What is the initial management approach for serous otitis media with effusion in both adults and children?

Management of Serous Otitis Media with Effusion

Initial Management: Watchful Waiting

The cornerstone of initial management for both children and adults with OME who are not at risk is watchful waiting for 3 months from the date of effusion onset or diagnosis. 1, 2, 3, 4 This approach is strongly recommended because approximately 75-90% of OME cases resolve spontaneously within this timeframe, avoiding unnecessary interventions with potential adverse effects. 1, 3

Documentation Requirements at Each Visit

At every assessment, clinicians must document three key elements: 1, 3, 4

• Laterality (unilateral vs bilateral)
• Duration of effusion (from onset if known, or from diagnosis)
• Presence and severity of associated symptoms (hearing difficulties, balance problems, ear discomfort, behavioral issues, poor school performance)

Risk Stratification

Children at risk for developmental difficulties require more prompt evaluation and should NOT follow standard watchful waiting. 1, 3 At-risk children include those with: 1

• Permanent hearing loss independent of OME
• Suspected or confirmed speech/language delay
• Autism spectrum disorder
• Syndromes or craniofacial disorders affecting eustachian tube function
• Cognitive, developmental, or learning disabilities

For at-risk children, management should include earlier hearing evaluation, speech and language assessment, and consideration for earlier surgical intervention. 1

Medications to AVOID

Do not use the following medications as they are ineffective or lack long-term benefit:

• Antihistamines and decongestants - These are completely ineffective for OME and should never be used. 1, 2, 3, 4 Multiple high-quality guidelines uniformly recommend against their use.

• Systemic antibiotics - While antibiotics may slightly reduce OME persistence at up to 3 months compared to no treatment, they lack long-term efficacy and should not be used for routine management. 1, 2, 3, 5 The short-term benefit does not justify the risks of antibiotic resistance and adverse effects.

• Oral and intranasal corticosteroids - These should not be used due to potential adverse effects without significant long-term benefit. 2, 4 Research confirms that oral steroids lead only to quick resolution with no long-term benefits. 6

Follow-Up Protocol During Watchful Waiting

Re-examine patients at 3-6 month intervals until one of three endpoints occurs: 1, 2, 3, 4

1. The effusion resolves completely
2. Significant hearing loss is identified
3. Structural abnormalities of the tympanic membrane or middle ear are suspected

Hearing Assessment Timing

Obtain age-appropriate hearing testing if: 1, 2, 4

• OME persists for 3 months or longer
• Language delay or learning problems are suspected at any time
• Significant hearing loss is suspected at any time

For children under 4 months of age, specialized tympanometry equipment with higher probe tone frequency is required; standard 226 Hz tympanometry is reliable for children 4 months and older. 1

Patient and Family Education

Counsel families about: 1, 2

• The natural history of OME and high likelihood of spontaneous resolution
• The need for consistent follow-up appointments
• Possible sequelae if OME persists
• Communication strategies for children with hearing difficulties (speaking in close proximity, face-to-face communication with clear speech, repeating phrases when misunderstood) 2, 4

Environmental modifications: Eliminate exposure to secondhand smoke, especially in enclosed spaces like cars and homes. 1 For children over 12 months who use pacifiers, consider discontinuation as this may improve outcomes. 1

Surgical Candidacy Criteria

A patient becomes a surgical candidate when: 1, 2, 3

• OME persists for 4 months or longer 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

Tympanostomy tube insertion is the preferred initial surgical procedure. 1, 2, 3 This is based on randomized controlled trials showing superiority over other surgical options.

Age-specific surgical recommendations: 2

• Children under 4 years: Tympanostomy tubes alone; adenoidectomy should NOT be performed unless a distinct indication exists (nasal obstruction, chronic adenoiditis)
• Children 4 years and older: Tympanostomy tubes, adenoidectomy, or both may be considered

For repeat surgery: Adenoidectomy plus myringotomy with or without tube insertion is recommended. 1

Do NOT perform: 1

• Tonsillectomy alone for OME treatment
• Myringotomy alone for OME treatment
• Adenoidectomy as initial surgery without distinct indication

Important Caveats

Screening is not recommended: Population-based screening programs for OME should not be performed in healthy, asymptomatic children, as they do not influence short-term language outcomes and may lead to overtreatment. 1 This does not apply to targeted monitoring of children with previous or recurrent OME.

Complementary and alternative medicine: No recommendation can be made regarding these treatments due to lack of scientific evidence. 1

Allergy management: No recommendation can be made as there are no prospective studies examining the effects of immunotherapy compared to observation. 1

Autoinflation: While some evidence suggests autoinflation may improve OME-specific quality of life and reduce persistence of OME in the short term, the evidence is of very low certainty and the benefits must be weighed against the inconvenience of regular use and possible risk of ear pain. 7