimize the listening environment:
  • Speak within 3 feet of the child
  • Face the child when speaking
  • Reduce background noise
  • Use visual cues when communicating 1

Non-Recommended Treatments

• Do not use the following treatments as they lack evidence for effectiveness:
  • Nasal steroids 1
  • Oral steroids 1
  • Antihistamines and decongestants 1
  • Antibiotics (no long-term efficacy) 1, 2

Potentially Helpful During Watchful Waiting

• Autoinflation devices may be considered as they show small but positive effects on middle ear function 1
  • Low-cost, low-risk option during the watchful waiting period 1
  • May slightly reduce persistence of OME at three months (RR 0.88) 3
  • May improve OME-specific quality of life in the short term 3
  • Note: Potential side effect of ear pain, though occurrence is low (4.4% vs 1.3%) 3

Management After 3 Months of Persistent OME

Hearing Assessment

• Perform age-appropriate hearing testing if OME persists ≥3 months 1:
  • Visual reinforcement audiometry for ages 6-24 months
  • Play audiometry for ages 24-48 months
  • Conventional screening audiometry for children ≥4 years old

Treatment Options Based on Hearing Assessment

If Normal Hearing or Minimal Hearing Loss:

• Continue watchful waiting with regular follow-up every 3-6 months 1

If Documented Hearing Difficulties:

• Surgical intervention should be considered 1:
  • Tympanostomy tubes (ventilation tubes) are the preferred initial surgical procedure 1
  • Tubes rapidly normalize hearing, clear middle ear effusion for up to 2 years, and improve hearing for approximately 6 months 1, 4
  • For children ≥4 years, consider adjuvant adenoidectomy to reduce the need for repeat tube placement 1, 5

Special Considerations for Earlier Intervention:

• Consider more prompt evaluation and earlier intervention for children with:
  • Permanent hearing loss
  • Speech/language delay
  • Autism spectrum disorders
  • Craniofacial disorders
  • Down syndrome
  • Developmental delays 1

Surgical Intervention Details

Tympanostomy Tubes

• Primary indications:
  • Persistent bilateral OME ≥3 months with documented hearing difficulties 1
  • Posterosuperior retraction pockets, ossicular erosion, adhesive atelectasis, or retraction pockets with keratin debris (immediate insertion recommended) 1
• Post-surgical care:
  • Routine prophylactic water precautions are not necessary 1
  • Treat acute tube otorrhea with topical antibiotic eardrops only (not oral antibiotics) 1

Adenoidectomy

• Consider as an adjunct to tympanostomy tubes for children ≥4 years 1, 5
• May reduce the need for repeat tube placement 1
• Particularly beneficial in children with adenoid hypertrophy 6

Alternative to Surgery

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

Pitfalls and Caveats

1. Avoid unnecessary medications: Antihistamines, decongestants, antibiotics, and steroids have not shown long-term effectiveness and may cause side effects 1

2. Don't miss underlying causes: Always evaluate for craniofacial dysmorphism, respiratory allergy, and gastro-oesophageal reflux, which can predispose to OME 6

3. Follow-up is essential: Children must be followed until OME has completely resolved to avoid missing complications 6

4. Consider individual factors: While watchful waiting is appropriate for most children, those with risk factors (developmental delays, craniofacial disorders) may benefit from earlier intervention 1

5. Autoinflation compliance: The benefits of autoinflation must be weighed against the inconvenience of regularly performing the procedure 3