What is the recommended management and treatment for patients with fluid in the ear (otitis media with effusion)?

Management of Otitis Media with Effusion (Fluid in Ear)

The recommended first-line management for otitis media with effusion (OME) is watchful waiting for 3 months from the date of effusion onset or diagnosis, as fluid often resolves spontaneously without intervention. 1

Diagnosis and Initial Assessment

• Clinicians should document the laterality (unilateral or bilateral), duration of effusion, and presence and severity of associated symptoms at each assessment 1
• Pneumatic otoscopy is the primary diagnostic method, with tympanometry as a useful confirmatory tool when diagnosis is uncertain 1
• Population-based screening for OME in asymptomatic children is not recommended due to potential risks of overdiagnosis and unnecessary treatment 1

Recommended Management Approach

Watchful Waiting (First-line)

• Implement watchful waiting for 3 months from the date of effusion onset (if known) or from diagnosis (if onset unknown) 1
• This approach takes advantage of the favorable natural history, as approximately 75-90% of OME cases resolve spontaneously within 3 months 1, 2
• Regular follow-up every 3-6 months is necessary until the effusion resolves 1

Patient Education (Essential Component)

• Educate families about:
  • Natural history of OME (often self-resolving) 1
  • Need for follow-up even if symptoms improve 1
  • Possible sequelae including hearing loss and speech/language impacts 1, 3
  • Importance of avoiding secondhand smoke exposure 1
  • For children >12 months, consider discontinuing pacifier use during daytime 1

Medications (Not Recommended)

• Do not prescribe the following medications as they have not shown benefit for OME 1, 4:
  • Antibiotics
  • Antihistamines
  • Decongestants
  • Steroids (oral or intranasal)
  • Acid reflux medications
  • Alternative therapies (chiropractic, special diets, herbal remedies) 1

Special Considerations

Children at Risk for Developmental Difficulties

• More promptly evaluate hearing, speech, and language in children with:
  • Permanent hearing loss independent of OME
  • Suspected or diagnosed speech/language delays
  • Autism spectrum disorder, Down syndrome, or other conditions affecting cognitive development
  • Cleft palate or other craniofacial abnormalities 1

Hearing Assessment

• Obtain age-appropriate hearing test if OME persists for 3 months or longer 5
• Counsel families of children with bilateral OME and documented hearing loss about potential impacts on speech and language development 5

Surgical Management (When Watchful Waiting Fails)

For Children <4 Years Old

• Recommend tympanostomy tubes when surgery is necessary 1
• Adenoidectomy should not be performed unless a distinct indication exists (e.g., nasal obstruction, chronic adenoiditis) 1

For Children ≥4 Years Old

• Recommend tympanostomy tubes, adenoidectomy, or both 1
• Adenoidectomy enhances the effectiveness of tympanostomy tubes in older children 3

Common Pitfalls to Avoid

• Unnecessary antibiotic prescriptions (shown to be common in practice despite guidelines) 6
• Failure to document resolution of OME, improved hearing, or improved quality of life during management 1
• Inadequate follow-up, which may miss complications or persistent hearing loss 1
• Underutilizing the watchful waiting approach, which can lead to overtreatment 6

Shared Decision-Making

When discussing management options with families, explain:

• Watchful waiting gives the child a chance to recover naturally with minimal risk 1
• Persistent fluid can cause hearing loss that may affect development 1, 3
• Surgical options have specific benefits and risks based on the child's age 1
• Regular follow-up is essential regardless of chosen management approach 1