Oral Steroids for Otitis Media with Effusion: Not Recommended
Oral steroids should NOT be used for treating otitis media with effusion (OME) in children, as current evidence demonstrates they are ineffective, not cost-effective, and lack of efficacy is explicitly stated in clinical practice guidelines. 1
Guideline-Based Recommendations
The American Academy of Otolaryngology-Head and Neck Surgery Foundation's 2016 Clinical Practice Guideline on OME explicitly states that medical treatments such as steroids are ineffective or may cause adverse effects and therefore should not be used. 1
Key Evidence Against Steroid Use
The most recent high-quality randomized controlled trial (OSTRICH, 2018) involving 389 children aged 2-8 years found no statistically significant benefit from a 7-day course of oral prednisolone (20-30 mg daily) compared to placebo. 2
At 5 weeks, only 39.9% of steroid-treated children achieved satisfactory hearing versus 32.8% in the placebo group (absolute difference 7.1%, 95% CI -2.8% to 16.8%), which was not statistically significant. 2
The economic analysis demonstrated that oral steroids were more expensive and accrued fewer quality-adjusted life-years than standard care, making them not cost-effective. 2
Any apparent small benefit is likely of questionable clinical significance and cannot justify routine use. 2
Recommended Management Approach
The evidence-based approach for OME management is watchful waiting for 3 months, as OME resolves spontaneously in most children within this timeframe. 1
Specific Management Algorithm:
Initial 3-month observation period for children with OME who are not at particular risk for speech, language, or learning problems. 1
Ventilation tubes are the intervention of choice for children with persistent OME and documented hearing difficulties after 3 months of watchful waiting. 1
Adenoidectomy (with or without tubes) is most beneficial in children ≥4 years of age with persistent OME. 1
Nasal balloon auto-inflation may be considered during the watchful waiting period, with a number needed to treat of 9 for clearing middle ear effusion in school-aged children. 1, 3
Important Caveats
Contradictory Older Evidence
While some older, smaller studies from the 1990s suggested potential benefit from oral steroids combined with antibiotics 4, 5, these findings have been superseded by the large, well-designed OSTRICH trial which definitively showed no clinically meaningful benefit. 2
Intranasal Steroids
Intranasal corticosteroids are also ineffective for OME and should not be used, despite one small study showing some benefit in children with adenoid hypertrophy. 1
Intratympanic Steroids
While one small study suggested potential benefit from intratympanic steroid injections 6, this approach is not recommended in current guidelines and requires further validation before clinical adoption. 1
Natural History Consideration
OME has a high rate of spontaneous resolution, particularly in children with documented hearing loss and symptoms for at least 3 months, which explains why the placebo group in the OSTRICH trial showed 32.8% resolution at 5 weeks. 2 This favorable natural history supports the watchful waiting approach over pharmacologic intervention.
When Steroids ARE Indicated for Ear Conditions
Oral steroids DO have a role in sudden sensorineural hearing loss (SSNHL), not OME. For SSNHL, prednisone 1 mg/kg/day (maximum 60 mg/day) for 7-14 days followed by a taper is recommended, ideally initiated within the first 14 days of symptom onset. 1, 7 This is a completely different condition from OME and should not be confused.