What is the treatment for chronic serous otitis media?

Treatment of Chronic Serous Otitis Media

The primary treatment for chronic serous otitis media (otitis media with effusion persisting ≥3 months) is watchful waiting with hearing assessment, reserving tympanostomy tube insertion for cases with documented hearing loss or children at risk for developmental difficulties. 1, 2

Initial Management: Watchful Waiting

• Observe for 3 months from diagnosis before considering surgical intervention, as many cases resolve spontaneously 1, 2
• Document laterality (unilateral vs bilateral), duration of effusion, and associated symptoms at each visit 2
• Use pneumatic otoscopy to confirm persistent effusion; obtain tympanometry if diagnosis is uncertain 2
• Educate families about the natural history, need for follow-up, and potential complications including hearing loss 2

Mandatory Hearing Assessment

• Obtain age-appropriate hearing testing when effusion persists ≥3 months or earlier if language delay, learning problems, or significant hearing loss is suspected 1, 2
• Average hearing loss with middle ear effusion is approximately 25 dB, with 20% of ears exceeding 35 dB hearing level 1
• If hearing is normal, continue watchful waiting with repeat testing in 3-6 months if effusion persists 2

Medical Therapy: NOT Recommended

Antimicrobials, steroids, antihistamines, and decongestants should NOT be used for chronic serous otitis media. 1, 2

• Antibiotics are ineffective for long-term resolution despite showing short-term benefit in some trials (7 children need treatment for one short-term response) 1
• Benefits become nonsignificant within 2 weeks of stopping medication 1
• Adverse effects include rashes, diarrhea, allergic reactions, bacterial resistance, and societal transmission of resistant pathogens 1
• Oral steroids show no long-term benefit and carry risks including behavioral changes, adrenal suppression, and avascular necrosis 1
• Intranasal steroids (beclomethasone) show no benefit over antimicrobials alone at 12 weeks 1
• Antihistamines and decongestants are completely ineffective 2

Exception for Medical Therapy

• A single 10-14 day course of antimicrobials may be considered only when parents express strong aversion to impending surgery, but prolonged or repetitive courses are strongly discouraged 1

Surgical Intervention: Tympanostomy Tubes

Offer tympanostomy tube insertion when:

• Bilateral effusion persists ≥3 months with documented hearing loss 2
• Hearing difficulties are documented regardless of duration 2
• Child is at increased risk for developmental difficulties 2

High-Risk Children Requiring Earlier Intervention

Children at increased risk include those with: 2

• Permanent hearing loss independent of otitis media
• Speech/language delay or disorder
• Autism spectrum disorders
• Syndromes or craniofacial disorders (including Down syndrome)
• Blindness or uncorrectable visual impairment

Follow-Up Protocol

• Reevaluate every 3-6 months until effusion resolves, significant hearing loss is identified, or structural abnormalities develop 2
• Monitor for tympanic membrane structural changes including retraction pockets, which may indicate need for intervention 2
• Language testing should be conducted for children with documented hearing loss 1

Common Pitfalls to Avoid

• Do not prescribe antibiotics routinely - they contribute to antimicrobial resistance without long-term benefit 1, 2
• Do not use antihistamines or decongestants - no proven efficacy for otitis media with effusion 2
• Do not delay hearing assessment beyond 3 months of persistent effusion 2
• Do not recommend tubes too early in children without risk factors, as spontaneous resolution is common 2
• Do not confuse chronic serous otitis media with chronic suppurative otitis media (which involves tympanic membrane perforation with discharge) 1, 3

Special Considerations

• Approximately 20% of children have disparate findings between ears, so each ear should be evaluated separately 1
• Conductive hearing loss may adversely affect binaural processing, sound localization, and speech perception in noise 1
• The child's home environment has greater impact on language outcomes than the effusion itself in children not otherwise at risk 1