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

Treatment of Prolonged Otitis Media with Effusion

For prolonged OME, initial management consists of watchful waiting for 3 months with interval monitoring, followed by hearing assessment if effusion persists, and tympanostomy tube insertion if OME continues beyond 4 months with documented hearing loss. 1, 2, 3

Initial Management: Watchful Waiting Period

• Observe for 3 months from diagnosis or onset as the first-line approach, since 75-90% of OME cases resolve spontaneously during this period 1, 3
• During observation, counsel families about the high likelihood of spontaneous resolution and the natural history of the condition 1, 2
• For children with hearing difficulties, recommend communication strategies including speaking in close proximity, face-to-face communication with clear speech, and repeating phrases when misunderstood 1, 2

Monitoring and Follow-Up Protocol

• Re-examine at 3-6 month intervals until effusion resolves, significant hearing loss is identified, or structural abnormalities are suspected 1, 2, 3
• Document laterality, duration of effusion, and severity of associated symptoms at each visit 2, 3
• Use pneumatic otoscopy as the primary diagnostic method at each assessment 3, 4

Hearing Assessment Threshold

• Obtain age-appropriate hearing testing if OME persists for 3 months or longer 1, 2, 3
• For at-risk children (those with baseline sensory, physical, cognitive, or behavioral factors), perform hearing testing at any duration without waiting 3 months 3
• If bilateral OME with documented hearing loss is present, counsel families about potential impact on speech and language development 1, 3

Medications to Avoid

The following treatments are not recommended due to lack of efficacy or potential adverse effects without long-term benefit:

• Systemic antibiotics - lack long-term efficacy 1, 2, 3, 4
• Intranasal or systemic corticosteroids - potential adverse effects without significant long-term benefit 1, 2, 3, 4
• Antihistamines and decongestants - ineffective for OME 1, 2, 3, 4

Surgical Management Criteria

• Tympanostomy tube insertion is the preferred initial surgical procedure when OME persists for 4 months or longer with persistent hearing loss or other significant symptoms 1, 2, 3
• For children younger than 4 years, perform tympanostomy tubes alone; adenoidectomy should not be performed unless a distinct indication exists (such as nasal obstruction or chronic adenoiditis) 1, 3
• For children 4 years or older, tympanostomy tubes, adenoidectomy, or both may be performed 1, 3
• Do not perform tonsillectomy alone or myringotomy alone to treat OME 3, 4

Special Considerations for At-Risk Children

• Identify children at increased risk for speech, language, or learning problems (those with permanent hearing loss, suspected speech/language delay, autism spectrum disorder, craniofacial abnormalities, or visual impairment) 3
• These children require more prompt evaluation of hearing, speech, and language at the time of diagnosis 3
• Evaluate at-risk children for OME at the time of diagnosis of the at-risk condition and at 12-18 months of age 3

Common Pitfalls

• Do not perform population-based screening in healthy, asymptomatic children without risk factors 3, 4
• Grommets improve hearing by approximately 9 dB at 6 months and 6 dB at 12 months, but this benefit diminishes over time, and tympanosclerosis occurs in 33% of treated ears 5
• The perceived dramatic clinical improvement often exceeds the modest objective benefits measured in trials 5