An algorithmic approach to otitis media with effusion

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Applied Evidence

An algorithmic approach to otitis media with effusion

J Fam Pract. 2013 December;62(12):700-702,704-706

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References

1. Lesinskas E. Factors affecting the results of nonsurgical treatment of secretory otitis media in adults. Auris Nasus Larynx. 2003:30:7-14.

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Other indications for referral to a surgeon for evaluation of tympanostomy tube placement include situations in which there is:
• structural damage to the tympanic membrane or middle ear (prompt referral is recommended)
• OME of ≥4 months’ duration with persistent hearing loss (≥40 dB) or other signs or symptoms related to the effusion
• bilateral OME for ≥3 months, unilateral OME ≥6 months, or total duration of any degree of OME ≥12 months.¹⁷

Any decision regarding surgery should involve an otolaryngologist, the primary care provider, and the patient and/or family. The AAP/AAFP/AAOHNS guideline recommends against adenoidectomy in children with persistent OME without an indication for the procedure other than OME (eg, chronic sinusitis or nasal obstruction).¹⁷

Keep in mind that evidence of lasting benefit (>12 months) is limited for surgery in most patients, and the surgical and anesthetic risks must be considered before moving forward.¹⁷ (For more on the evidence regarding surgery, see “Cochrane weighs in on tympanostomy tubes”.²⁵) Tonsillectomy also does not appear to affect outcomes and is not advised.¹⁷

When a referral is always needed. Regardless of hearing status, promptly refer children with recurrent or persistent OME who are at risk of speech, language, or learning problems (including those with autism spectrum disorder, developmental delay, Down’s syndrome, diagnosed speech or language delay, or craniofacial disorders such as cleft palate) to a specialist.¹⁷

CASE › You tell your young patient’s mother that watchful waiting is appropriate at this point, since his acute otitis media was only 2 weeks ago, and his OME likely started after the acute infection. Given that his speech is clear and he is otherwise meeting his milestones, you tell her that he does not need a referral at this time, but that she should bring him back in 4 weeks for reassessment. At the next visit, his effusion has resolved, and his mother reports he is sleeping well through the night again.