Welcome to NGC. Skip directly to: Search Box, Navigation, Content.
A direct comparison of Cincinnati Children's Hospital Medical Center (CCHMC) and University of Michigan Health System (UMHS) recommendations for the diagnosis and management of otitis media with effusion (OME) is provided in the tables below. Both guidelines focus on the pediatric population, targeting children 2 months and older.
In addition to addressing OME, the UMHS guideline also addresses diagnosis and management of AOM. Recommendations for AOM are addressed in a separate synthesis.
A summary discussion of the areas of agreement and areas of differences among the guidelines is presented following the content comparison tables.
TABLE 3: COMPARISON OF RECOMMENDATIONS | |
---|---|
Definition Of OME | |
CCHMC (2004) |
OME is defined as the presence of fluid in the middle ear without signs or symptoms of AOM. More specifically:
|
UMHS (2007) |
Diagnostic Definitions OME (ICD-9-CM code 381.4) MEE without symptoms of AOM with or without evidence of inflammation |
Diagnosis and Evaluation | |
CCHMC (2004) |
General Signs and symptoms of OME are often only identified upon follow-up to AOM or at an unrelated office visit. History and Physical Examination
|
UMHS (2007) |
Diagnosis
Diagnosis and Treatment of OME Evaluate tympanic membranes at every well child and sick child exam when feasible. Perform pneumatic otoscopy or tympanometry when possible. Record findings. If the tympanic membrane (TM) is occluded with cerumen, consider removal. If MEE, determine nature of effusion. Attempt to distinguish between effusions that are likely to be transient, such as serous or purulent effusions and effusions likely to be persistent or associated with significant morbidity, such as mucoid effusions. Rationale for Recommendations Diagnosis Distinguishing AOM and OME OME is defined as MEE in the absence of acute symptoms. Techniques for identifying MEE The basic question facing a clinician evaluating a patient's ears is whether or not MEE is present. If the presence or absence of MEE is not clear, all available techniques should be used. Techniques include otoscopy, pneumatic otoscopy, and tympanometry. Pneumatic otoscopy. In the national guidelines, pneumatic otoscopy is recommended as an essential technique for the diagnosis of AOM and OME. In skilled hands with appropriate equipment, this technique is 70% to 90% sensitive and specific for determining the presence of middle ear effusion. This can be compared to 60% to 70% accuracy with simple otoscopy. Pneumatic otoscopy is most helpful when cerumen is removed from the external auditory canal and the otoscopist uses equipment such as hard plastic reusable ear tips with rounded edges rather than disposable tips. Having a well-maintained, fully-charged otoscope is also important. Pneumatic otoscopy is also helpful in identifying middle ear pathology such as retraction pockets and tympanic membrane adhesion to the ossicles even in the absence on MEE. Tympanometry/acoustic reflectometry. Tympanometry and acoustic reflectometry can be valuable adjuncts to, but not a substitute for, otoscopy and pneumatic otoscopy. Tympanometry provides an important confirmation of middle ear fluid and is helpful for physicians honing their otoscopy skills. Tympanometry can also measure middle ear pressures and easily demonstrate the patency of myringotomy tubes by measuring increased external canal volumes. Tympanometry has a sensitivity and specificity of 70% to 90% for the detection of middle ear fluid, but depends on patient cooperation. Technical factors such as cerumen and probe position can lead to artifactual flattening of the tympanogram. The presence of a "normal" curve does not rule out the presence of air-fluid levels and effusion in the middle ear. However, together with normal otoscopy, a normal tympanogram is predictive of the lack of middle ear fluid. A "flat" tympanogram should be confirmed through repeated measurements, recording appropriate external canal volumes, and through correlation with pneumatic otoscopy. Acoustic reflectometry is also an appropriate approach for evaluating the presence of middle ear fluid, but, like tympanometry, it has imperfect sensitivity and specificity and must be correlated with the clinical exam. |
Children At Risk For Speech, Language, or Learning Problems | |
CCHMC (2004) |
It is recommended that the child with OME who is at risk for developmental difficulties be identified early. These children include those with sensory, physical, cognitive, or behavioral factors listed below (AAFP/AAOHNS/AAP, 2004 [S]). Note: Children with Down Syndrome (Shott, Joseph, & Heithaus, 2001 [C]; Whiteman, Simpson, & Compton, 1986 [C]), cranial facial dysostosis (Corey, Caldarelli, & Gould, 1987 [C]), cleft palate (Paradise & Bluestone, 1974 [C]), and autism (Rosenhall et al., 1999 [C]) have been shown to be at higher risk for OME and/or its associated outcomes of developmental delay in hearing, speech, or language. Risk Factors for Developmental Difficulties (AAFP/AAOHNS/AAP, 2004 [S])
|
UMHS (2007) |
Therapy of OME
Risk Factors for Developmental Disabilities
Management of OME Although it is often possible to rule out significant language delay using a routine screen for developmental milestones, a referral to Early On (1-800-EARLY-ON) for a formal developmental evaluation is frequently appropriate. Early On is a state program mandated to provide developmental testing for children at risk of developmental delays. Such an evaluation would also provide parents with guidance in maximizing their child's development. This is particularly important since socioeconomic factors appear to have a substantial impact on language development and probably have more of an effect than the presence of OME with hearing loss. In many cases educational interventions may be as effective as surgical interventions. Interventions might include educating parents about effective strategies for optimizing the listening-learning environment for children with OME and hearing loss and providing appropriate books for parent/child reading (e.g., Reach Out and Read, which is program providing books to the parents of young children at all well child visits). |
Non-Surgical Management | |
CCHMC (2004) |
The foundation of OME management is follow-up and monitoring of the presence or resolution of effusion. This monitoring is clinically important for the early identification of the child at risk for developmental difficulties and for the appropriate timing for referral of the child with persistent OME.
|
UMHS (2007) |
Therapy of OME
Diagnosis and Treatment of OME For likely transient effusions, reevaluate at 3 month intervals, including a screen for language delay. In the absence of anatomic damage or evidence for developmental or behavioral complications, continue to observe at 3 month intervals. If complications appear to arise, refer to otolaryngology. For apparent mucoid effusions or effusions that appear to be associated with anatomic damage, such as adhesive otitis or retraction pockets, reevaluate in 3 months. If abnormality persists, refer to otolaryngology. No antibiotics are indicated. If symptoms arise, see AOM (Table 2 in the original guideline document). Rationale for Recommendations Management of OME The diagnosis and treatment of OME is summarized in Table 3 of the original guideline document. In the absence of a significant hearing loss, evidence of damage to middle ear structures, or risk factors for poor outcome (see Table 4 in the original guideline document), we recommend clinical reevaluation for all children with OME at 3 month intervals until the effusion is cleared or complications are identified. If developmental delay becomes apparent, the child should be referred to otolaryngology. In the event that the effusion appears mucoid or the tympanic membrane exhibits retraction pockets, tympanic membrane atelectasis, tympanic membrane adhesion to ossicles, or apparent cholesteatoma, the child should be revaluated in 3 months to confirm the findings and then be referred to otolaryngology. |
Hearing Testing | |
CCHMC (2004) |
It is recommended that a child be referred for audiologic evaluation (see Table 4 in the original guideline document):
|
UMHS (2007) |
No specific recommendations offered. Refer to "Referral to Subspecialists" section of this synthesis for recommendations pertaining to referral to otolaryngology. |
Referral To Subspecialists | |
CCHMC (2004) |
Consults and Referrals
|
UMHS (2007) |
|
Tympanostomy (PE) Tube Placement | |
CCHMC (2004) |
Consults and Referrals Evaluation for placement of PE tubes is the most common reason children with OME are referred to an otolaryngologist. The discussion of alternatives, risks, benefits, and expected outcomes associated with tube placement begins with the primary care clinician and is continued with the otolaryngologist if the patient is referred.
|
UMHS (2007) |
Special Situations Primary care follow-up and management of tympanostomy tubes. Be familiar with the preferences of the surgeon to whom you refer patients, since he/she will likely be handling any complications of tube placement. Recommendations of the Division of Pediatric Otolaryngology at the University of Michigan Medical Center are summarized below. Post-op irrigation. After the tubes are placed in the operating room, antibiotic ear drops are placed in both ears to irrigate the tubes. The parent is given the bottle to administer the drops for the next 2 to 3 days. Ear drainage. Ear drops combining a fluoroquinolone with a corticosteroid are the safest and most effective therapy for the draining ear. This includes ears draining either through a perforated ear drum or through a patent tympanostomy tube. To be maximally effective, ensure that the drops can get to the site of infection. For this reason, clear the ear of purulent material prior to administration of antibiotic drops and introduce the antibiotic drops into the middle ear by pumping on the external ear canal with the tragus. Purulent debris can be easily cleared by warm water irrigation using 10 cc syringe topped with the luer from a cut off butterfly needle. The canal can then be dried using cotton or soft tissue paper. Aminoglycoside containing ear drops, such as gentamicin, tobramycin, and neomycin (Cortisporin) should not be used in the presence or tympanic membrane perforations or ventilation tubes since they are ototoxic. Patients with significant systemic symptoms, such as fever, might benefit from systemic antibiotics. Management of tympanostomy tubes. Most otolaryngologists no longer advise their patients to use ear plugs with swimming, bathing, or washing hair. In most cases physical characteristics of ventilation tubes prevent the entry of liquids into the middle ear space unless the child dives into deep water or pumps the liquid into the middle ear. In the event of subsequent otorrhea, infusion of fluoroquinolone drops is usually the only therapy necessary. Patients with tubes should follow up with otolaryngology every six months and should be referred back to otolaryngology in the event of suspicion for ongoing middle ear disease. Tubes should be removed if they remain in place longer than 3 years. |
TABLE 4: BENEFITS AND HARMS | |
---|---|
Benefits | |
CCHMC (2004) |
|
UMHS (2007) |
Accurate diagnosis and effective treatment and management of OM |
Harms | |
CCHMC (2004) |
None stated |
UMHS (2007) |
Placement of ventilation tubes is also associated with an increased risk of long-term tympanic membrane abnormalities and reduced hearing compared to medical therapy |
TABLE 5: EVIDENCE RATING SCHEMES AND REFERENCES | |
---|---|
CCHMC (2004) |
Evidence Based Grading Scale: A: Randomized controlled trial: large sample References Supporting the Recommendations American Academy of Family Physicians, American Academy of Otolaryngology-Head and Neck Surgery, American Academy of Pediatrics Subcommittee on Otitis Media with Effusion. Otitis media with effusion. Pediatrics 2004 May;113(5):1412-29. [172 references] PubMed American Academy of Pediatrics Subcommittee on Management of Acute Otitis Media. Diagnosis and management of acute otitis media. Pediatrics 2004 May;113(5):1451-65. PubMed Barnett ED, Klein JO, Hawkins KA, Cabral HJ, Kenna M, Healy G. Comparison of spectral gradient acoustic reflectometry and other diagnostic techniques for detection of middle ear effusion in children with middle ear disease. Pediatr Infect Dis J 1998 Jun;17(6):556-9; discussion 580. PubMed Barriga F, Schwartz RH, Hayden GF. Adequate illumination for otoscopy. Variations due to power source, bulb, and head and speculum design. Am J Dis Child 1986 Dec;140(12):1237-40. PubMed Block SL, Mandel E, McLinn S, Pichichero ME, Bernstein S, Kimball S, Kozikowski J. Spectral gradient acoustic reflectometry for the detection of middle ear effusion by pediatricians and parents. Pediatr Infect Dis J 1998 Jun;17(6):560-4; discussion 580. PubMed Block SL, Pichichero ME, McLinn S, Aronovitz G, Kimball S. Spectral gradient acoustic reflectometry: detection of middle ear effusion in suppurative acute otitis media. Pediatr Infect Dis J 1999 Aug;18(8):741-4. PubMed Brody R, Rosenfeld RM, Goldsmith AJ, Madell JR. Parents cannot detect mild hearing loss in children. First place--Resident Clinical Science Award 1998. Otolaryngol Head Neck Surg 1999 Dec;121(6):681-6. PubMed Brookhouser PE. Use of tympanometry in office practice for diagnosis of otitis media. Pediatr Infect Dis J 1998 Jun;17(6):544-51; discussion 580. PubMed Carney AE, Moeller MP. Treatment efficacy: hearing loss in children. J Speech Lang Hear Res 1998 Feb;41(1):S61-84. [224 references] PubMed Casselbrant ML, Furman JM, Rubenstein E, Mandel EM. Effect of otitis media on the vestibular system in children. Ann Otol Rhinol Laryngol 1995 Aug;104(8):620-4. PubMed Corey JP, Caldarelli DD, Gould HJ. Otopathology in cranial facial dysostosis. Am J Otol 1987 Jan;8(1):14-7. PubMed Eisenberg DM, Davis RB, Ettner SL, Appel S, Wilkey S, Van Rompay M, Kessler RC. Trends in alternative medicine use in the United States, 1990-1997: results of a follow-up national survey. JAMA 1998 Nov 11;280(18):1569-75. PubMed Engel-Yeger B, Golz A, Parush S. Impact of middle ear effusion on balance performance in children. Disabil Rehabil 2004 Jan 21;26(2):97-102. PubMed Ernst E. Serious adverse effects of unconventional therapies for children and adolescents: a systematic review of recent evidence. Eur J Pediatr 2003 Feb;162(2):72-80. [79 references] PubMed Fallon JM. The role of chiropractic adjustment in the care and treatment of 332 children with otitis media. 1997;2:167-83. Friel-Patti S, Finitzo T. Language learning in a prospective study of otitis media with effusion in the first two years of life. J Speech Hear Res 1990 Mar;33(1):188-94. PubMed Golz A, Angel-Yeger B, Parush S. Evaluation of balance disturbances in children with middle ear effusion. Int J Pediatr Otorhinolaryngol 1998 Feb;43(1):21-6. PubMed Gordon MA, Grunstein E, Burton WB. The effect of the season on otitis media with effusion resolution rates in the New York Metropolitan area. Int J Pediatr Otorhinolaryngol 2004 Feb;68(2):191-5. PubMed Harrison H, Fixsen A, Vickers A. A randomized comparison of homoeopathic and standard care for the treatment of glue ear in children. Complement Ther Med 1999 Sep;7(3):132-5. PubMed Johnston LC, Feldman HM, Paradise JL, Bernard BS, Colborn DK, Casselbrant ML, Janosky JE. Tympanic membrane abnormalities and hearing levels at the ages of 5 and 6 years in relation to persistent otitis media and tympanostomy tube insertion in the first 3 years of life: a prospective study incorporating a randomized clinical trial. Pediatrics 2004 Jul;114(1):e58-67. PubMed Jones WS, Kaleida PH. How helpful is pneumatic otoscopy in improving diagnostic accuracy? Pediatrics 2003 Sep;112(3 Pt 1):510-3. PubMed Karma PH, Penttila MA, Sipila MM, Kataja MJ. Otoscopic diagnosis of middle ear effusion in acute and non-acute otitis media. I. The value of different otoscopic findings. Int J Pediatr Otorhinolaryngol 1989 Feb;17(1):37-49. PubMed Kimball S. Acoustic reflectometry: spectral gradient analysis for improved detection of middle ear effusion in children. Pediatr Infect Dis J 1998 Jun;17(6):552-5; discussion 580. PubMed Kuyvenhoven MM, De Melker RA. Referrals to specialists. An exploratory investigation of referrals by 13 General Practitioners to medical and surgical departments. Scand J Prim Health Care Suppl 1990 Mar;8(1):53-7. PubMed Mandel EM, Rockette HE, Bluestone CD, Paradise JL, Nozza RJ. Efficacy of amoxicillin with and without decongestant-antihistamine for otitis media with effusion in children. Results of a double-blind, randomized trial. N Engl J Med 1987 Feb 19;316(8):432-7. PubMed Miller LG, Hume A, Harris IM, Jackson EA, Kanmaz TJ, Cauffield JS, Chin TW, Knell M. White paper on herbal products. American College of Clinical Pharmacy. Pharmacotherapy 2000 Jul;20(7):877-91. [66 references] PubMed Paradise JL, Bluestone CD. Early treatment of the universal otitis media of infants with cleft palate. Pediatrics 1974 Jan;53(1):48-54. PubMed Paradise JL, Dollaghan CA, Campbell TF, Feldman HM, Bernard BS, Colborn DK, Rockette HE, Janosky JE, Pitcairn DL, Kurs-Lasky M, Sabo DL, Smith CG. Otitis media and tympanostomy tube insertion during the first three years of life: developmental outcomes at the age of four years. Pediatrics 2003 Aug;112(2):265-77. PubMed Paradise JL, Feldman HM, Campbell TF, Dollaghan CA, Colborn DK, Bernard BS, Rockette HE, Janosky JE, Pitcairn DL, Sabo DL, Kurs-Lasky M, Smith CG. Early versus delayed insertion of tympanostomy tubes for persistent otitis media: developmental outcomes at the age of three years in relation to prerandomization illness patterns and hearing levels. Pediatr Infect Dis J 2003 Apr;22(4):309-14. PubMed Paradise JL, Feldman HM, Campbell TF, Dollaghan CA, Colborn DK, Bernard BS, Rockette HE, Janosky JE, Pitcairn DL, Sabo DL, Kurs-Lasky M, Smith CG. Effect of early or delayed insertion of tympanostomy tubes for persistent otitis media on developmental outcomes at the age of three years. N Engl J Med 2001 Apr 19;344(16):1179-87. PubMed Paradise JL. A 15-month-old child with recurrent otitis media. JAMA 2002 Nov 27;288(20):2589-98. PubMed Pichichero ME, Poole MD. Assessing diagnostic accuracy and tympanocentesis skills in the management of otitis media. Arch Pediatr Adolesc Med 2001 Oct;155(10):1137-42. PubMed Pichichero ME. Diagnostic accuracy, tympanocentesis training performance, and antibiotic selection by pediatric residents in management of otitis media. Pediatrics 2002 Dec;110(6):1064-70. PubMed Robert JE, Burchinal MR, Medley LP, Zeisel SA, Mundy M, Roush J, Hooper S, Bryant D, Henderson FW. Otitis media, hearing sensitivity, and maternal responsiveness in relation to language during infancy. J Pediatr 1995 Mar;126(3):481-9. PubMed Roberts JE, Burchinal MR, Zeisel SA, Neebe EC, Hooper SR, Roush J, Bryant D, Mundy M, Henderson FW. Otitis media, the caregiving environment, and language and cognitive outcomes at 2 years. Pediatrics 1998 Aug;102(2 Pt 1):346-54. PubMed Roberts JE, Burchinal MR, Zeisel SA. Otitis media in early childhood in relation to children's school-age language and academic skills. Pediatrics 2002 Oct;110(4):696-706. PubMed Roberts JE, Rosenfeld RM, Zeisel SA. Otitis media and speech and language: a meta-analysis of prospective studies. Pediatrics 2004 Mar;113(3 Pt 1):e238-48. PubMed Roberts JE, Zeisel SA, Rosenfeld RM, Reitz P. Meta-analysis of speech and language sequalae. In: Rosenfeld RM, Bluestone CD, editor(s). Evidence based otitis media. Hamilton, Ont. London: B C Decker; 2003. p. 383-99. Rosenfeld RM, Goldsmith AJ, Madell JR. How accurate is parent rating of hearing for children with otitis media? Arch Otolaryngol Head Neck Surg 1998 Sep;124(9):989-92. PubMed Rosenhall U, Nordin V, Sandstrom M, Ahlsen G, Gillberg C. Autism and hearing loss. J Autism Dev Disord 1999 Oct;29(5):349-57. PubMed Shekelle PG, et al. Diagnosis, natural history, and late effects of otitis media with effusion. Evidence report/technology assessment no. 55. Rockville (MD): Agency for Healthcare Research and Quality (AHRQ); 2003. (AHRQ publication; no. 03-E-23). Shott SR, Joseph A, Heithaus D. Hearing loss in children with Down syndrome. Int J Pediatr Otorhinolaryngol 2001 Dec 1;61(3):199-205. PubMed Spigelblatt L, Laine-Ammara G, Pless IB, Guyver A. The use of alternative medicine by children. Pediatrics 1994 Dec;94(6 Pt 1):811-4. PubMed Teele DW, Klein JO, Rosner B. Epidemiology of otitis media during the first seven years of life in children in greater Boston: a prospective, cohort study. J Infect Dis 1989 Jul;160(1):83-94. PubMed The assessment and management of acute pain in infants, children, and adolescents. Pediatrics 2001 Sep;108(3):793-7. PubMed Whiteman BC, Simpson GB, Compton WC. Relationship of otitis media and language impairment in adolescents with Down syndrome. Ment Retard 1986 Dec;24(6):353-6. PubMed Williamson I. Otitis media with effusion. Clin Evid 2002 Jun;(7):469-76. [28 references] PubMed |
UMHS (2007) |
Levels of Evidence
|
The Cincinnati Children's Hospital Medical Center (CCHMC) and University of Michigan Health System (UMHS) present recommendations for diagnosis and management of OME. Within the pediatric population, both guidelines target children 2 months and older.
In addition to addressing OME, the UMHS guideline also provides recommendations for the diagnosis and management of AOM. These recommendations are provided in a separate synthesis.
The guidelines agree that otoscopy should be used to determine if MEE is present and that pneumatic otoscopy is preferable to simple otoscopy. Both groups cite research showing that pneumatic otoscopy has higher diagnostic sensitivity and specificity than simple otoscopy.
Both guidelines agree that tympanometry is a useful adjunct to otoscopy for diagnosing OME.
According to CCMHC, acoustic reflectometry is acceptable for determining the presence of MEE. They add, however, that it is not often used nor readily available in the Cincinnati area. UMHS notes that acoustic reflectometry, like tympanometry, has imperfect sensitivity and specificity and must be correlated with the clinical exam.
There is general agreement among the guidelines that the majority of OME cases resolve spontaneously within a few weeks. Both groups explicitly recommend that the child with OME who is not at risk be managed by watchful waiting for 3 months.
Antibiotics. The guidelines are in agreement that antibiotics should not be used to treat most cases of OME. While both groups recommend against the use of antibiotics for OME in otherwise healthy children, CCHMC does include antibiotic therapy as an option for aggressive individual management of children with OME who are at risk for developmental difficulties.
Other Medications. CCHMC recommends against the use of decongestants, antihistamines, systemic steroids, and complementary or alternative treatments in the management of OME. UMHS does not address these therapies.
There is agreement among the guidelines that children at risk for hearing, speech and language, and/or developmental problems should be identified early and managed aggressively, including early referral for hearing, speech, and language assessment and evaluation by an otolaryngologist.
For uncomplicated OME, CCHMC recommends hearing testing when OME persists for 3 months or longer. CCHMC further recommends hearing testing 3 months following initial audiologic evaluation in the child being observed with OME.
UMHS does not make specific recommendations for hearing testing, but recommends referral to otolaryngology if effusion or abnormal physical findings persist for 3 months.
Both guidelines recommend prompt hearing testing when language delay, learning problems, and/or a significant hearing loss is suspected in a child with OME, regardless of the duration of OME.
The guidelines agree that early referral to an otolaryngologist is warranted for children at risk for hearing, speech and language, or developmental delays; children with anatomical abnormalities (such as cleft palate, bifid uvula, and Down Syndrome); and children with clinical complications of OME. They also agree that PE tube insertion is the surgical intervention of choice. CCHMC generally recommends surgical evaluation for children with OME lasting 3 or 4 months with hearing loss or other complications. UMHS' recommendations regarding the decision to undergo PE tube placement are primarily targeted at AOM, not OME patients. They also include recommendations regarding primary care follow-up and management of tympanostomy tubes.
As discussed above, while both guidelines recommend against the routine use of antibiotics for OME, CCHMC includes exceptions for which antibiotic use may be warranted, such as for aggressive individualized management of the child with OME who is at risk for developmental difficulties.
This synthesis was prepared by ECRI on February 13, 2006. The information was verified by AAP on March 6, 2006, and by CCHMC and UMHS on March 20, 2006. This synthesis was updated on December 6, 2007 to remove recommendations from UMHS and on April 18, 2008 to update UMHS recommendations. This synthesis was updated in December 2008 to remove recommendations from SIGN. This synthesis was revised in February 2009 to remove AAFP/AAOHNS/AAP recommendations.
Internet citation: National Guideline Clearinghouse (NGC). Guideline synthesis: Otitis media with effusion. In: National Guideline Clearinghouse (NGC) [Web site]. Rockville (MD): 2006 Mar (revised 2009 Mar). [cited YYYY Mon DD]. Available: http://www.guideline.gov.