Prednisone Should NOT Be Used for Ear Effusion
Prednisone and other oral corticosteroids are ineffective for treating otitis media with effusion (OME) and should not be used, as explicitly stated by the American Academy of Otolaryngology-Head and Neck Surgery Foundation guidelines. 1
Why Steroids Don't Work for OME
The 2016 AAO-HNSF Clinical Practice Guideline on OME is unequivocal: medical treatments such as steroids are ineffective or may cause adverse effects and therefore should not be used. 1 This recommendation supersedes older research from the 1980s-1990s that showed mixed results with oral steroids. 2, 3, 4
The evidence base demonstrates:
- A 1986 double-blind crossover study of 60 children found no statistical difference between prednisone and placebo for chronic middle ear effusion lasting at least 2 months, with 60% clearing in both groups. 4
- While earlier studies from 1980-1981 suggested some benefit (68-70% resolution rates), these were not replicated in higher-quality controlled trials. 2, 3
- Intranasal corticosteroids are also ineffective and should not be used, despite one small study showing benefit in children with adenoid hypertrophy. 1
The Correct Management Approach for OME
Watchful waiting for 3 months is the evidence-based first-line approach, as OME resolves spontaneously in most children within this timeframe. 1 This applies to children who are not at particular risk for speech, language, or learning problems. 1
After 3 months of persistent OME with documented hearing difficulties:
- Tympanostomy tubes are the intervention of choice. 1
- Tube placement significantly improves hearing, reduces effusion prevalence, and may reduce recurrent acute otitis media incidence. 5
- The procedure takes 10-20 minutes under general anesthesia, with tubes typically falling out in 12-18 months. 5
For children ≥4 years old with persistent OME:
- Adenoidectomy (with or without tubes) is most beneficial and reduces the need for future ear tubes by approximately 50%. 5, 1
During the watchful waiting period:
- Nasal balloon auto-inflation may be considered, with a number needed to treat of 9 for clearing middle ear effusion in school-aged children. 1
Important Clinical Distinction
Prednisone DOES have a role in sudden sensorineural hearing loss (SSNHL), NOT OME. 1 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
One Exception: Acute Otorrhea Through Tympanostomy Tubes
The only context where steroids showed benefit for middle ear disease is acute otitis media with discharge through existing tympanostomy tubes. A 1999 study found that prednisolone (2 mg/kg/day for 3 days) plus antibiotics reduced otorrhea duration from 3 days to 1 day compared to antibiotics alone. 6 However, this is a completely different clinical scenario than treating OME itself.
Common Pitfalls to Avoid
- Don't prescribe oral steroids for OME based on outdated literature from the 1980s. The current guideline evidence is clear that they don't work. 1
- Don't confuse OME with SSNHL. OME presents with middle ear fluid and conductive hearing loss; SSNHL presents with sudden-onset sensorineural hearing loss without middle ear pathology. 1
- Don't rush to surgery before 3 months unless the child has risk factors for developmental difficulties (permanent hearing loss, speech/language delay, autism-spectrum disorder, Down syndrome, cleft palate, blindness, or developmental delay). 5