A. DEFINITIONS:
Otitis Media with Effusion (OME) is defined by the presence of an asymptomatic middle ear effusion, with suggestive physical findings of air fluid levels, serous middle ear fluid and a translucent TM with diminished mobility (reference 1). Most OME cases are residual effusions remaining after treatment of acute otitis media (AOM), lasting 6-16 weeks after the initial diagnosis of AOM.
B. POTENTIAL ENVIRONMENTAL RISK FACTORS:
- Bottle - rather than breast- feeding
- Passive exposure to cigarette smoke
- Day care attendance
A direct linkage between these risk factors and OME is not well supported in the available scientific literature but their role in the pathogenesis of OME had strong support among a panel of experts (reference 11). Bacteriologic findings in OME are similar to those in AOM but it has not been well-proven that these pathogens cause the effusion nor that their treatment helps in resolving the effusion.
C. CLINICAL FEATURES:
History may include previous AOM and/or exposure to the above risk factors.
Physical exam may include visualization of air-fluid levels, serous middle ear fluid or decreased TM mobility upon pneumatic otoscopy. When pneumatic otoscopy is performed by an experienced examiner, the accuracy of diagnosis of OME approaches approximately 75%. Tympanometry is a well-studied confirmatory adjunct to the physical exam.
D. ADDITIONAL TESTING:
The use of formal audiograms is an option in a child with OME present bilaterally for less than or equal to 12 weeks and is recommended for children with bilateral OME for greater than 12 weeks' duration.
E. TREATMENT:
Several options exist, including:
Observation alone--a highly recommended option in otherwise healthy young children without craniofacial or neurologic abnormalities or sensory deficits given that studies have found that 60-85% of OME resolves spontaneously within 2 to 6 months.
Antibiotics--are an option only if infection is suspected, due to a small increase in resolution of OME found with their administration vs. placebo. Following a period of observation for 6 to 8 weeks, antibiotic therapy is recommended if indicated.
Myringotomy with placement of tympanostomy tubes--recommended to restore hearing to pre-effusion threshold when OME has been present for greater than 3 months and is accompanied by bilateral hearing deficiency.
Antibiotic prophylaxis--not recommended due to concerns over emerging resistance of Streptococcus pneumoniae.
Corticosteroids--not recommended due to limited scientific data proving their efficacy.
Combination of antibiotics and corticosteroids--not recommended due to limited scientific evidence proving their efficacy.
Antihistamine/decongestants-- not recommended due to limited scientific evidence proving their efficacy.
Tonsillectomy and/or adenoidectomy--not recommended as a treatment option for OME in children less than 4 years old due to limited scientific evidence proving its efficacy. Adenoidectomy may be a clinical option if OME has been present for greater than 3 months in a child aged four or older or in any child who has a primary indication for this procedure coexistent with OME.
F. COMPLICATIONS:
Of untreated OME: Include possible conductive hearing loss, possible delay in speech and language development and possible attention deficits. None of these are well- proven complications of OME and not enough information exists currently to show that treatment of OME can decrease these abnormalities.
Adhesive otitis, tympanosclerosis and cholesteatoma may also be complications of OME.
Of OME treated with antibiotics: Are related to risks of antibiotic administration, including nausea, vomiting, diarrhea, dermatologic reactions, rare organ system effects and anaphylaxis. Also must consider cost of repeated courses of antibiotics and their impact on development of resistant
strains of bacteria.
G. INDICATIONS FOR CONSULTATION OR REFERRAL:
If bilateral OME is present for 12 weeks and bilateral hearing impairment exists, then referral to otolaryngology for consultation is recommended. Referral to otolaryngology for consultation is recommended if an effusion has been present for 16 weeks or longer.
H. PATIENT EDUCATION:
Distribution of care card(s) about OME is recommended. This information should include a discussion of the complications of untreated OME as well as the benefits and risks of the treatment options for OME.
I. FOLLOW-UP:
Of OME present for 6 weeks: Physical exam and tympanogram—if type B then followup in 6 weeks.
Of OME present for less than or equal to 12 weeks: physical exam and tympanogram. A formal hearing evaluation is an option at this time.
Of OME present for 12 weeks with no or unilateral hearing deficiency: Follow clinically.
Of OME present for 12 weeks withbilateral hearing deficiency: Refer to otolaryngology for consultation. OfOME present for 16 weeks: Refer to otolaryngology for consultation.
ALGORITHM
REFERENCES
Berman, Stephen. Management of acute and chronic otitis media in pediatric practice. Current Opinion in Pediatrics. Mosby, 1995: 7:513-22.
Berman, Stephen. Otitis media in pediatric decision making. Current Opinion in Pediatrics. Mosby, 1995, 7:513-22.
Cantekin, E.I. et. al. Lack of efficacy of a decongestant- antihistamine combination for otitis media with effusion (secretary otitis media) in children. New England Journal of Medicine. Vol. 308, No. 6, 1983: 297-301.
Eden, A.N., et al. Managing acute otitis: a fresh look at a familiar problem. Contempory Pediatrics. 13,3. March 1996: 64-78.
Marchant, Colin. Earache. Practical Strategies in Pediatric Diagnosis and Therapy. W.B. Saunders Co., 1996: 116-25.
Nelson, C.T., et al. Activity of oral antibiotics in middle ear and sinus infections caused by penicillin- resistant streptococcus pneumonia: implications for treatment. Pediatric Infectious Disease Journal. 1994, 13: 585.
Paradise, Jack L. Treatment guidelines for otitis media: the need for breadth and flexibility. Pediatric Infectious Disease Journal. 1995, Vol. 14, No. 5: 429-35.
Roberts, J.E., et al. Otitis media in early childhood and cognitive, acacemid and behavior outcomes at 12 years of age. Journal of Pediatric Psychology. Vol. 20, No. 5: 645-60.
Rosenfeld, R.M., Post, J.C. Meta- analysis of antibiotics for the treatment of otitis media with effusion. Otolarygology Head Neck Surgery. 1992: 378-86.
Rosenfeld, R.M. What to expect from medical treatment of otitis media. Pediatric Infectious Disease Journal. September, 1995, Vol. 14, No. 9: 731- 37.
Stool, S.E., Berg, A.O., Berman, S., Carney, C.J., Cooley, J.R., Culpepper, L., Eavey, R.D., Feagans, L.V., et al. Otitis media with effusion in young children: clinical practice guideline. Number 12. Rockville, MD: Agency for Health Care Policy and Research, Public Health Service, U.S. Department of Health & Human Services; 1994 (AHCPR Publications No. 94-0622).
Teele, D.W., Klein, J.0., Rosner, B. Epidemiology of otitis media during the first seven years of life in children in greater Boston: a prospective, cohort study. Journal of Infectious Disease, 1989: 160: 83-94.
Williams, R.L., et al. Use of antibiotics in preventing recurrent otitis media and in treating otitis media with effusion. Journal of the American Medical Association. 1993, 270:1344
Drafted by: Drs.Ray Newman, Sarah Hampl, Nasreen Talib, Pediatric Nurse
Practitioner Julie Fugate
Reviewed by: Pediatric care clinic Practitioners, ENT, Dr.L.Fitzmaurice (ER),
CPG Task Force
Approved by: Campbell Howard M.D., President Medical Staff, Date 1/30/98