What is the treatment for serous otitis media in children and adults?

Treatment of Serous Otitis Media (Otitis Media with Effusion)

Initial Management: Watchful Waiting is the Standard Approach

The cornerstone of treatment for serous otitis media (otitis media with effusion, OME) is watchful waiting for 3 months from diagnosis, as 75-90% of cases resolve spontaneously without intervention. 1, 2

Who Should Receive Watchful Waiting

• All children without risk factors should be managed with observation for 3 months from the date of effusion onset or diagnosis 1, 2
• During this period, monitor with pneumatic otoscopy or tympanometry at clinician discretion 1
• Inform parents that the child may experience reduced hearing (especially if bilateral) until effusion resolves 1
• Recommend strategies to optimize the listening environment: speaking in close proximity, facing the child, speaking clearly, repeating when misunderstood, and providing preferential classroom seating 1

Nasal Balloon Auto-Inflation During Observation

• Use nasal balloon auto-inflation during the watchful waiting period due to its low cost, absence of adverse effects, and proven efficacy (NNT = 9 for clearing effusion at 3 months) 2
• This intervention showed that after 8 weeks, only 4 of 45 children required tympanostomy tubes 2

Medical Therapies: What NOT to Use

Antihistamines, decongestants, oral corticosteroids, intranasal corticosteroids, and antibiotics are all ineffective for OME and should NOT be used. 1, 2

Specific Medications to Avoid

• Antihistamines and decongestants: Cochrane meta-analysis showed no benefit (RR 0.99,95% CI 0.92-1.05) 1, 2
• Intranasal corticosteroids: No improvement in symptoms or middle ear function 2
• Oral corticosteroids: No benefit within 2 weeks; short-term benefit when combined with antimicrobials becomes nonsignificant after several weeks 1
  • Adverse effects include behavioral changes, increased appetite, weight gain, adrenal suppression, fatal varicella infection, and avascular necrosis of the femoral head 1
• Antimicrobials: Do not have long-term efficacy; adverse effects include rashes, vomiting, diarrhea, allergic reactions, bacterial resistance, and societal transmission of resistant pathogens 1, 2
• Prolonged or repetitive courses of antimicrobials or steroids are strongly contraindicated 2

Exception: Topical Decongestants for Acute Symptoms

• Short-term topical decongestants (oxymetazoline or xylometazoline) may be used for acute nasal congestion associated with ETD, but limit to 3 days maximum to avoid rhinitis medicamentosa 2
• These are appropriate only for acute, short-term management, not for OME treatment 2

When to Obtain Hearing Testing

Obtain age-appropriate hearing testing if OME persists for 3 months or longer. 2

• OME causes an average hearing loss of 25 dB HL at the 50th percentile, with approximately 20% of ears exceeding 35 dB HL 2
• Reevaluate every 3-6 months with otologic examination and audiologic assessment until effusion resolves, significant hearing loss is identified, or structural abnormalities develop 2

Surgical Intervention: Tympanostomy Tubes

Tympanostomy tube insertion is the preferred initial surgical procedure for persistent OME lasting 3 months or longer with documented hearing loss or structural changes. 2

Indications for Tympanostomy Tubes

• Bilateral effusions for ≥3 months with mild hearing loss (16-40 dB HL) 2
• Chronic OME with structural changes of the tympanic membrane (retraction, atelectasis) 2
• Type B (flat) tympanogram indicating persistent fluid or negative pressure after 3 months 2
• Tubes provide hearing improvement of 6-12 dB while patent and clear effusion for up to 2 years 2
• High-level evidence shows benefit for hearing and quality of life for up to 9 months 2

Critical Timing

• Do NOT insert tympanostomy tubes before 3 months of documented OME 2
• There is no evidence of benefit before 3 months, and it exposes the patient to unnecessary surgical risks 2
• Tympanostomy tubes have no evidence of beneficial effect on language development 2

Age-Specific Surgical Considerations

Children Under 4 Years

• Recommend tympanostomy tubes alone 2
• Do NOT perform adenoidectomy unless a distinct indication exists other than OME (such as nasal obstruction or chronic adenoiditis) 2

Children 4 Years and Older

• Consider tympanostomy tubes, adenoidectomy, or both 2
• For repeat surgery: Adenoidectomy plus myringotomy (with or without tubes) is recommended unless cleft palate is present 2
• Adenoidectomy reduces the need for ventilation tube re-insertions by approximately 10% and confers a 50% reduction in the need for future operations 2

Special Populations Requiring Earlier or More Aggressive Intervention

At-risk children may receive tympanostomy tubes earlier than the standard 3-month waiting period. 2

High-Risk Groups

• Children with severe visual impairments: They depend on hearing more than children with normal vision; any decrease in hearing may significantly compromise language development 1
• Children with Down syndrome: Require hearing assessments every 6 months starting at birth and otolaryngologic evaluation for recurrent AOM and OME due to poor eustachian tube function 2
• Children with cleft palate: Require management by a multidisciplinary team and continued monitoring throughout childhood, even after palate repair, due to nearly universal occurrence of OME 2
• Children with developmental disabilities: Require closer monitoring as they may lack communication skills to express pain or discomfort 2
• Children with craniofacial syndromes 2

Monitoring for At-Risk Children

• These children should be considered more vulnerable to OME sequelae and may warrant earlier surgical intervention 1, 2
• The severity of OME correlates with lower IQ, hyperactive behavior, and reading defects 2

Allergy Management

For patients with OME secondary to allergic rhinitis, treat the underlying allergies. 2

• Intranasal corticosteroids are first-line treatment for allergic rhinitis itself (not for OME) 2
• Second-generation antihistamines for sneezing and itching associated with allergic rhinitis 2

Post-Treatment Monitoring

• After tympanostomy tube placement, evaluate children within 3 months and then periodically while tubes remain in place 2
• Educate caregivers about tube function duration, follow-up schedule, and how to detect complications 2
• Water precautions may be necessary, particularly for swimming in non-chlorinated water or dunking head during bathing 2

Management of Tube Otorrhea

• For ear infections with tubes in place: Antibiotic ear drops (ofloxacin or ciprofloxacin-dexamethasone) are the treatment of choice, applied twice daily for up to 10 days 2
• Quinolone ear drops have not shown ototoxicity and are preferred over systemic antibiotics 2
• Oral antibiotics are generally unnecessary unless the child is very ill or the infection doesn't respond to ear drops 2
• Do not use antibiotic eardrops frequently or for more than 10 days at a time to avoid yeast infections of the ear canal 2