What is the initial management for an adult with otitis media with effusion?

Initial Management of Otitis Media with Effusion in Adults

The initial management for an adult with otitis media with effusion is watchful waiting for 3 months, during which antihistamines, decongestants, antibiotics, and corticosteroids should be avoided as they are ineffective or lack long-term benefit. 1

Diagnostic Confirmation and Documentation

• Document the laterality (unilateral vs bilateral), duration of effusion, and presence and severity of associated symptoms at the initial assessment and each follow-up visit 1
• Use pneumatic otoscopy as the primary diagnostic method to confirm middle ear effusion 1
• Obtain tympanometry when the diagnosis is uncertain after pneumatic otoscopy 1
• Perform hearing testing if OME persists for 3 months or longer, or when hearing loss is suspected at any time 1

Initial Management: Watchful Waiting

• Observe for 3 months from the date of diagnosis (or from onset if known), as approximately 75-90% of OME cases resolve spontaneously within this timeframe 2, 1
• During observation, counsel patients about the natural history of OME and the high likelihood of spontaneous resolution 3, 1
• For patients experiencing hearing difficulties, recommend communication strategies: speaking in close proximity, face-to-face communication with clear speech, and repeating phrases when misunderstood 3, 1

Medications to Avoid

Do not prescribe the following medications, as they are ineffective or lack long-term efficacy:

• Antihistamines and decongestants – ineffective for OME 4, 2, 1
• Antibiotics – no long-term efficacy and potential for adverse effects including resistance 4, 2, 1
• Oral or intranasal corticosteroids – may provide short-term benefit but no long-term efficacy, with potential adverse effects including behavioral changes, weight gain, and adrenal suppression 4, 3, 1

Investigation for Underlying Causes in Adults

Unlike children, adults with OME require evaluation for underlying causes, particularly:

• Paranasal sinus disease (most common cause, found in 66% of adult cases) – consider CT imaging of sinuses if clinically indicated 5
• Nasopharyngeal pathology – perform nasendoscopy to evaluate for masses, lymphoid hyperplasia, or adenoidal hypertrophy 5, 6
• Nasopharyngeal carcinoma – must be ruled out, though found in only 4.8% of cases 5
• Allergic rhinitis and upper respiratory tract inflammation – common co-morbidities in 38.6% and 14.5% of cases respectively 6

Follow-Up Management

• Re-examine at 3-6 month intervals until the effusion resolves, significant hearing loss is identified, or structural abnormalities of the tympanic membrane or middle ear are suspected 1
• Obtain age-appropriate hearing testing if OME persists for 3 months or longer 1

Surgical Referral Criteria

Consider tympanostomy tube insertion (the preferred initial surgical procedure) when the patient becomes a surgical candidate 1:

• OME lasting 4 months or longer with persistent hearing loss or other significant symptoms 1
• Structural damage to the tympanic membrane or middle ear 1

Common Pitfalls to Avoid

• Do not prescribe antibiotics or steroids routinely – the evidence shows no long-term benefit and potential for harm 4, 1
• Do not skip the evaluation for underlying causes in adults – unlike pediatric OME, adult-onset OME often has identifiable causes requiring specific treatment, particularly sinusitis 5, 6
• Do not delay nasendoscopy – this is the mainstay of diagnostic evaluation to rule out nasopharyngeal pathology 5