What are the treatment options for otitis media with effusion?

Treatment of Otitis Media with Effusion

Initial Management: Watchful Waiting

The first-line treatment for otitis media with effusion (OME) is watchful waiting for 3 months, as 75-90% of cases resolve spontaneously during this period. 1, 2

• Observation should begin from the date of effusion onset (if known) or from diagnosis (if onset is unknown). 1, 3
• During this 3-month period, interval monitoring can be performed at clinician discretion using pneumatic otoscopy or tympanometry. 4, 2
• Patients and families should be counseled about the high likelihood of spontaneous resolution and the natural history of OME. 1, 2

Communication Strategies During Observation

For patients experiencing hearing difficulties from OME, implement these specific strategies:

• Speak in close proximity to the child, facing them directly with clear speech. 4, 1
• Repeat phrases when misunderstood. 4
• Provide preferential classroom seating for school-aged children. 4
• Counsel families that hearing may remain reduced until the effusion resolves, particularly if bilateral. 2

Medications to Avoid

Antihistamines and decongestants should NOT be used for OME as they are completely ineffective. 1, 2, 3, 5

Systemic antibiotics should NOT be used for routine management of OME. 1, 2, 3 While antimicrobials may show short-term benefit in some trials, this benefit becomes nonsignificant within 2 weeks of stopping medication, and approximately 7 children would need to be treated to achieve one short-term response. 4 The risks include rashes, vomiting, diarrhea, allergic reactions, alteration of nasopharyngeal flora, development of bacterial resistance, and cost. 4, 2

Oral and intranasal corticosteroids should NOT be used for OME. 1, 2, 3 Although oral steroids plus antimicrobials may show short-term benefit in 1 out of 3 children treated, this benefit becomes nonsignificant after several weeks. 4 Adverse effects include behavioral changes, increased appetite, weight gain, adrenal suppression, fatal varicella infection, and avascular necrosis of the femoral head. 4, 2

Follow-Up Protocol

Re-examine patients at 3-6 month intervals until the effusion resolves, significant hearing loss is identified, or structural abnormalities of the eardrum or middle ear are suspected. 4, 1, 3

Hearing Assessment Timing

• Obtain age-appropriate hearing testing when OME persists for 3 months or longer. 4, 1, 3
• Perform hearing testing at ANY time if language delay, learning problems, or significant hearing loss is suspected, regardless of duration. 4, 3
• For at-risk children (those with permanent hearing loss, suspected speech/language delay, autism spectrum disorder, craniofacial abnormalities, or visual impairment), obtain hearing testing at diagnosis without waiting 3 months. 3

The average pure tone hearing loss in OME ranges from normal to moderate (0-55 dB), with the 50th percentile around 25 dB HL and approximately 20% of ears exceeding 35 dB HL. 4

Surgical Management

Tympanostomy tube insertion is the preferred initial surgical procedure when a patient becomes a surgical candidate. 4, 1, 3, 5

Surgical Candidacy Criteria

Candidates for surgery include patients with:

• OME lasting 4 months or longer with persistent hearing loss. 4, 1
• Bilateral OME with documented hearing loss after 3 months of observation. 1
• Structural abnormalities of the tympanic membrane or middle ear. 4, 1

Age-Specific Surgical Recommendations

For children younger than 4 years: Tympanostomy tubes alone are recommended. 1 Adenoidectomy should NOT be performed unless a distinct indication exists, such as nasal obstruction or chronic adenoiditis. 4, 1, 5

For children 4 years or older: Tympanostomy tubes, adenoidectomy, or both may be recommended when surgery is performed. 1 Adenoidectomy enhances the effectiveness of tympanostomy tubes, particularly in children with adenoid hypertrophy. 6

For repeat surgery: Adenoidectomy plus myringotomy with or without tube insertion is the preferred approach. 4

Procedures to Avoid

• Tonsillectomy alone should NOT be used to treat OME. 4, 1, 5
• Myringotomy alone should NOT be used to treat OME. 4, 3, 5

Common Pitfalls

• Do NOT perform population-based screening for OME in healthy, asymptomatic children without risk factors. 3, 5
• Do NOT use prolonged or repetitive courses of antimicrobials or steroids, as the likelihood of long-term resolution is small. 4
• Avoid secondhand smoke exposure, which may exacerbate OME. 2
• Do NOT miss underlying sensorineural hearing loss by failing to perform comprehensive audiometry when indicated. 2