Management of Otitis Media with Effusion (OME)
Initial Management: Watchful Waiting
The first-line management for OME is watchful waiting for 3 months from diagnosis or onset, as approximately 75-90% of cases resolve spontaneously during this period. 1, 2
- This observation period applies to children who are not at risk for speech, language, or learning problems 1, 2
- The 3-month waiting period carries minimal harm compared to unnecessary interventions and takes advantage of the favorable natural history of OME 3, 2
- During observation, parents should be informed that the child may experience reduced hearing until effusion resolves, especially if bilateral 3
Communication Strategies During Observation
While waiting for spontaneous resolution, implement these environmental modifications:
- Speak in close proximity to the child, face-to-face with clear speech 1, 4
- Repeat phrases when misunderstood 4
- Provide preferential classroom seating 3
At-Risk Children Require Different Approach
Children with the following conditions need more prompt evaluation rather than routine watchful waiting 2:
- Severe visual impairments (they depend more heavily on hearing for language development) 3
- Suspected speech, language, or learning problems 1, 2
- Craniofacial syndromes 5
Follow-Up Protocol
- Re-examine at 3-6 month intervals until effusion resolves, significant hearing loss is identified, or structural abnormalities are suspected 1, 4, 2
- Obtain age-appropriate hearing testing if OME persists for 3 months or longer 1, 4
- Document laterality, duration of effusion, and presence/severity of associated symptoms at each visit 4, 2
Medications: What NOT to Use
Avoid the following medications as they are ineffective or lack long-term benefit:
- Antihistamines and decongestants - completely ineffective for OME 3, 1, 4, 2
- Systemic antibiotics - lack long-term efficacy despite possible short-term benefit (only 1 in 7 children benefit short-term, and benefits disappear within 2 weeks of stopping) 3, 1, 4, 6
- Oral or intranasal corticosteroids - no significant long-term benefit, with potential adverse effects including behavioral changes, weight gain, adrenal suppression, and rare serious complications 3, 1, 4, 7
The evidence is clear: a recent large RCT found oral steroids provided no statistically significant improvement in hearing at 5 weeks (39.9% vs 32.8% with placebo), and any benefit was small and clinically questionable 7
Surgical Management: When and What
Indications for Surgery
Proceed to surgical intervention when:
- OME persists for 4 months or longer with documented hearing loss or other symptoms 1, 2
- Structural damage to the tympanic membrane or middle ear is present 4, 2
- Recurrent or persistent OME in at-risk children 2
Surgical Procedure Selection
Tympanostomy tube (TT) insertion is the preferred initial surgical procedure when a child becomes a surgical candidate 1, 4, 2
Age-Based Surgical Algorithm:
- Children < 4 years old: Tympanostomy tubes alone (do not perform adenoidectomy unless a distinct indication exists, such as obstructive symptoms) 1
- Children ≥ 4 years old: Tympanostomy tubes, adenoidectomy, or both may be recommended 1
- Adenoidectomy enhances TT effectiveness and should be considered in children with adenoid hypertrophy identified by nasal endoscopy 5
Surgical Outcomes
- TTs may provide short- to medium-term improvements in hearing and OME persistence, though long-term benefits remain unclear 8
- Risk of persistent tympanic membrane perforation is low but present (approximately 1-8% depending on tube type and duration) 8
- TTs rapidly normalize hearing and prevent cholesteatoma development but do not prevent tympanic atrophy or retraction pockets 5