How should serous otitis media (otitis media with effusion) be managed, including initial conservative treatment and criteria for tympanostomy tube placement?

Management of Serous Otitis Media (Otitis Media with Effusion)

Initial Conservative Management: Watchful Waiting

Clinicians should manage children with OME who are not at risk with watchful waiting for 3 months from the date of effusion onset (if known) or from diagnosis (if onset is unknown). 1

• Document laterality, duration of effusion, and presence/severity of associated symptoms at each assessment to track disease progression and guide intervention timing 1
• Most OME resolves spontaneously: approximately 75-90% of effusions following acute otitis media clear within 3 months, though primary OME has lower spontaneous resolution rates (19% at 3 months, 25% at 6 months, 31% at 12 months) 1
• Do NOT use antibiotics, antihistamines, decongestants, or systemic/intranasal steroids for routine OME treatment as these lack long-term efficacy 1, 2

Diagnostic Confirmation

Use pneumatic otoscopy as the primary diagnostic method to document middle ear effusion 1, 2

• Obtain tympanometry when the diagnosis is uncertain after pneumatic otoscopy to confirm middle ear effusion presence 2
• Type B (flat) tympanogram indicates persistent effusion unlikely to resolve quickly, with only 20% resolution at 3 months and 28% at 6 months 1
• Distinguish OME from acute otitis media: OME lacks signs of acute inflammation (fever, severe otalgia) and represents fluid without active infection 1

Identifying At-Risk Children Requiring Earlier Intervention

Determine if the child is at increased risk for speech, language, or learning problems from OME due to baseline sensory, physical, cognitive, or behavioral factors 1, 2

At-risk conditions include:

• Permanent hearing loss independent of OME 1, 2
• Suspected or confirmed speech/language delay 1, 2
• Autism spectrum disorder or other pervasive developmental disorders 1, 2
• Syndromes or craniofacial anomalies affecting eustachian tube function (Down syndrome, cleft palate) 1, 2
• Blindness or uncorrectable visual impairment 1, 2
• Intellectual disability, learning disorder, or attention-deficit/hyperactivity disorder 1

Evaluate at-risk children at the time of diagnosis of the at-risk condition and at 12-18 months of age if diagnosed earlier 2

Hearing Evaluation Criteria

Obtain age-appropriate hearing testing when OME persists for 3 months or longer, OR at any time for at-risk children regardless of duration 1, 2

• Normal hearing is 0-15 dB; slight hearing loss is 16-25 dB; mild hearing loss is 26-40 dB 1
• Counsel families of children with bilateral OME and documented hearing loss about potential impact on speech and language development 2
• Hearing testing is mandatory before considering surgical intervention 1

Surveillance Protocol for Persistent OME

Reevaluate children with chronic OME at 3- to 6-month intervals until effusion resolves, significant hearing loss is identified, or structural abnormalities are suspected 1, 2

• Continue surveillance as long as OME persists without intervention criteria being met 1
• Do not routinely screen asymptomatic children without risk factors for OME 1, 2

Criteria for Tympanostomy Tube Placement

Offer bilateral tympanostomy tube insertion to children with bilateral OME for 3 months or longer AND documented hearing difficulties 1

Surgical candidacy includes:

• OME lasting 4 months or longer with persistent hearing loss or other significant symptoms 1
• Recurrent or persistent OME in at-risk children regardless of hearing status 1
• OME with structural damage to the tympanic membrane or middle ear 1

Do NOT perform tympanostomy tube insertion for a single episode of OME lasting less than 3 months 1

Age-Specific Surgical Recommendations

For children younger than 4 years: tympanostomy tubes are the preferred procedure; adenoidectomy should NOT be performed unless a distinct indication exists (nasal obstruction, chronic adenoiditis) 1, 2

For children 4 years or older: tympanostomy tubes, adenoidectomy, or both may be performed 1, 2

• Repeat surgery consists of adenoidectomy plus myringotomy with or without tube insertion 1
• Tonsillectomy alone or myringotomy alone should NOT be used to treat OME 1
• Do not place long-term tubes as initial surgery unless there is anticipated need for prolonged middle ear ventilation beyond that of short-term tubes 1

Special Considerations and Common Pitfalls

Educate families regarding the natural history of OME, need for follow-up, and possible sequelae 2

• About 90% of children experience OME at some time before school age, most commonly between 6 months and 4 years 1
• Many episodes resolve spontaneously, but 30-40% of children have recurrent OME and 5-10% of episodes last 1 year or longer 1
• Do not routinely prescribe prophylactic antibiotic ear drops after tympanostomy tube surgery 1

When referring to an otolaryngologist, document effusion duration, laterality, previous hearing test results, suspected speech/language problems, conditions exacerbating OME effects, and history of acute otitis media 1

• Explain to parents the reason for referral, possibility of surgery, and management alternatives 1
• Ensure routine periodic follow-up to examine ears until tubes extrude 1

No recommendation can be made regarding complementary/alternative medicine or allergy management for OME due to insufficient evidence 1, 2