Treatment for Fluid Behind Ear (Otitis Media with Effusion)
For otitis media with effusion (OME), watchful waiting for 3 months is the recommended first-line approach, as 75-90% of cases resolve spontaneously within this timeframe. 1, 2
Initial Assessment and Diagnosis
- Document the laterality (unilateral or bilateral), duration of effusion, and presence/severity of associated symptoms at each assessment 1, 2
- Pneumatic otoscopy is the primary diagnostic method, with tympanometry as a useful confirmatory tool when diagnosis is uncertain 2
- Hearing testing is recommended when OME persists for 3 months or longer, or if language delay, learning problems, or significant hearing loss is suspected 1
Management Algorithm
First-Line Approach: Watchful Waiting
- Implement watchful waiting for 3 months from the date of effusion onset or diagnosis 1, 2
- Regular follow-up every 3-6 months until the effusion resolves, significant hearing loss is identified, or structural abnormalities are suspected 1
- Educate patients/families about the natural history of OME and the need for follow-up 2
Medications to AVOID
- Do not use antihistamines and decongestants - ineffective for OME 1
- Do not use antimicrobials - no long-term efficacy 1
- Do not use corticosteroids - not recommended for routine management 1
- These medications have potential side effects without convincing evidence of long-term effectiveness 3
Surgical Management (When Watchful Waiting Fails)
- Consider surgical intervention if OME persists beyond 3 months with associated hearing loss or developmental concerns 1, 4
- Tympanostomy tube insertion is the preferred initial surgical procedure for children who become surgical candidates 1
- For children under 4 years: Tympanostomy tubes only (adenoidectomy should not be performed unless specific indications exist) 1, 2
- For children 4 years and older: Tympanostomy tubes, adenoidectomy, or both 2, 4
Special Considerations
- Identify children at risk for speech, language, or learning problems who may need more prompt evaluation and intervention 1
- Auto-inflation (Valsalva maneuver) may be beneficial as a low-risk, low-cost non-surgical therapy 3, 5
- Hearing must be evaluated before and after treatment to rule out other causes of hearing loss 6
- Tympanostomy tubes work by allowing air to enter the middle ear directly, keeping the middle ear space clear and eliminating negative pressure 1
Follow-up Recommendations
- The surgeon or designee should examine the ears within 3 months of tympanostomy tube insertion 1
- Educate families regarding the need for routine, periodic follow-up until the tubes extrude 1
- Do not routinely prescribe postoperative antibiotic ear drops after tympanostomy tube placement 1
- For acute tympanostomy tube otorrhea, prescribe topical antibiotic ear drops only, without oral antibiotics 1
Common Pitfalls to Avoid
- Unnecessary antibiotic prescriptions for OME 2
- Failure to document resolution of OME, improved hearing, or improved quality of life during management 2
- Inadequate follow-up that might miss complications or persistent hearing loss 2
- Routine water precautions (earplugs, headbands, avoiding swimming) are not necessary for children with tympanostomy tubes 1