How do you treat otitis media with effusion in adults?

Treatment of Otitis Media with Effusion in Adults

In adults with otitis media with effusion, initial management should be watchful waiting for 3 months, as most cases resolve spontaneously, followed by hearing evaluation and consideration of tympanostomy tubes if effusion persists beyond 4 months with hearing loss or symptoms. 1

Initial Assessment and Documentation

At each clinical encounter, document the following specific details:

• Laterality (unilateral vs bilateral involvement) 1
• Duration of effusion (from onset if known, or from diagnosis) 1
• Associated symptoms including hearing loss, ear fullness, or discomfort 1
• Perform pneumatic otoscopy as the primary diagnostic tool 1
• Obtain tympanometry when diagnosis is uncertain after pneumatic otoscopy 1

Watchful Waiting Protocol (First 3 Months)

The cornerstone of initial management is observation for 3 months, as approximately 75-90% of OME cases resolve spontaneously during this period. 1, 2

During the observation period:

• Counsel patients about the natural history and high likelihood of spontaneous resolution 1
• Implement communication strategies for those with hearing difficulties: speak in close proximity, use face-to-face communication with clear speech, and repeat phrases when misunderstood 1
• Schedule re-examination at 3-6 month intervals until effusion resolves, significant hearing loss is identified, or structural abnormalities are suspected 1

Medications to Avoid

The following treatments have been proven ineffective and should not be used:

• Antihistamines and decongestants - completely ineffective for OME 1, 2
• Systemic antibiotics - lack long-term efficacy and are not recommended for routine management 1, 2
• Intranasal and systemic steroids - potential adverse effects without significant long-term benefit 1, 2

While one study showed short-term benefit of oral steroids at 6 weeks, there were no differences at 3,6, and 9 months, confirming no long-term benefit. 3

Hearing Evaluation

Obtain age-appropriate hearing testing when:

• OME persists for 3 months or longer 1
• Hearing loss is suspected at any time 1
• Before and after treatment to rule out underlying sensorineural hearing loss 4

For patients with bilateral OME and documented hearing loss, counsel about potential impact on communication and quality of life. 2

Surgical Intervention Criteria

Tympanostomy tube insertion is the preferred surgical procedure when patients become surgical candidates. 1

Surgical candidacy includes:

• OME lasting 4 months or longer with persistent hearing loss or other symptoms 1
• Structural damage to the tympanic membrane or middle ear 1
• Persistent symptoms affecting quality of life despite conservative management 1

Evaluation for Underlying Causes

In adults, OME may have specific etiologies requiring investigation:

• Paranasal sinus disease (particularly ethmoid sinusitis) is the most common cause in 66% of adult cases 5
• Nasopharyngeal pathology must be ruled out, particularly in unilateral cases 4, 5
• Nasendoscopy is indicated for unilateral OME or suspected nasopharyngeal obstruction 4
• CT imaging may be warranted in selected cases to evaluate sinuses or skull base 5
• Allergy is a common co-morbidity in 38.6% of adult OME cases 6

Common Pitfalls to Avoid

• Do not assume OME is benign in adults - unlike children, adults require investigation for underlying causes, particularly nasopharyngeal carcinoma in unilateral cases (4.8% prevalence) 5
• Do not prescribe antibiotics or steroids for routine management - these provide no long-term benefit and expose patients to unnecessary adverse effects 1, 3
• Do not delay hearing evaluation beyond 3 months of persistent effusion - this may miss concomitant sensorineural hearing loss 1
• Do not perform surgery prematurely - the 3-month observation period is evidence-based and allows for spontaneous resolution in the majority of cases 1

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