What is the recommended treatment approach for an adult with serous otitis media with effusion?

Treatment for Adults with Serous Otitis Media with Effusion

For adults with serous otitis media with effusion, initiate watchful waiting for 3 months, as 75-90% of cases resolve spontaneously without intervention, and avoid antibiotics, antihistamines, decongestants, and corticosteroids, which are either ineffective or provide no long-term benefit. 1, 2

Initial Management: Watchful Waiting Protocol

• Observe for 3 months from the date of diagnosis, with interval evaluations at your discretion using pneumatic otoscopy or tympanometry to confirm persistent middle ear effusion 1, 2
• Document the laterality (unilateral vs bilateral), duration of effusion, and severity of hearing symptoms at each visit 1, 3
• Counsel patients that hearing may remain reduced until the effusion resolves, particularly if bilateral, and this is expected during the observation period 1, 2

Communication Strategies During Observation

• Advise patients to have conversations within 3 feet, face-to-face, to optimize hearing 1, 2
• Recommend speaking clearly and repeating phrases when misunderstood 1, 2
• Eliminate background noise during important conversations 2
• Strongly advise avoiding secondhand smoke exposure, which may exacerbate OME 1, 2

Medications to Explicitly Avoid

The evidence is unequivocal that multiple medication classes have no role in adult OME management:

Antibiotics

• Do not prescribe antibiotics for OME, as they provide no long-term benefit and carry unnecessary risks including rashes, diarrhea, allergic reactions, and promotion of bacterial resistance 1, 2
• This recommendation applies even to prolonged or repetitive courses 2

Corticosteroids

• Avoid oral or intranasal corticosteroids for OME treatment, as any short-term benefits become nonsignificant within 2 weeks of stopping therapy 1, 2
• Risks include behavioral changes, weight gain, adrenal suppression, and rare serious complications 1
• Note: One small trial showed some benefit from intratympanic steroid injections in adults with OME for subjective symptoms, but this is not standard practice 4

Antihistamines and Decongestants

• These medications are completely ineffective for OME and should never be used, regardless of formulation or combination 1, 2
• The only exception is if the patient has documented allergic rhinitis as a separate condition requiring treatment 2

Management After 3 Months of Persistent OME

If the effusion persists at the 3-month mark:

• Obtain formal audiometric testing to quantify the degree of hearing loss and guide further management decisions 1, 2
• This testing also excludes underlying sensorineural hearing loss that may require different management 1
• Continue re-examination at 3-6 month intervals until complete resolution occurs 2, 3

Surgical Intervention Criteria

Consider tympanostomy tube insertion if:

• OME persists ≥4 months with documented hearing loss on audiometry 1, 2
• Significant symptoms affect quality of life despite the duration 1, 2
• Structural damage to the tympanic membrane or middle ear is identified 3

Additional Surgical Considerations

• If nasal obstruction is present, adenoidectomy may be considered in adults, though this is less common than in pediatric populations 1
• High-level evidence supports tympanostomy tubes for hearing improvement and quality of life for up to 9 months after insertion 4

Prognostic Information for Patient Counseling

• If effusion has been present for ≥3 months, spontaneous resolution rates drop significantly: only 19% at 3 additional months, 25% at 6 months, and 31% at 12 months 2
• A Type B (flat) tympanogram predicts poor resolution: only 20% resolve at 3 months and 28% at 6 months 2
• These factors should lower your threshold for proceeding to audiometric testing and surgical referral 2

Common Pitfalls to Avoid

• Do not prescribe antibiotics simply because the effusion has persisted beyond a few weeks—this is expected and does not indicate bacterial infection 1, 2
• Do not substitute tympanometry alone for formal audiometric testing when assessing hearing loss at 3 months 2
• Do not delay evaluation in adults with risk factors such as craniofacial anomalies, immunodeficiency, or severe visual impairment, as they may benefit from earlier intervention 4, 2
• Be aware that adult-onset OME commonly co-exists with allergy (38.6% of cases) and inflammatory diseases of the upper respiratory tract (rhinosinusitis in 24.1%), which may require separate management 5