What is the recommended treatment for middle ear effusion?

Management of Middle Ear Effusion

For children with otitis media with effusion (OME) who are not at risk for developmental problems, watchful waiting for 3 months is the recommended initial approach, avoiding antibiotics, antihistamines, decongestants, and corticosteroids. 1, 2

Initial Assessment and Risk Stratification

• Document laterality (unilateral vs bilateral), duration of effusion, and severity of associated symptoms at each visit using pneumatic otoscopy as the primary diagnostic method 1, 3

• Identify at-risk children who require more aggressive management, including those with:

  • Permanent hearing loss independent of OME 1, 2
  • Speech/language delay or disorder 1, 2
  • Autism spectrum disorders 2
  • Craniofacial syndromes 1, 2
  • Blindness or uncorrectable visual impairment 2
  • Cognitive or behavioral disorders 4

• Confirm diagnosis with tympanometry if pneumatic otoscopy findings are uncertain 1, 4

Management Algorithm for Non-Risk Children

First 3 Months: Watchful Waiting

• Observe for 3 months from diagnosis (or from onset if known), as 75-90% of OME cases resolve spontaneously within this timeframe 1, 3

• Educate families about the natural history of OME, the need for follow-up, and possible sequelae 2, 4

• Re-examine at 3-6 month intervals until effusion resolves, significant hearing loss is identified, or structural abnormalities are suspected 1, 2

After 3 Months: Hearing Assessment

• Obtain age-appropriate hearing testing when OME persists for 3 months or longer 1, 3, 2

• If hearing is normal: Continue watchful waiting with repeat hearing test in 3-6 months if OME persists 2

• If mild hearing loss with bilateral effusions ≥3 months: Offer tympanostomy tube insertion 2

• If significant hearing loss at any time: Consider earlier surgical intervention 1, 2

Medications to Avoid

Do not prescribe the following, as they lack long-term efficacy and may cause harm:

• Antibiotics - show no long-term benefit for OME resolution and contribute to antimicrobial resistance 1, 2, 4, 5

• Antihistamines and decongestants - proven ineffective for OME 1, 2, 4

• Intranasal or systemic corticosteroids - not effective for treating OME 2, 4

The evidence is clear that while antibiotics may slightly reduce OME persistence at 3 months compared to no treatment, the effect on hearing is very uncertain and the long-term benefits do not justify routine use 5. A 2023 Cochrane review confirmed this, finding very low-certainty evidence for antibiotic benefit 5.

Surgical Management

Indications for Surgery

• OME persisting ≥3 months with documented hearing loss 2, 4

• Bilateral OME with documented hearing difficulties 2

• Structural damage to tympanic membrane or middle ear 1, 3

• At-risk children with persistent OME regardless of duration 2, 4

Surgical Approach by Age

For children <4 years old:

• Tympanostomy tubes are the preferred procedure 1, 4
• Adenoidectomy should NOT be performed unless a distinct indication exists (nasal obstruction, chronic adenoiditis) 1

For children ≥4 years old:

• Tympanostomy tubes, adenoidectomy, or both may be recommended 1, 4
• Adenoidectomy reduces future need for ear tubes by approximately 50% 1

Management of At-Risk Children

• Evaluate for OME at diagnosis of at-risk condition and at 12-18 months of age if diagnosed earlier 4

• Obtain hearing testing promptly without waiting 3 months 1, 3, 2

• Consider earlier surgical intervention with tympanostomy tubes 2, 4

• Provide concurrent speech/language therapy as needed 1

• Consider hearing aids or amplification devices for hearing loss independent of OME 1

Common Pitfalls to Avoid

• Prescribing antibiotics routinely - they show only short-term benefits with potential adverse effects including antimicrobial resistance 2, 5

• Using antihistamines or decongestants - no proven efficacy and potential for adverse effects 1, 2

• Failing to obtain hearing assessment when OME persists beyond 3 months 2

• Recommending tympanostomy tubes too early in non-risk children, as most cases resolve spontaneously 2

• Performing adenoidectomy alone in children <4 years for OME treatment 1

• Performing tonsillectomy or myringotomy alone for OME treatment 1

Special Consideration: Newborn Screening Failures

• Document counseling of parents regarding the importance of follow-up when infants fail newborn hearing screening due to OME 4

• Ensure hearing is normal when OME resolves and exclude underlying sensorineural hearing loss 4

• Note that congenital MEE causing screening failure is more persistent than non-congenital MEE and resolves at lower rates 6