What is the recommended treatment for serous ear effusion?

Treatment of Serous Ear Effusion (Otitis Media with Effusion)

Watchful waiting for 3 months is the recommended initial management for children with otitis media with effusion (OME) who are not at risk for developmental problems, as 75-90% of cases resolve spontaneously without intervention. 1

Initial Management Strategy

Observation Period

• Manage non-at-risk children with watchful waiting for 3 months from the date of effusion onset (if known) or from diagnosis (if onset is unknown) 1
• During observation, monitor the child at 3- to 6-month intervals using pneumatic otoscopy or tympanometry until the effusion resolves 1
• This approach avoids unnecessary interventions and takes advantage of the favorable natural history of OME 1

Patient Education During Observation

• Inform parents that the child may experience reduced hearing until the effusion resolves, especially if bilateral 1
• Recommend strategies to optimize the listening environment: speaking in close proximity to the child, facing the child and speaking clearly, repeating phrases when misunderstood, and providing preferential classroom seating 1

Medical Therapy: NOT Recommended

Do not use medications for routine management of OME - the evidence strongly supports avoiding pharmacologic interventions: 1

Antibiotics

• Systemic antibiotics should NOT be used for treating OME 1
• While antibiotics may show short-term benefit (resolving OME in 1 out of 7 children treated), this benefit becomes nonsignificant within 2 weeks of stopping medication 1
• Adverse effects include rashes, vomiting, diarrhea, allergic reactions, altered nasopharyngeal flora, and development of bacterial resistance 1

Steroids

• Intranasal and systemic steroids should NOT be used for treating OME 1
• Oral steroids plus antibiotics show short-term benefit in 1 out of 3 children, but this becomes nonsignificant after several weeks 1
• Adverse effects include behavioral changes, increased appetite, weight gain, adrenal suppression, and potentially fatal varicella infection 1
• Cochrane review confirms no evidence of benefit for hearing loss or long-term OME resolution 2

Antihistamines and Decongestants

• Antihistamines and decongestants are ineffective and should NOT be used 1

Hearing Assessment

When to Test

• Obtain age-appropriate hearing test if OME persists ≥3 months OR at any time for at-risk children 1
• Conduct hearing testing when language delay, learning problems, or significant hearing loss is suspected 1
• Average hearing loss with OME ranges from 0-55 dB, with median around 25 dB 1

At-Risk Children Requiring Earlier Evaluation

At-risk children include those with: 1

• Permanent hearing loss independent of OME
• Suspected or confirmed speech/language delay or disorder
• Autism spectrum disorder or other pervasive developmental disorders
• Syndromes or craniofacial disorders affecting eustachian tube function
• Blindness or uncorrectable visual impairment
• Cleft palate (repaired or unrepaired)
• Developmental delay or cognitive impairment

Surgical Management

Indications for Surgery

Surgical candidates include children with: 1

• OME lasting ≥4 months with persistent hearing loss or other significant symptoms
• Recurrent or persistent OME in at-risk children regardless of hearing status
• OME with structural damage to the tympanic membrane or middle ear

Surgical Approach by Age

For children <4 years old: 1

• Tympanostomy tubes are the preferred initial procedure
• Adenoidectomy should NOT be performed unless a distinct indication exists (nasal obstruction, chronic adenoiditis) other than OME
• Tubes provide a 62% relative decrease in effusion prevalence and improve hearing by 6-12 dB while patent 1

For children ≥4 years old: 1

• Tympanostomy tubes, adenoidectomy, or both are appropriate options
• Adenoidectomy plus myringotomy has comparable efficacy to tubes in this age group but is more invasive 1

For repeat surgery (after tube extrusion with OME relapse): 1

• Adenoidectomy is recommended (unless cleft palate present) as it confers a 50% reduction in need for future operations
• Benefit is greatest for children ≥3 years old and independent of adenoid size
• Perform myringotomy concurrent with adenoidectomy; add tube insertion for younger children or at-risk children 1

Procedures NOT Recommended

• Tonsillectomy alone - ineffective with risks (2% hemorrhage rate) outweighing any potential benefits 1
• Myringotomy alone (without tubes or adenoidectomy) - ineffective as incision closes within days 1

Common Pitfalls to Avoid

• Do not prescribe antibiotics or steroids for routine OME management despite parental pressure - the harm outweighs minimal short-term benefit 1
• Do not delay hearing assessment in at-risk children or when OME persists ≥3 months 1
• Do not perform adenoidectomy as initial surgery in children <4 years without specific indications 1
• Do not screen asymptomatic, healthy children for OME - population-based screening has not influenced outcomes and leads to overtreatment 1