Otitis Media With Effusion Guidelines

Guidelines for the diagnosis and management of otitis media with effusion (OME) have been issued by the following organizations:

• American Academy of Otolaryngology-Head and Neck Surgery Foundation (AAO-HNSF) (2016)
• University of Michigan Health System (UMHS) (2013)
• National Institute for Health and Care Excellence (NICE) (2008)

In 2016, the AAO-HNSF released updated practice guidelines for the management of OME which have been endorsed by the American Academy of Family Physicians (AAFP). ^[37]  The UMHS published an update to its 2007 guidelines in 2013. ^[38]  The guidelines from the NICE, published in 2008 and reaffirmed in 2011, are primarily focused on surgical interventions. ^[39]

Screening and diagnosis

The 2016 AAO-HNSF recommendations for the diagnosis of OME include the following ^[37] :

• Document the presence of middle ear effusion with pneumatic otoscopy 
• Pneumatic otoscopy should be used to assess for OME in a child with otalgia and/or hearing loss
• If the diagnosis is uncertain after performing pneumatic otoscopy, tympanometry should be obtained
• Counsel parents of infants with OME who fail a newborn hearing screen regarding the importance of follow-up to ensure that hearing is normal when OME resolves and to exclude an underlying sensorineural hearing loss (SNHL)
• Determine if the child is at increased risk for speech, language, or learning problems because of baseline sensory, physical, cognitive, or behavioral factors
• Children at high risk for developing otitis media with effusion—ie, those with an increased likelihood due to developmental issues or a syndrome or condition—should be screened for OME when the risk factor is diagnosed and again between age 12 and 18 months
• Routine screening of children for OME who are not at risk and do not have symptoms that may be attributable to OME, such as hearing difficulties, balance (vestibular) problems, poor school performance, behavioral problems, or ear discomfort, is not recommended

The 2013 UMHS guidelines recommend the combined use of otoscopy, pneumatic otoscopy, and tympanometry when necessary to determine the presence of middle ear effusion. ^[38]

The NICE guidelines note that concerns from parents, caregivers, or professionals about features suggestive of OME should precipitate an initial assessment. In addition, all children with Down syndrome or cleft palate should be assessed regularly for OME. Features suggestive of OME include the following ^[39] :

• Hearing difficulty (for example, mishearing when not looking at the speaker, difficulty in a group, asking for things to be repeated)
• Indistinct speech or delayed language development
• Repeated ear infections or earache
• History of recurrent upper respiratory tract infections or frequent nasal obstruction
• Behavioral problems, particularly lack of concentration or attention, or being withdrawn
• Poor educational progress
• Less frequently, balance difficulties (for example, clumsiness), tinnitus, and intolerance of loud sounds

Treatment

Updated guidelines on the use of tympanostomy tubes in children were published in February 2022 by the AAO-HNSF. Action statements include the recommendation that a hearing evaluation be performed in children who have had otitis media with perfusion (OME) for at least 3 months or should be carried out prior to surgery in pediatric patients who have become candidates for tympanostomy tube insertion. ^[40]

The 2016 AAO-HNSF recommendations for treatment of OME include the following ^[37] :

• Watchful waiting for 3 months from the date of effusion onset or, if the onset date is unknown, 3 months from the date of diagnosis for children who are not at risk for speech, language, or learning problems 

• Medical therapy for OME—including systemic antibiotics, systemic steroids, intranasal steroids, antihistamines, and decongestants—should be employed only in exceptional circumstances

• An age-appropriate hearing test should be given if OME persists for more than 3 months or should be administered to any at-risk child with OME regardless of duration

• At 3- to 6-month intervals, reevaluate children with chronic OME until the effusion is no longer present, significant hearing loss is identified, or structural abnormalities of the eardrum or middle ear are suspected

• Tympanostomy tube insertion when surgery is performed in a child under age 4 years; adenoidectomy should not be performed unless an indication for adenoid removal, such as nasal obstruction or chronic adenoiditis, is present

• Tympanostomy tube insertion, adenoidectomy, or both when surgery is performed in a child aged 4 years or older

Children who, as mentioned above, may be at risk for speech, language, or learning problems, according to the AAO-HNSF, include the following:

• Children with permanent hearing loss independent of OME

• Those with suspected or diagnosed speech and language delay or disorder

• Those with autism spectrum disorder or other pervasive developmental disorders

• Children with syndromes (eg, Down syndrome) or craniofacial disorders that include cognitive, speech, and language delays

• Those who are blind or have uncorrectable visual impairment

• Children with cleft palate, with or without an associated syndrome

• Children with developmental delay

In 2013, the AAO-HNSF released specific guidelines on use tympanostomy tube insertion for children with otitis media that included the following recommendations ^[41] :

• Tympanostomy tube insertion should not be performed in children with a single episode of OME of less than 3 months' duration
• Bilateral tympanostomy tube insertion should be offered to children with bilateral OME of more than 3 months' duration and documented hearing difficulties
• Tympanostomy tube insertion may be considered in children with unilateral or bilateral OME of more than 3 months' duration and symptoms that include balance problems, poor school performance, behavioral problems, ear discomfort, or reduced quality of life
• Children with chronic OME who do not receive tympanostomy tubes should be reevaluated at 3- to 6-month intervals until the effusion is no longer present, significant hearing loss is detected, or structural abnormalities of the tympanic membrane or middle ear are suspected
• Tympanostomy tube insertion may be offered to at-risk children with unilateral or bilateral OME that is unlikely to resolve quickly, as reflected by a type B (flat) tympanogram or persistence of effusion for more than 3 months 
• Educate caregivers of children with tympanostomy tubes regarding the expected duration of tube function, recommended follow-up schedule, and detection of complications
• Clinicians should prescribe topical antibiotic eardrops only, without oral antibiotics, for children with uncomplicated acute tympanostomy tube otorrhea
• Encourage routine, prophylactic water precautions (use of earplugs or headbands; avoidance of swimming or water sports) for children with tympanostomy tubes

The NICE guidelines include the following recommendations ^[39] :

• Consider surgical intervention after bilateral OME and hearing loss have been confirmed over a 3-month period and the impact of the hearing loss on a child's developmental, social, or educational status is judged to be significant
• Insertion of ventilation tubes is recommended
• Adenoidectomy is not recommended in the absence of persistent and/or frequent upper respiratory tract symptoms
• Autoinflation may be considered during the active observation period for children with OME who are likely to cooperate with the procedure
• Hearing aids should be offered to children with persistent bilateral OME and hearing loss as an alternative to surgical intervention if surgery is contraindicated or not acceptable

The following treatments are not recommended for the management of OME, according to the NICE guidelines:

• Antibiotics
• Topical or systemic antihistamines
• Topical or systemic decongestants
• Topical or systemic steroids
• Homeopathy
• Cranial osteopathy
• Acupuncture
• Dietary modification, including probiotics
• Immunostimulants
• Massage

Coronavirus disease 2019 (COVID-19)

Bann et al compiled a set of recommendations for best pediatric otolaryngology practices with regard to the coronavirus disease 2019 (COVID-19) pandemic. These included the following for procedures involving the oral cavity, oropharynx, nasal cavity, or nasopharynx ^[29] :

• Whenever possible, defer procedures involving the nasal cavity, nasopharynx, oral cavity, or oropharynx, as these pose a high risk for COVID-19 owing to the high viral burden in these locations
• Whenever possible, preoperative COVID-19 testing should be administered to patients and caregivers prior to surgical intervention
• Employment of enhanced personal protective equipment (PPE), with a strong recommendation for the use of a powered air-purifying respirator (PAPR), should be undertaken with any patient with unknown, suspected, or positive COVID-19 status
• Limit the use of powered instrumentation, including microdebriders, to reduce aerosol generation

With regard to audiologic evaluation and otologic surgery, the recommendations include the following ^[29] :

• Perform routine newborn hearing screening and early intervention as indicated in the Joint Committee on Infant Hearing (JCIH) recommendations
• Defer tympanostomy tube placement for unilateral otitis media with effusion
• Although it should be prioritized, intervention for bilateral otitis media with effusion and hearing loss may be deferred based on the availability of COVID-19 testing
• Surgery involving the middle ear and mastoid, owing to their continuity with the upper aerodigestive tract, should be considered high risk for COVID-19 transmission
• Whenever possible, defer mastoidectomy, but if the surgery is required, employ enhanced PPE and avoid the use of high-speed drills
• Employment of a PAPR is strongly recommended when, in patients with unknown, suspected, or positive COVID-19 status, high-speed drills are required for otologic procedures

With regard to head and neck surgery and deep neck space infections, the recommendations include the following ^[29] :

• Defer surgical excision of benign neck masses
• A multidisciplinary tumor board should decide the most appropriate treatment modality for pediatric patients with solid tumors of the head and neck, including thyroid cancer, with the availability of local resources taken into account
• Prior to surgical intervention, medical management of infectious conditions should, whenever possible, be attempted; on admission, patients and caregivers should be tested for COVID-19 and strictly quarantined pending test results

With regard to craniomaxillofacial trauma, the guidelines include the following ^[29] :

• When urgent or emergent bedside procedures, including closure of facial lacerations, are required, patients should be presumed positive for COVID-19, even if they are asymptomatic; carry out procedures in a negative-pressure room using enhanced PPE
• Employ closed-reduction techniques, when possible, until preoperative COVID-19 testing is available
• Avoid the use of high-speed drills, to reduce aerosol formation
• When urgent or emergent surgical intervention is required, patients should be presumed positive for COVID-19, even if they are asymptomatic