What is the best treatment approach for a patient, particularly a child, with middle ear effusion (MEE) without infection?

Treatment of Middle Ear Effusion Without Infection

The best treatment for middle ear effusion (OME) without infection is watchful waiting for 3 months, with no antibiotics, steroids, antihistamines, or decongestants, as these medications are ineffective and 75-90% of cases resolve spontaneously. 1, 2

Initial Management: Watchful Waiting

Observation for 3 months is the cornerstone of OME management. 1, 2, 3

• Clinicians should manage children with OME using watchful waiting for 3 months from diagnosis (if onset unknown) or from onset (if known) 1, 2
• This approach is based on the highly favorable natural history: 75-90% of OME cases resolve spontaneously within 3 months, particularly following acute otitis media 2
• The child should be monitored every 3-6 months using pneumatic otoscopy to document presence or absence of middle ear fluid 1, 2

What NOT to Do: Avoid Ineffective Medical Therapies

Strong recommendations exist against multiple medical interventions that lack efficacy:

• Do NOT use antibiotics - they lack long-term efficacy for OME and contribute to bacterial resistance 1, 2, 3, 4
• Do NOT use oral or intranasal steroids - no benefit has been demonstrated and potential adverse effects exist 1, 2, 3, 4
• Do NOT use antihistamines or decongestants - these are completely ineffective for OME 1, 2, 3, 4
• Do NOT use acid reflux medications, chiropractic care, or herbal remedies - no evidence supports their use 2

These are strong recommendations against these therapies, meaning the evidence is clear that they should be avoided. 1, 3

Patient Education During Observation Period

While waiting for spontaneous resolution, counsel families on practical management strategies:

• The child may experience reduced hearing until effusion resolves, especially if bilateral 2
• Speak in close proximity to the child and face them when speaking 2
• Repeat phrases when misunderstood 2
• Provide preferential classroom seating if applicable 2
• Avoid secondhand smoke exposure, which can prolong OME 2
• Consider stopping pacifier use during daytime if child is >12 months old 2

When to Obtain Hearing Testing

Perform age-appropriate hearing assessment if OME persists for 3 months or longer. 1, 2, 3

• Hearing testing is a recommendation (not optional) after 3 months of persistent OME 1, 3
• The hearing loss from OME is typically conductive, averaging 25 decibels 1
• Testing helps identify which children may benefit from surgical intervention 2

Identifying At-Risk Children Who Need Earlier Intervention

Not all children should be managed with simple observation. Identify at-risk children who require closer monitoring or earlier intervention: 1, 2, 3

• Children with baseline developmental delays, speech/language problems, autism spectrum disorder, or learning disabilities 1, 2
• Children with craniofacial abnormalities, Down syndrome, or cleft palate 2
• Children with severe visual impairments who depend more heavily on hearing 2
• These at-risk children should be evaluated at the time of diagnosis of the at-risk condition and at 12-18 months of age 1, 3

Surgical Intervention: When and What Type

Consider tympanostomy tubes only after 3 months of persistent OME with documented hearing loss or in at-risk children. 1, 2, 3

For children <4 years old:

• Recommend tympanostomy tubes when surgery is performed 1, 3
• Adenoidectomy should NOT be performed unless a distinct indication exists (nasal obstruction, chronic adenoiditis) 1, 3

For children ≥4 years old:

• Recommend tympanostomy tubes, adenoidectomy, or both when surgery is performed 1, 3
• Adjuvant adenoidectomy should be considered in children over 4 years with significant nasal obstruction or infection 4

Evidence on surgical outcomes:

• Tympanostomy tubes reduce time with effusion and improve hearing by approximately 9 dB at 6 months and 6 dB at 12 months 2
• Tubes significantly improve hearing and reduce recurrent acute otitis media episodes while in place 4
• However, the benefit-to-harm ratio favors initial observation for otherwise healthy children 2
• Short-term improvements in hearing may occur with tubes, but it's unclear whether benefits persist after longer follow-up 5

Common Pitfalls to Avoid

• Do NOT confuse OME with acute otitis media - they have completely different management strategies 2
• Do NOT routinely screen asymptomatic children without risk factors or symptoms attributable to OME 1, 2
• Do NOT use myringotomy alone as a treatment - it does not facilitate adequate drainage (51% still had MEE 10 days later in one study) 6
• Do NOT rush to surgery - within 6 weeks, spontaneous resolution occurs in 85% of children with MEE detected after acute otitis media 6

Diagnosis Confirmation

Use pneumatic otoscopy as the primary diagnostic method to confirm OME. 1, 3

• Pneumatic otoscopy should document the presence of middle ear effusion 1, 3
• Diagnose OME when tympanic membrane movement is sluggish, dampened, or restricted; complete absence of mobility is not required 1
• Obtain tympanometry if the diagnosis is uncertain after performing (or attempting) pneumatic otoscopy 3
• OME is diagnosed by reduced tympanic membrane mobility, opaque tympanic membrane, or visible air-fluid interface behind the tympanic membrane 1