What is the recommended treatment for otitis media with effusion (OME)?

Treatment of Otitis Media with Effusion

For children with OME who are not at risk for developmental problems, watchful waiting for 3 months is the recommended first-line management, with avoidance of antibiotics, steroids, antihistamines, and decongestants. 1, 2

Initial Diagnostic Approach

• Use pneumatic otoscopy as the primary diagnostic method to document the presence of middle ear effusion and distinguish OME from acute otitis media 1
• Obtain tympanometry when the diagnosis is uncertain after pneumatic otoscopy 1, 3
• Document laterality (unilateral vs bilateral), duration of effusion, and severity of associated symptoms at each visit 1

Risk Stratification

Identify children at increased risk for speech, language, or learning problems, including those with:

• Permanent hearing loss independent of OME 1, 2
• Suspected or confirmed speech/language delay 1, 4
• Autism spectrum disorder or other developmental disorders 1
• Craniofacial abnormalities that affect eustachian tube function 1
• Visual impairment 1

At-risk children require more prompt evaluation of hearing, speech, and language at the time of diagnosis 1, 4

Management Algorithm for Non-Risk Children

Months 0-3: Watchful Waiting Period

• Manage with observation for 3 months from effusion onset (if known) or from diagnosis (if onset unknown), as 75-90% of cases resolve spontaneously 1, 2, 4
• Educate families about the natural history of OME and the high likelihood of spontaneous resolution 1, 2
• Recommend communication strategies: speaking in close proximity, face-to-face communication with clear speech 2
• Re-examine at 3-6 month intervals until effusion resolves 1, 2

Month 3: Hearing Assessment

• Obtain age-appropriate hearing testing if OME persists for 3 months or longer 1, 2, 3
• For bilateral OME with documented hearing loss, counsel families about potential impact on speech and language development 1, 2

Month 4+: Surgical Consideration

Tympanostomy tube insertion is the preferred initial surgical procedure when OME persists beyond 4 months with hearing loss or other significant symptoms 1, 2, 4

Age-specific surgical recommendations:

• Children <4 years old: Tympanostomy tubes alone; adenoidectomy should NOT be performed unless a distinct indication exists (nasal obstruction, chronic adenoiditis) 1, 2, 3
• Children ≥4 years old: Tympanostomy tubes, adenoidectomy, or both may be recommended 1, 2, 3

Medications to Avoid (Strong Recommendations Against)

Do NOT use the following treatments for OME, as they are ineffective or lack long-term benefit:

• Systemic antibiotics - no long-term efficacy 1, 2, 3
• Intranasal or systemic corticosteroids - potential adverse effects without significant long-term benefit 1, 2, 3
• Antihistamines and/or decongestants - ineffective for OME 1, 2, 3

These represent strong negative recommendations from the American Academy of Otolaryngology-Head and Neck Surgery, American Academy of Pediatrics, and American Academy of Family Physicians 1, 3

Management of At-Risk Children

• Evaluate for OME at the time of diagnosis of the at-risk condition and at 12-18 months of age 1, 4
• Obtain hearing testing at ANY duration of OME (do not wait 3 months) 1, 2
• More prompt evaluation of hearing, speech, language, and intervention needs 1, 4
• Consider earlier surgical intervention if developmental concerns arise 4

Common Pitfalls to Avoid

• Do not perform population-based screening in healthy, asymptomatic children without risk factors 1
• Do not perform tonsillectomy alone or myringotomy alone to treat OME 1
• Ensure follow-up after newborn screening failures to exclude underlying sensorineural hearing loss when OME resolves 1, 3
• Document resolution of OME, improved hearing, or improved quality of life in the medical record 1, 3