HCTZ is Not Indicated for Refractory Serous Chronic Otitis Media
Hydrochlorothiazide (HCTZ) has no role in the treatment of chronic serous otitis media and should not be used for this indication. The evidence-based guidelines for otitis media with effusion (OME) explicitly recommend against systemic medications including steroids, antibiotics, antihistamines, and decongestants—and diuretics like HCTZ are not mentioned as a treatment option in any otolaryngology guideline 1.
Why HCTZ is Not Appropriate
No evidence base: HCTZ is a thiazide diuretic used primarily for hypertension and edema from cardiac or renal disease 1. There are no clinical trials, case series, or guideline recommendations supporting its use in chronic serous otitis media 1.
Wrong mechanism: While diuretics like chlorothiazide are used in chronic lung disease of infancy to reduce pulmonary edema 1, middle ear effusion is not caused by systemic fluid overload that would respond to diuretic therapy. The pathophysiology involves eustachian tube dysfunction and local inflammatory processes 2, 3.
Guidelines explicitly recommend against systemic medications: The American Academy of Otolaryngology-Head and Neck Surgery provides strong recommendations against using systemic steroids, antibiotics, antihistamines, or decongestants for OME 1. These medications have documented short-term benefits in some studies but show preponderance of harm over benefit for long-term outcomes 1.
What Should Be Done Instead
For refractory chronic serous otitis media, the evidence-based approach is:
Watchful waiting for 3 months from diagnosis if the child is not at risk, with re-evaluation at 3-6 month intervals 1.
Obtain age-appropriate hearing testing if effusion persists ≥3 months or for any duration in an at-risk child 1.
Surgical intervention with tympanostomy tubes is the definitive treatment when OME persists beyond 3 months with documented hearing loss or in at-risk children 1.
For children ≥4 years old, consider tympanostomy tubes, adenoidectomy, or both 1.
Common Pitfall to Avoid
Do not prescribe systemic medications (including diuretics, steroids, antibiotics, antihistamines, or decongestants) for chronic serous otitis media, as these delay definitive therapy and expose patients to unnecessary side effects without improving long-term outcomes 1.