What are the treatment options for adult middle ear effusion when pharmacological treatment is not preferred or effective?

Non-Pharmacological Treatment Options for Adult Middle Ear Effusion

For adults with middle ear effusion, tympanostomy tube insertion is the preferred surgical intervention when symptomatic hearing loss persists despite watchful waiting for 3 months. 1

Diagnostic Approach

• Pneumatic otoscopy should be used as the primary diagnostic method to document the presence of middle ear effusion 1
• Tympanometry can be used to confirm the diagnosis when pneumatic otoscopy results are uncertain 1
• Document the laterality, duration of effusion, and presence and severity of associated symptoms at each assessment 1

Initial Management: Watchful Waiting

• Watchful waiting for 3 months from the date of effusion onset (if known) or from diagnosis (if onset is unknown) is the recommended first-line approach 1
• During watchful waiting, patients should be monitored for:
  • Resolution of effusion
  • Development of significant hearing loss
  • Structural abnormalities of the eardrum or middle ear 1

Hearing Assessment

• Hearing testing should be conducted when middle ear effusion persists for 3 months or longer 1
• Patients with symptomatic hearing loss should be evaluated for potential intervention 1

Surgical Interventions

• Tympanostomy tubes (ventilation tubes):

  • First-line surgical intervention for persistent middle ear effusion with symptomatic hearing loss 1
  • Provides immediate relief by equalizing pressure and draining fluid 1
  • Most effective intervention with high-level evidence of benefit for hearing and quality of life for up to 9 months after treatment 1

• Adenoidectomy:

  • Not recommended as an initial procedure unless there are distinct indications such as nasal obstruction or chronic adenoiditis 1
  • May be considered in combination with tympanostomy tubes in recurrent cases 1
  • The benefit is controversial and age-dependent 1

• Balloon dilation of the Eustachian tube:

  • Emerging procedure that may improve outcomes in selected cases 1
  • Limited evidence from uncontrolled case series in adults with OME, with heterogeneous data collection methods and no long-term follow-up 1

• Mastoid surgery:

  • Reserved for rare cases where conventional treatment fails to control the condition 2
  • Indicated only when middle ear effusion persists despite tympanostomy tubes and medical management 2

Ineffective Treatments to Avoid

• Antihistamines and decongestants:

  • Ineffective for middle ear effusion and should not be used 1
  • No evidence of benefit for resolution of middle ear effusion 1

• Systemic antibiotics:

  • Do not have long-term efficacy and should not be used for routine management 1

• Oral or topical steroids:

  • Not recommended for routine management of middle ear effusion 1
  • Limited evidence of benefit and potential side effects 1

Alternative Approaches

• Auto-inflation:
  • May have small but positive effects on middle ear effusion 1
  • Low cost and absence of adverse effects make it a reasonable option during watchful waiting 1
  • Can be performed using specialized devices designed for this purpose 1

Follow-up Care

• Patients with persistent middle ear effusion should be reexamined at 3-6 month intervals until:
  • The effusion resolves
  • Significant hearing loss is identified
  • Structural abnormalities of the eardrum or middle ear are suspected 1

Special Considerations

• Evaluate for possible cerebrospinal fluid leak if clear otorrhea develops, especially after tympanostomy tube insertion 3
• Consider referral to an otolaryngologist for cases with prolonged course and persistent hearing loss 1