From the Guidelines
Middle ear effusion is best managed with watchful waiting for 3 months in most cases before considering intervention. This approach is based on the most recent and highest quality evidence, which suggests that most episodes of middle ear effusion resolve spontaneously within 3 months 1. Initial treatment should focus on addressing any underlying causes such as allergies or upper respiratory infections. For allergic causes, intranasal steroids like fluticasone (1-2 sprays per nostril daily) or oral antihistamines such as cetirizine (10mg daily for adults, weight-appropriate dosing for children) may help. However, antibiotics are only indicated if there's evidence of acute infection with pain, fever, or significant symptoms. If effusion persists beyond 3 months with hearing loss or recurrent infections, referral to an ENT specialist for possible tympanostomy tube placement is recommended. Autoinflation techniques using a Valsalva maneuver or commercial devices may help equalize pressure and promote drainage. Middle ear effusion occurs when the Eustachian tube becomes blocked, preventing proper drainage and ventilation of the middle ear space, leading to fluid accumulation. This condition is particularly common in children due to their shorter, more horizontal Eustachian tubes, but can affect adults as well, especially following upper respiratory infections or with allergic conditions.
Some key points to consider in the management of middle ear effusion include:
- Watchful waiting for 3 months before considering intervention 1
- Addressing underlying causes such as allergies or upper respiratory infections
- Avoiding unnecessary antibiotic use unless there's evidence of acute infection 1
- Referral to an ENT specialist for possible tympanostomy tube placement if effusion persists beyond 3 months with hearing loss or recurrent infections
- Autoinflation techniques to help equalize pressure and promote drainage
It's also important to note that tympanostomy tubes can improve quality of life for children with chronic middle ear effusion, recurrent acute otitis media, or both 1. However, the risks of tube insertion must be balanced against the risks of chronic middle ear effusion, recurrent otitis media, or both, which include suppurative complications, damage to the tympanic membrane, adverse effects of antibiotics, and potential developmental sequelae of mild to moderate hearing loss.
From the Research
Definition and Diagnosis of Middle Ear Effusion
- Middle ear effusion is defined as the presence of fluid in the middle ear without signs or symptoms of acute ear infection 2.
- Diagnosis of middle ear effusion can be made using pneumatic otoscopy, and tympanometry can be used to assess for middle ear effusion when the diagnosis is uncertain 2.
Treatment Options for Middle Ear Effusion
- Myringotomy and aspiration of the middle ear effusion is indicated for acute otitis media in certain situations, such as persistent or recurrent symptoms, severe otalgia, or suppurative complications 3.
- Myringotomy with tympanostomy tube insertion is indicated for recurrent acute otitis media, eustachian tube dysfunction, severe retraction pocket of the tympanic membrane, and suppurative complications 3.
- Watchful waiting for 3 months is recommended for children with otitis media with effusion who are not at risk 2.
- The use of intranasal or systemic steroids, systemic antibiotics, antihistamines, and decongestants is not recommended for treating otitis media with effusion 2.
Surgical Management of Middle Ear Effusion
- Myringotomy with tube placement is a common surgical procedure for the treatment of otitis media with effusion 4.
- Laser myringotomy is a relatively new procedure that has been shown to be effective in treating otitis media with effusion, with higher effectiveness and fewer complications compared to incisional myringotomy 5.
- Tympanostomy tubes are recommended for children under 4 years old, while adenoidectomy may be considered for children over 4 years old 2.
Special Considerations
- Children with underlying conditions that predispose to otitis media with effusion, such as developmental disabilities, require special consideration and monitoring 2.
- The natural history of otitis media with effusion and the potential benefits and risks of treatment options should be discussed with parents and patients 2.
- Hearing and language evaluation should be performed in children with persistent otitis media with effusion 2.