Otitis media with effusion, a common condition in early childhood, is characterized by accumulation of fluid in the middle ear space without signs of an infection. Sometimes asymptomatic, otitis media with effusion can cause fluctuating or persistent hearing loss, which can affect learning, behavior, confidence, and long-term auditory functioning. The UK National Institute for Health and Care Excellence (NICE) released guidelines for the evaluation and treatment of otitis media with effusion.

DIAGNOSIS

Symptoms

Children who have otitis media with effusion most often present with symptoms that may include ear discomfort, hearing difficulties, tinnitus, or delayed speech or language development. Behavioral issues such as lack of concentration or attention can be present. Children who have otitis media with effusion may appear withdrawn or irritable and may have poor school performance. Some children may have associated balance difficulties and appear clumsy.

Associated Conditions

A history of upper respiratory tract infections or acute otitis media increases the risk of otitis media with effusion. Asthma, wheezing, shortness of breath, and snoring are all associated with higher risk. Allergic conditions (e.g., eczema, conjunctivitis, nasal itching, paroxysmal sneezing) also increase the risk.

Otitis media with effusion is more common in children with craniofacial abnormalities and in those who suck their fingers or pacifiers.

Evaluation

Physical examination should include otoscopy and an evaluation of general developmental status and upper respiratory health.

Based on expert opinion, NICE recommends that children with middle ear effusions should receive hearing testing for conductive hearing loss and any coexisting hearing loss. Tympanometry is also recommended.

TREATMENT

Nonsurgical Management

Autoinflation with a device such as a nasal balloon may be considered for nonsurgical management because low-quality evidence suggests short-term improvement in hearing.

Parents can support their child who has hearing loss by being close and facing the child when speaking, minimizing background noise, using visual aids, and requesting adjustments in the classroom, including having the child sitting near the front. Parents should be advised to protect their child from exposure to any tobacco smoke, which increases the risk of otitis media with effusion.

Hearing aids with air-conduction devices can be considered when hearing loss is not fluctuating. Bone-conduction devices should be considered in patients with fluctuating hearing loss, history of otorrhea, or narrow ear canals.

Antibiotics should be avoided because low-quality evidence suggests a clinically insignificant improvement in hearing and persistence of otitis media with effusion. Oral and nasal corticosteroids can offer limited short- and medium-term benefits for otitis media with effusion but are not routinely recommended. Use of leukotriene receptor antagonists, mucolytics, decongestants, and antireflux medications does not improve outcomes; homeopathy, cranial osteopathy, acupuncture, dietary changes, and massage are not beneficial.

Surgery

Based on very low-quality evidence of short-term improvement in hearing, physicians should consider referral for tube tympanostomy for management of otitis media with effusion-related hearing loss. Adverse events (e.g., permanent tympanic membrane perforation, otorrhea, localized atrophy, tympanosclerosis) should be discussed with parents to ensure that an informed decision is made. A single dose of intraoperative ciprofloxacin ear drops reduces the risks of otorrhea and tube blockage. Children should avoid swimming and keep water from filling the ear when bathing for 2 weeks after surgery.

Very low-quality evidence of reduced presence and persistence of otitis media with effusion supports consideration of adding adenoidectomy to tube tympanostomy if no palatal abnormalities are found. Although hearing outcomes have not been studied, adenoidectomy should improve hearing. The risks of adenoidectomy have decreased, but hemorrhage and nasal regurgitation or velopharyngeal dysfunction (more common with palatal anomalies) after the procedure are still possible.

REASSESSMENT

Without Surgery

When otitis media with effusion is associated with hearing loss, reassessment of hearing is recommended after 3 months.

Earlier reassessment can be considered if hearing difficulties significantly affect day-to-day living. If bilateral hearing loss persists, surgical management should be considered. Patients with unilateral hearing loss should receive further reassessment after 3 months.

After Surgery

NICE recommends a postoperative hearing test 6 weeks after surgery. If hearing loss has resolved, annual reassessment may be considered, with earlier testing if parents are concerned about a recurrence and for children at increased risk of recurrence.

Editor’s Note: This guideline provides succinct guidance on the management of otitis media with effusion, with a focus on the major complication of hearing loss. Interestingly, the guideline committee recommend autoinflation, which raises intranasal pressure with techniques such as blowing up a nasal balloon with or without swallowing to open the eustachian tubes. A 2023 Cochrane review of 11 studies demonstrated very low-quality evidence of benefit with a number needed to treat of 2 to resolve hearing loss at 11 weeks in one study with 94 children.1 Because the evidence supporting tympanostomy tubes is similarly very low quality, this may be worth recommending.

—Michael J. Arnold, MD, Assistant Medical Editor

Reference

1. Webster KE, Mulvaney CA, Galbraith K, et al. Autoinflation for otitis media with effusion (OME) in children. Cochrane Database Syst Rev. 2023; (9): CD015253.

The views expressed are those of the author and do not necessarily reflect the official policy or position of the Naval Undersea Medical Institute, Uniformed Services University of the Health Sciences, U.S. Navy, U.S. Department of Defense, or U.S. government.

Guideline source: UK National Institute for Health Care and Excellence

Available at https://www.nice.org.uk/guidance/ng233