How should otitis media with effusion be managed in an adult?

Treatment of Otitis Media with Effusion in Adults

In adults with OME, begin with 3 months of watchful waiting while avoiding antibiotics, antihistamines, decongestants, and steroids—all of which are ineffective—and reserve tympanostomy tube insertion for cases persisting beyond 4 months with documented hearing loss or significant symptoms. 1

Initial Diagnostic Confirmation

• Use pneumatic otoscopy as your primary diagnostic tool to document middle ear effusion and distinguish OME from acute otitis media 1
• Confirm uncertain diagnoses with tympanometry 1
• Document laterality, duration of effusion, and severity of associated symptoms at each visit 1

The 3-Month Observation Period: What to Do and What to Avoid

Active management during observation:

• Counsel patients that 75-90% of OME resolves spontaneously within 3 months 1
• Implement communication strategies: speak within 3 feet, face-to-face, use clear speech, eliminate background noise, and repeat phrases when misunderstood 1

Critical medications to avoid (all are ineffective or harmful):

• No systemic antibiotics – they provide no long-term benefit despite any short-term symptomatic effects 2, 1
• No antihistamines or decongestants – completely ineffective for OME 1
• No intranasal or systemic steroids – potential adverse effects without significant long-term benefit 1

The evidence is unequivocal on this point: a 2017 guideline review found intratympanic steroid injections showed some benefit in adults with OME 3, but systemic and intranasal steroids lack long-term efficacy and carry unnecessary risks 1.

Management After 3 Months of Persistent OME

Obtain formal audiometric testing to quantify hearing loss and guide surgical decision-making 1

Re-examine at 3-6 month intervals until one of three endpoints occurs: 1

1. Complete effusion resolution
2. Identification of significant hearing loss
3. Detection of structural abnormalities (retraction pockets, perforation, ossicular erosion)

Surgical Intervention Criteria

Refer for tympanostomy tube insertion when: 1

• OME persists ≥4 months with documented hearing loss
• Significant symptoms affect quality of life
• Structural damage to the tympanic membrane or middle ear is present

Tympanostomy tubes are the preferred initial surgical procedure – do not perform adenoidectomy, tonsillectomy alone, or myringotomy alone for OME 1

Emerging but Unproven Options

Balloon dilation of the eustachian tube showed promise in a small 2011 pilot study of 11 adults with refractory OME—all patients could self-insufflate post-procedure and atelectases resolved 4. However, the 2017 guideline review found only uncontrolled case series with heterogeneous data and no long-term follow-up 3, making this an investigational option only at specialized centers.

Common Pitfalls to Avoid

• Do not screen asymptomatic adults without risk factors or attributable symptoms 1
• Do not use prolonged or repetitive antibiotic courses – the likelihood of long-term resolution is negligible 2
• Do not delay hearing assessment if OME persists at 3 months, as this drives surgical decision-making 1
• Recognize co-morbidities: Adult OME commonly co-exists with allergic rhinitis (38.6%) and rhinosinusitis (24.1%) 5, but treating these conditions does not substitute for the core OME management algorithm above