Treatment algorithm

Please note that formulations/routes and doses may differ between drug names and brands, drug formularies, or locations. Treatment recommendations are specific to patient groups: see disclaimer

ACUTE

duration <3 months

1st line – watchful waiting

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ACUTE
|
duration <3 months
|
no risk of developmental sequelae
1st line – 

watchful waiting

Clinicians should manage OME in a child who is not at risk of developmental sequelae with watchful waiting for 3 months (from the date of onset of effusion, if known, or else from the date of diagnosis).[2] Children who have the following conditions are considered to be at risk of developmental sequelae as a result of OME:[53]

  • Permanent non-OME related hearing loss

  • Speech and language delay or disorder

  • Autism-spectrum disorder

  • Genetic syndromes or craniofacial disorders associated with cognitive or language delays

  • Blindness or uncorrectable visual impairment

  • Cleft palate

  • Developmental delay

  • Intellectual disability, learning disorders, or attention deficit/hyperactivity disorder.

OME is common in childhood and most cases resolve spontaneously within 3 months.[68] OME related to acute otitis media (AOM) has a high rate of spontaneous resolution, with 90% resolving by 3 months.[69] OME that is not preceded by AOM has a resolution rate of 28% to 52% within 3-4 months of diagnosis.[70][71] However, 30% to 40% of children in whom OME spontaneously clears will have repeated episodes of OME.[72][73][71][70]

Adults

Adults with OME have similar rates of spontaneous resolution to that of children, especially if the effusion is associated with an upper respiratory tract infection.[74] As such, watchful waiting is an acceptable option for patients with a first-time diagnosis of OME. However, keep a high index of suspicion in adults with persistent OME, especially if unilateral, to evaluate for nasopharyngeal carcinoma.

However, in the authors' opinion, tympanostomy tube placement can be a first-line treatment in adults when uncommon circumstances are compelling, on a case-by-case basis; for example, an adult patient who is a pilot or flight attendant may choose tympanostomy tube placement after the initial diagnosis in order to continue working. An adenoidectomy can be considered at the time of initial tympanostomy tube placement. It also extends the hearing benefits experienced by the first set of tympanostomy tubes.[94][95]

According to US guidelines, patients with OME undergoing a watchful waiting approach should be reassessed every 3-6 months with otoscopy and audiological testing, although realistically this may not be practical in a primary care setting in some countries.[2][53] Regular surveillance should occur until the OME has resolved, a complication of chronic OME is identified and an intervention is indicated, or when the OME is significantly impacting the patient's quality of life (ear discomfort, or problems with behaviour) and they wish to pursue treatment. A complication may include significant hearing loss or structural abnormality of the tympanic membrane or middle ear.[2][53]

Corticosteroids, antihistamines (with or without decongestants), montelukast, and antibiotics are not recommended for the treatment of OME.[2][1]

Consider – Eustachian tube autoinflation

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ACUTE
|
duration <3 months
|
no risk of developmental sequelae
Consider – 

Eustachian tube autoinflation

Additional treatment recommended for SOME patients in selected patient group

Autoinflation of the Eustachian tubes is a minimally invasive option in the treatment of OME at any point. Autoinflation can be performed with either a specialty device (e.g., the Politzer device) or by asking the patient to inflate a balloon with their nose.

One randomised controlled trial found autoinflation 3 times per day for 1-3 months plus routine care in school children aged 4-11 years with unilateral or bilateral OME to be effective in both clearing effusions and improving patient quality of life and symptoms, compared with routine care alone.[88] One prospective cohort study of children aged 2-8 years with chronic bilateral OME found that autoinflation 2 times per day for 4 weeks led to similar improvements in hearing when compared to tympanostomy tube placement.[89]

The disadvantages of Eustachian tube autoinflation are the cost and possible logistical challenges in children who may not be cooperative; however, given the low risk profile and evidence, this treatment can be considered in the management of OME.[2][1][90]

1st line – tympanostomy tube placement ± adenoidectomy

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ACUTE
|
duration <3 months
|
risk of developmental sequelae
1st line – 

tympanostomy tube placement ± adenoidectomy

Tympanostomy tube placement is recommended in children at-risk of developmental sequelae if unilateral or bilateral OME is deemed as likely to persist for more than 3 months (based on a type B tympanogram).[2][53]

Children who have the following conditions are considered to be at risk of developmental sequelae as a result of OME:[53]

  • Permanent non-OME related hearing loss

  • Speech and language delay or disorder

  • Autism-spectrum disorder

  • Genetic syndromes or craniofacial disorders associated with cognitive or language delays

  • Blindness or uncorrectable visual impairment

  • Cleft palate

  • Developmental delay

  • Intellectual disability, learning disorders, or attention deficit/hyperactivity disorder.

Obtain a hearing test prior to surgery.[2][53]

Risks of tympanostomy tube placement include early tube extrusion, tube otorrhoea, tube obstruction, tube retention, and tympanic membrane perforation.[92][93] There may be a need to replace the tubes.

The most recent tympanostomy tube guidelines indicate that a routine postoperative course of antibiotic ear drops is not necessary (unless there is evidence of acute otitis media with a purulent effusion at the time of surgery).[53] See Acute otitis media.

An adenoidectomy can be considered at the time of initial tympanostomy tube placement in children 4 years of age or older as it has been found to decrease the rates of repeat tympanostomy tube placement.[53]​ It also extends the hearing benefits experienced by the first set of tympanostomy tubes.[94][95]

In children younger than 4 years, an adenoidectomy is recommended at the time of tympanostomy tube placement only in those with symptoms of adenoid hyperplasia or adenoiditis that are not responsive to conservative management.[53]

Risks of adenoidectomy include primary and secondary haemorrhage as well as adverse reactions to general anaesthesia.[96]

duration ≥3 months

1st line – watchful waiting

Back
ACUTE
|
duration ≥3 months
|
without or not at risk of hearing loss, speech delay, or developmental delay
1st line – 

watchful waiting

Use a watchful waiting approach. According to US guidelines, patients with OME undergoing a watchful waiting approach should be reassessed every 3-6 months with otoscopy and audiological testing, although realistically this may not be practical in a primary care setting in some countries.[2][53] Regular surveillance should occur until the OME has resolved, a complication of chronic OME is identified and an intervention is indicated, or when the OME is significantly impacting the patient's quality of life (ear discomfort, or problems with behaviour) and they wish to pursue treatment. A complication may include significant hearing loss or structural abnormality of the tympanic membrane or middle ear.[2][53]

Adults

Adults with OME have similar rates of spontaneous resolution to that of children, especially if the effusion is associated with an upper respiratory tract infection.[74] As such, watchful waiting is an acceptable option for patients with a first-time diagnosis of OME. However, keep a high index of suspicion in adults with persistent OME, especially if unilateral, to evaluate for nasopharyngeal carcinoma.

Corticosteroids, antihistamines (with or without decongestants), montelukast, and antibiotics are not recommended for the treatment of OME.[2][1]

Consider – Eustachian tube autoinflation

Back
ACUTE
|
duration ≥3 months
|
without or not at risk of hearing loss, speech delay, or developmental delay
Consider – 

Eustachian tube autoinflation

Additional treatment recommended for SOME patients in selected patient group

Autoinflation of the Eustachian tubes is a minimally invasive option in the treatment of OME at any point. Autoinflation can be performed with either a specialty device (e.g., the Politzer device) or by asking the patient to inflate a balloon with their nose.

One randomized controlled trial found autoinflation 3 times per day for 1-3 months plus routine care in school children aged 4-11 years with unilateral or bilateral OME to be effective in both clearing effusions and improving patient quality of life and symptoms, compared with routine care alone.[88] One prospective cohort study of children aged 2-8 years with chronic bilateral OME found that autoinflation 2 times per day for 4 weeks led to similar improvements in hearing when compared to tympanostomy tube placement.[89]

The disadvantages of Eustachian tube autoinflation are the cost and possible logistical challenges in children who may not be cooperative; however, given the low risk profile and evidence, this treatment can be considered in the management of OME.[2][1][90]

1st line – tympanostomy tube placement ± adenoidectomy

Back
ACUTE
|
duration ≥3 months
|
with or at risk of hearing loss, speech delay, or developmental delay
1st line – 

tympanostomy tube placement ± adenoidectomy

Tympanostomy tube placement with or without adenoidectomy is the recommended treatment for chronic (≥3 months) OME in children who have hearing loss or speech delay, or are at risk for speech and other developmental sequelae.[53] Tympanostomy tube placement in patients with persistent OME has been associated with improved hearing and quality of life.[91]

Tympanostomy tube placement is recommended in children with chronic (≥3 months) bilateral OME and either documented hearing loss or speech delay.[2][53]

For children with chronic unilateral OME or bilateral OME without documented hearing loss, tympanostomy tubes may be placed if the child is at increased risk for developmental sequelae (i.e., where persistent OME is predicted or where serious outcomes are more likely).[2][53]

Children who have the following conditions are considered to be at risk of developmental sequelae as a result of OME:[53]

  • Permanent non-OME related hearing loss

  • Speech and language delay or disorder

  • Autism-spectrum disorder

  • Genetic syndromes or craniofacial disorders associated with cognitive or language delays

  • Blindness or uncorrectable visual impairment

  • Cleft palate

  • Developmental delay

  • Intellectual disability, learning disorders, or attention deficit/hyperactivity disorder.

While there are no guidelines for tympanostomy tube placement in adults, in practice it can be considered for chronic OME with hearing loss and/or significant discomfort such as otalgia and aural fullness.

Obtain a hearing test prior to surgery.[2][53]

Risks of tympanostomy tube placement include early tube extrusion, tube otorrhoea, tube obstruction, tube retention, and tympanic membrane perforation.[92][93]​ There may be a need to replace the tubes.

The most recent tympanostomy tube guidelines indicate that a routine postoperative course of antibiotic ear drops is not necessary (unless there is evidence of acute otitis media with a purulent effusion at the time of surgery).[53] See Acute otitis media.

An adenoidectomy can be considered at the time of initial tympanostomy tube placement in children 4 years of age or older as it has been found to decrease the rates of repeat tympanostomy tube placement.[53] It also extends the hearing benefits experienced by the first set of tympanostomy tubes.[94][95]

In children who are younger than 4 years, an adenoidectomy is recommended at the time of tympanostomy tube placement only in those with symptoms of adenoid hyperplasia or adenoiditis that are not responsive to conservative management.[53]

Risks of adenoidectomy include primary and secondary haemorrhage as well as adverse reactions to general anaesthesia.[96]

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Please note that formulations/routes and doses may differ between drug names and brands, drug formularies, or locations. Treatment recommendations are specific to patient groups. See disclaimer

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