What is the initial management for otitis media with effusions (OME)?

Initial Management of Otitis Media with Effusion (OME)

For children with otitis media with effusion (OME) who are not at risk for speech, language, or learning problems, watchful waiting for 3 months from the date of effusion onset (if known) or from the date of diagnosis (if onset is unknown) is the recommended initial management approach. 1

Assessment and Documentation

• Document the laterality (unilateral or bilateral), duration of effusion, and presence and severity of associated symptoms at each assessment 1
• Distinguish children at risk for speech, language, or learning problems from other children with OME, as they require more prompt evaluation 1
• At-risk children include those with baseline sensory, physical, cognitive, or behavioral factors that may make them less tolerant of hearing loss 1, 2

Initial Management Algorithm

For Non-Risk Children:

1. Watchful waiting for 3 months from effusion onset or diagnosis 1

   • Approximately 75-90% of residual OME after an episode of acute otitis media resolves spontaneously within 3 months 1
   • This period of observation carries little harm compared to unnecessary interventions 1

2. During watchful waiting:

   • Inform parents/caregivers about potential reduced hearing until effusion resolves 1
   • Discuss strategies to optimize listening environment (speaking in close proximity, facing the child, speaking clearly, repeating phrases when misunderstood) 1
   • May include interval visits to monitor OME using pneumatic otoscopy or tympanometry 1

3. After 3 months of persistent OME:

   • Obtain age-appropriate hearing testing 1
   • For children ≥4 years, initial hearing testing can be conducted in primary care 1
   • Comprehensive audiologic examination for children who fail primary care testing, are <4 years old, or cannot be tested in primary care 1

For At-Risk Children:

• More prompt evaluation of hearing, speech, language, and need for intervention 1
• Consider speech and language therapy concurrent with managing OME 1
• Consider hearing aids or other amplification for hearing loss independent of OME 1
• Consider earlier tympanostomy tube insertion 1

Medications to Avoid

• Antihistamines and decongestants are ineffective for OME and should not be used 1, 2
• Antimicrobials do not have long-term efficacy and are not recommended for routine management 1
• Corticosteroids (oral or intranasal) are not recommended for routine management 1
• Short-term benefits of antimicrobials may be seen but become nonsignificant within 2 weeks of stopping medication 1
• Adverse effects of antimicrobials include rashes, vomiting, diarrhea, allergic reactions, altered nasopharyngeal flora, and bacterial resistance 1

Follow-up Management

• Re-examine children with persistent OME at 3-6 month intervals until the effusion resolves, significant hearing loss is identified, or structural abnormalities are suspected 1
• If OME persists for 3 months or longer, obtain hearing testing 1
• For children with bilateral OME and documented hearing loss, counsel families about potential impact on speech and language development 2

Surgical Considerations

• Tympanostomy tube insertion is the preferred initial surgical procedure when a child becomes a surgical candidate 1
• Surgical candidates include children with:
  • OME lasting 4 months or longer with persistent hearing loss or other signs/symptoms 1
  • Recurrent or persistent OME in at-risk children regardless of hearing status 1
  • OME with structural damage to the tympanic membrane or middle ear 1

Common Pitfalls to Avoid

• Unnecessary medical treatment with ineffective medications (antihistamines, decongestants) 1
• Prolonged or repetitive courses of antimicrobials 1
• Failure to identify children at risk for speech, language, or learning problems 1
• Population-based screening of asymptomatic children is not recommended 1, 3
• Failure to document laterality, duration, and severity of symptoms 1
• Relying on non-pneumatic otoscopy for primary diagnosis 1