Guideline sources The following summarized guidelines for the evaluation and management of otitis media with effusion (OME) are prepared by our editorial team based on guidelines from the Oto-Rhino- Laryngological Society of Japan (ORLSJ/JOS 2022), the American Academy of Otolaryngology- Head and Neck Surgery Foundation (AAO-HNSF 2022; 2016), and the Danish Society of Otorhinolaryngology, Head and Neck Surgery (DSOHH/DHMA 2016). 1 2 3 4 Guidelines 1. Screening and diagnosis Indications for screening: Evaluate at-risk children for OME at the time of diagnosis of any of the following at-risk conditions and at 12-18 months of age (if diagnosed as being at risk before this time): permanent hearing loss independent of OME https://web.pathway.md/diseases/recplXCmWmeB1RKXl 1/6 6/30/23, 1:24 AM Otitis media with effusion Pathway p g p suspected or confirmed speech and language delay or disorder autism spectrum disorder and other pervasive developmental disorders syndromes (such as Down) or craniofacial disorders including cognitive, speech, or language delays blindness or uncorrectable visual impairment cleft palate, with or without associated syndrome developmental delay. B Do not obtain routine screening for OME in children not being at risk and not having symptoms likely attributable to OME, such as hearing difficulties, balance (vestibular) problems, poor school performance, behavioral problems, or ear discomfort. D 2. Diagnostic investigations Clinical assessment: assess whether a pediatric patient with recurrent OME of any duration is at increased risk for speech, language, or learning problems from otitis media because of baseline sensory, physical, cognitive, or behavioral factors. B Pneumatic otoscopy: Obtain pneumatic otoscopy to assess for OME in pediatric patients with otalgia, hearing loss, or both. B Document the presence of middle ear effusion with pneumatic otoscopy when diagnosing OME in a pediatric patient. B Tympanometry: obtain tympanometry in pediatric patients with suspected OME, if the diagnosis is uncertain after obtaining (or attempting) pneumatic otoscopy. B Hearing test: As per AAO-HNSF 2022 guidelines, obtain a hearing evaluation if OME persists for 3 months, and before surgery if a child becomes a candidate for tympanostomy tube insertion. B As per AAO-HNSF 2016 guidelines, obtain an age-appropriate hearing test in patients with OME persisting for 3 months or in at-risk patients with OME of any duration. B 3. Diagnostic procedures Myringotomy: perform myringotomy to diagnose and determine treatment protocol for OME in pediatric patients. Do not perform it for long-term treatment, although it is effective for short-term prognosis. B 4. Medical management Watchful waiting: https://web.pathway.md/diseases/recplXCmWmeB1RKXl 2/6 6/30/23, 1:24 AM Otitis media with effusion Pathway As per JOS 2022 guidelines, offer watchful waiting for 3 months from the date of effusion onset or from the date of diagnosis for managing pediatric patients with OME not at risk for pathological changes in the tympanic membrane. B Show 2 more As per AAO-HNSF 2016 guidelines, offer watchful waiting for 3 months from the date of effusion onset (if known) or 3 months from the date of diagnosis (if onset is unknown) in not-at-risk pediatric patients with OME. B Antibiotics: As per JOS 2022 guidelines, do not use antibacterial agents for the treatment of OME in pediatric patients. Consider administering macrolides (long-term, low-dose clarithromycin) as a therapeutic option in pediatric patients with OME associated with rhinosinusitis. D As per AAO-HNSF 2016 guidelines, do not use systemic antibiotics for the treatment of patients with OME. D Corticosteroids: As per JOS 2022 guidelines, do not use oral corticosteroids for the treatment of OME in pediatric patients, as the risks outweigh the benefits. D As per AAO-HNSF 2016 guidelines, do not use intranasal or systemic corticosteroids for the treatment of patients with OME. D Antihistamines and decongestants: As per JOS 2022 guidelines, consider administering second-generation antihistamines as a treatment option for OME in pediatric patients with allergic rhinitis. Do not use first-generation antihistamines, as the risks outweigh the benefits. C As per AAO-HNSF 2016 guidelines, do not use antihistamines or decongestants for the treatment of patients with OME. D Mucolytics: offer carbocysteine as a treatment option in pediatric patients with OME. B 5. Therapeutic procedures Local therapies: consider offering local treatment of the paranasal sinus or middle ear inflation procedure during the monitoring period before surgical treatment of pediatric patients with OME. C Consider offering balloon autoinflation > TID as a treatment option. C 6. Surgical interventions Tympanostomy: As per AAO-HNSF 2022 guidelines, do not perform tympanostomy tube insertion in pediatric patients with a single episode of OME of < 3 months duration, from the date of onset (if known) or from the date of diagnosis (if onset is unknown). D Show 4 more https://web.pathway.md/diseases/recplXCmWmeB1RKXl 3/6 6/30/23, 1:24 AM Otitis media with effusion Pathway As per JOS 2022 guidelines, perform tympanostomy tube insertion in pediatric patients with bilateral OME persisted for 3 months and with any of the following: pathological changes of the tympanic membrane are observed, such as atelectasis and tympanic membrane adhesion B hearing difficulties with hearing loss, i.e. 30 dB, of the ear on the better-hearing side are documented B clinical findings that may be caused by OME are revealed, such as impaired academic performance, problems in behavior, vestibular symptoms, hypoactivity, ear discomfort, and a decrease in quality of life; symptoms due to developmental disorders are excluded. B Show 2 more Tympanoplasty: consider performing tympanoplasty in patients with a tympanic membrane exhibiting atrophy and adhesions, complicated with otorrhea and/or hearing loss, and cases progressing to cholesteatoma. C Adenoidectomy: As per AAO-HNSF 2022 guidelines, consider performing adenoidectomy as an adjunct to tympanostomy tube insertion in pediatric patients with symptoms directly related to the adenoids (adenoid infection or nasal obstruction) or in 4 years old patients to potentially reduce future incidence of recurrent otitis media or the need for repeat tube insertion. C As per JOS 2022 guidelines, consider performing adenoidectomy for the treatment of OME in patients with adenoid hyperplasia, taking into account the following considerations: do not perform adenoidectomy as the initial surgery for OME in < 4 years old patients in the absence of a clear indication for adenoidectomy in upper airway disease B consider performing a combination of adenoidectomy and tympanostomy tube insertion in > 4 years old patients to reduce the recurrence rate of OME B perform adenoidectomy at the time of reoperation for recurrent cases of ventilation tube dislodgement after the initial surgery, if the absence of cleft palate has been confirmed. C As per AAO-HNSF 2016 guidelines: Do not perform adenoidectomy in < 4 years old patients with OME unless a distinct indication (such as nasal obstruction, chronic adenoiditis) exists. D Offer adenoidectomy when surgery is performed for OME in 4 years old patients. B Tonsillectomy: do not perform tonsillectomy for the treatment of OME in pediatric patients. D 7. Specific circumstances Patients with Down syndrome: obtain a newborn hearing screening test to diagnose hearing impairment as early as possible in infant patients with Down syndrome. E Show 3 more Patients with cleft palate: ensure early diagnosis of hearing loss through newborn hearing screening tests. Obtain a detailed hearing test as soon as possible if the result of a newborn https://web.pathway.md/diseases/recplXCmWmeB1RKXl 4/6 6/30/23, 1:24 AM Otitis media with effusion Pathway hearing screening test is 'refer.'. E Show 4 more 8. Patient education General counseling: Educate families of pediatric patients with OME regarding the natural history of OME, need for follow-up, and the possible sequelae. B Counsel families of pediatric patients with bilateral OME and documented hearing loss about the potential impact on speech and language development. B 9. Follow-up and surveillance Follow-up: As per AAO-HNSF 2022 guidelines: Reevaluate pediatric patients with chronic OME not received tympanostomy tubes 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. B Examine the ears of a pediatric patient within 3 months of tympanostomy tube insertion and educate families regarding the need for routine, periodic follow-up to examine the ears until the tubes extrude. B As per JOS 2022 guidelines: Obtain early postoperative and routine follow-up (up to once every 4-6 months) to observe the postoperative condition of tympanostomy tubes and to evaluate hearing. B Obtain follow-up and evaluation for recurrence of OME and the necessity for additional treatment (including re-insertion) after extubation of the tympanostomy tube. B Tympanostomy tube care: as per AAO-HNSF 2022 guidelines, educate caregivers of pediatric patients with tympanostomy tubes regarding the expected duration of tube function, recommended follow-up schedule, and detection of complications in the perioperative period. B Show 3 more Clinical findings Symptoms Past medical history A sudden increase in air pressure Allergic rhinitis Developmental delay Delayed speech and language skills Down's syndrome Primary ciliary dyskinesia Difficulty sleeping Recent upper respiratory infection Drinking while lying on the back https://web.pathway.md/diseases/recplXCmWmeB1RKXl 5/6 6/30/23, 1:24 AM Otitis media with effusion Pathway Ear pain Head and neck exam Irritability Listlessness Bulging tympanic membrane Loss of appetite Cleft palate Cloudy tympanic membrane Social history Enlarged adenoids Hearing loss Exposure to irritans Immobile tympanic membrane Retracted tympanic membrane References 1. Rosenfeld RM, Shin JJ, Schwartz SR et al. Clinical Practice Guideline: Otitis Media with Effusion Update). Otolaryngol Head Neck Surg. 2016 Feb;154 1 Suppl):S1 S41. Open 2. Hiroshi Hidaka, Makoto Ito, Ryoukichi Ikeda et al. Clinical practice guidelines for the diagnosis and management of otitis media with effusion OME in children in Japan 2022 update. Auris Nasus Larynx. 2022 Dec 26;S0385 8146 22 00232 2. Open 3. Richard M Rosenfeld, David E Tunkel, Seth R Schwartz et al. Clinical Practice Guideline: Tympanostomy Tubes in Children Update). Otolaryngol Head Neck Surg. 2022 Feb;166 1_suppl):S1 S55. Open 4. C H Heidemann, J Lous, J Berg et al. Danish guidelines on management of otitis media in preschool children. Int J Pediatr Otorhinolaryngol. 2016 Aug;87 154 63. Open 5. Rosenfeld RM, Schwartz SR, Pynnonen MA et al. Clinical practice guideline: Tympanostomy tubes in children. Otolaryngol Head Neck Surg. 2013 Jul;149 1 Suppl):S1 35. Open 6. Roger Zoorob, Mohamad A Sidani, Richard D Fremont et al. Antibiotic use in acute upper respiratory tract infections. Am Fam Physician. 2012 Nov 1;86 9 817 22. Open https://web.pathway.md/diseases/recplXCmWmeB1RKXl 6/6