Approach

Introduction

Treatment of otitis media with effusion (OME) entails watchful waiting or surgical intervention depending on the duration of effusion, the presence and/or severity of symptoms, and the risk of developmental sequelae. The goals of treatment are to:

  • Alleviate symptoms associated with OME

  • Prevent potential complications associated with untreated disease

  • Resolve any unrecognized etiologies.

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.[69] OME related to acute otitis media (AOM) has a high rate of spontaneous resolution, with 90% resolving by 3 months.[70] OME that is not preceded by AOM has a resolution rate of 28% to 52% within 3-4 months of diagnosis.[71][72] However, 30% to 40% of children in whom OME spontaneously clears will have repeated episodes of OME.[73][74][72][71]

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.[75] 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.

Patients with OME undergoing a watchful waiting approach should be reassessed every 3-6 months with otoscopy and audiologic testing.[2][53] See Monitoring.

Oral and nasal corticosteroids

Oral and nasal corticosteroids are not recommended for the treatment of OME.[2][1]

The presence of nasal and nasopharyngeal inflammation may contribute to Eustachian tube dysfunction and subsequently OME. As such, anti-inflammatory treatment in the form of intranasal and systemic corticosteroids have been investigated for OME. One Cochrane review including 12 studies with a total of 945 participants (mainly children up to age 12 years) found that treatment with oral steroids and antibiotics was beneficial for 'a quicker resolution of OME in the short term' compared to antibiotics alone.[76] However, the trials included in this review were mostly small and of poor quality. A subsequent trial found that oral steroids (alone or followed up with intranasal steroids) led to faster resolution of OME at 6 weeks than management with watchful waiting, but there was no difference at 3 months of follow-up.[77] Another trial did not find any significant differences in hearing outcomes or quality of life with oral steroid treatment for OME.[78] Intranasal steroids have also not been found to lead to significant improvements in OME resolution, hearing loss, or other OME-related symptoms.[79][76] ​​

In patients with concomitant intranasal findings such as inflammation, allergy, or adenoid hypertrophy, nasal steroids may be directed at these conditions.[80][81][82]

Antihistamines and decongestants

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

Given the possible association between allergy and OME, antihistamines and other allergy treatments have been examined. In a Cochrane review of 16 studies of children (aged 18 and under) with a diagnosis of OME, antihistamine treatment with or without nasal decongestants was found to offer no short- or long-term benefit for the resolution of OME. There was also no evidence for improved hearing outcomes. In the groups treated with antihistamines, decongestants, or a combination of both, there was a higher rate of side-effects such as irritability, sedation, and gastrointestinal upset.[83]

Similarly, leukotriene inhibitors such as montelukast have not been found to lead to faster OME resolution.[84]

Oral antibiotics

Oral antibiotics are not recommended for OME treatment due to the risk of side-effects and inappropriate antibiotic prescribing outweighing the benefits.[1][2]

Oral antibiotics have been investigated in the treatment of OME, as bacteria have been detected in middle ear effusions.[85] One Cochrane review of 23 trials investigated children (age 18 years and under) with a diagnosis of unilateral or bilateral OME at time of randomization, comparing oral antibiotics with a placebo group of no treatment or a therapy of unproven effectiveness (such as antihistamines, decongestants, mucolytics, and intranasal corticosteroids). It found:[86]

  • Oral antibiotics were associated with higher rates of OME resolution at 2-3 months

  • Use of oral antibiotics was associated with side-effects such as diarrhea, vomiting, and skin rash.

There is no consistent evidence that the higher rates of OME resolution is associated with improved hearing or speech outcomes or long-term benefits.[87][88]

Eustachian tube autoinflation

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.

A randomized controlled trial found autoinflation 3 times per day for 1-3 months plus routine care in school children ages 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.[89] One prospective cohort study of children ages 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.[90]

The disadvantages of this treatment 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 treatment of OME.[2][1][91]

Tympanostomy tube placement

Tympanostomy tube placement with or without adenoidectomy is the recommended treatment for chronic (≥3 months) OME in children who have hearing loss, 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.[92]

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] Tympanostomy tube placement is also 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]

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

Tympanostomy tube placement is not recommended for children with a single episode of OME of less than 3 months' duration.[2][53]

Adults

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. In the authors' opinion, tympanostomy tube placement can also 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.

Complications

Risks of tympanostomy tube placement include early tube extrusion, tube otorrhea, tube obstruction, tube retention, and tympanic membrane perforation.[93][94] 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.

Adenoidectomy

The adenoid may contribute to OME by being enlarged and obstructive of the Eustachian tube orifice or by acting as a reservoir for bacteria.[53]

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.[95][96]

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 hemorrhage as well as adverse reactions to general anesthesia.[97]

Other considerations

Adults with a nasopharyngeal lesion as the underlying cause of OME should undergo appropriate work-up and treatment, which may require referral to a head and neck oncology surgeon, oncologist, and/or radiation oncologist.

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