What is the initial treatment for an adult patient with serous otitis media?

Treatment of Serous Otitis Media in Adults

Initial Management: Watchful Waiting

For adults with serous otitis media (also called otitis media with effusion or OME), the initial treatment is watchful waiting for 3 months with age-appropriate hearing testing, as medical treatment is discouraged. 1

The evidence strongly supports observation rather than immediate intervention because:

• Spontaneous resolution is common – middle ear effusion frequently resolves without treatment, making an expectant approach initially appropriate 2, 3
• Antibiotics are not indicated – medical treatment with antibiotics is specifically discouraged for OME in the absence of acute infection symptoms 1
• Hearing assessment is paramount – age-appropriate hearing testing should be performed when OME is diagnosed and repeated at 3-month follow-up 1

Symptomatic Relief Options

While awaiting spontaneous resolution, clinicians may recommend the following for symptom relief:

• Nasal saline irrigation for comfort 1
• Topical intranasal corticosteroids may provide some benefit, with evidence showing improved tympanometry and audiometry outcomes, particularly in patients with adenoid hypertrophy 1
• Auto-inflation devices show small but positive effects on OME-associated hearing loss with no adverse effects and low cost, making them reasonable during the watchful waiting period 1

When to Consider Intervention

Surgical intervention with tympanostomy tubes should be considered only in selected cases after the initial 3-month observation period when:

• Bilateral disease persists >3 months with documented hearing loss 1
• Hearing loss varies across guidelines but generally >25-40 dB HL in the better ear 1
• Significant effect on well-being, behavior, or development is documented 1
• Tympanic membrane morphological findings require surgical treatment 1

Critical Pitfalls to Avoid

• Do not prescribe antibiotics – there is no role for antibiotic therapy in uncomplicated OME without signs of acute infection 1
• Do not use antihistamine/decongestant preparations – these are ineffective for OME 4
• Avoid repetitive or prolonged antibiotic treatment – this accelerates bacterial resistance without improving outcomes 4
• Do not confuse OME with acute otitis media – antibiotics are indicated for AOM but not for effusion in the absence of acute symptoms 5

Special Considerations for Adults

• Intratympanic steroid injections have shown some benefit on subjective symptoms and middle ear effusion in adults and older children with OME, though evidence is limited 1
• Balloon dilatation of the eustachian tube has only uncontrolled case series data in adults with heterogeneous outcomes and no long-term follow-up, making it experimental at this time 1
• Concomitant adenoidectomy should only be performed if there is concomitant pathology, not routinely for OME 1

Follow-Up Protocol

• Reassess at 3 months with repeated hearing testing 1
• Involve the patient in decision-making about whether to continue observation or proceed with surgical intervention 1
• Monitor for complications including persistent hearing loss, speech/language effects, or structural changes to the tympanic membrane 1, 2