From the Guidelines
Watchful waiting is the recommended initial approach for otitis media with effusion (OME), as most cases resolve spontaneously within 3 months without intervention. During this period, regular follow-up every 3-6 months is advised to monitor for resolution or complications, as recommended by the most recent guideline 1. Antibiotics, antihistamines, decongestants, and intranasal steroids are generally not recommended for uncomplicated OME as they provide minimal benefit and contribute to antibiotic resistance or other adverse effects 1. If OME persists beyond 3 months with significant hearing loss or recurrent acute otitis media episodes, referral to an otolaryngologist for possible tympanostomy tube placement should be considered, with the decision guided by the child's risk factors and hearing status 1.
Some key considerations in managing OME include:
- Documenting the presence of middle ear effusion with pneumatic otoscopy when diagnosing OME in a child 1
- Obtaining tympanometry in children with suspected OME for whom the diagnosis is uncertain after performing pneumatic otoscopy 1
- Evaluating at-risk children for OME at the time of diagnosis of an at-risk condition and at 12 to 18 months of age 1
- Counseling families of children with bilateral OME and documented hearing loss about the potential impact on speech and language development 1
- Recommending tympanostomy tubes when surgery is performed for OME in a child less than 4 years old, with adenoidectomy considered for children 4 years old or older 1
The rationale for watchful waiting stems from the pathophysiology of OME, which typically results from eustachian tube dysfunction causing negative middle ear pressure and fluid accumulation. This condition often resolves as eustachian tube function improves, particularly as children grow and their anatomy develops. Therefore, a period of watchful waiting for 3 months is recommended before considering surgical intervention, unless the child is at increased risk for speech, language, or learning problems due to baseline sensory, physical, cognitive, or behavioral factors 1.
From the Research
Treatment Options for Otitis Media with Effusion
- Tympanostomy tube insertion with adenoidectomy has been shown to have a significant treatment effect for children with recurrent otitis media with effusion, reducing the recurrent rate after surgery and shortening the time of middle ear cavity effusion 2.
- Adenoidectomy may be beneficial in treating otitis media in children who are older than 4 years of age and who have previously undergone tympanostomy-tube insertion 3.
- The American Academy of Otolaryngology-Head and Neck Surgery Foundation recommends tympanostomy tubes when surgery is performed for OME in a child <4 years old, and adenoidectomy should not be performed unless a distinct indication exists 4.
- For children ≥4 years old, the recommendation is for tympanostomy tubes, adenoidectomy, or both when surgery is performed for OME 4.
Effectiveness of Adenoidectomy and Tympanostomy Tubes
- Adenoidectomy and tympanostomy tubes have been shown to be effective in reducing the time spent with effusion and improving hearing in children with chronic otitis media with effusion 5.
- A systematic review of surgical treatments for otitis media with effusion found that tubes and adenoidectomy reduce time with OME and improve hearing in the short-term, but both treatments have associated harms 6.
Recommendations for Management
- Clinicians should document the presence of middle ear effusion with pneumatic otoscopy when diagnosing OME in a child, and perform pneumatic otoscopy to assess for OME in a child with otalgia, hearing loss, or both 4.
- Watchful waiting for 3 months from the date of effusion onset or 3 months from the date of diagnosis is recommended for children with OME who are not at risk 4.
- Clinicians should educate children with OME and their families regarding the natural history of OME, need for follow-up, and the possible sequelae 4.