1a. Pneumatic otoscopy

The clinician should document the presence of middle ear effusion with pneumatic otoscopy when diagnosing otitis media with effusion (OME) in a child.

Strong recommendation

High-Quality Evidence (systematic review of cross-sectional studies with a consistent reference standard)^3,4

1b. Pneumatic otoscopy

The clinician should perform pneumatic otoscopy to assess for OME in a child with otalgia, hearing loss, or both.

Strong recommendation

High-Quality Evidence (systematic review of cross-sectional studies with a consistent reference standard)^12-14

2.Tympanometry

Clinicians should obtain tympanometry in children with suspected OME for whom the diagnosis is uncertain after performing (or attempting) pneumatic otoscopy.

Strong recommendation

High Quality Evidence (extrapolation from systematic review of cross-sectional studies with a consistent reference standard for tympanometry as a primary diagnostic method)^15-17

3. Failed newborn hearing screening

Clinicians should document in the medical record counseling of 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.^18-20

Conditional Recommendation

Moderate Quality Evidence (indirect observational evidence on the benefits of longitudinal follow-up for effusions in newborn screening programs and the prevalence of SNHL in newborn screening failures with OME)

4a. Identifying at-risk children

Clinicians should determine if a child with OME is at increased risk for speech, language, or learning problems from middle ear effusion because of baseline sensory, physical, cognitive, or behavioral factors

Conditional Recommendation

Moderate Quality Evidence (observational studies regarding the high prevalence of OME in at-risk children and the known impact of hearing loss on child development; expert opinion on the ability of prompt diagnosis to alter outcomes)^21-23

4b. Evaluating at-risk children

Clinicians should evaluate at-risk children (Table 4) for OME at the time of diagnosis of an at-risk condition and at 12 to 18 mo of age (if diagnosed as being at risk prior to this time).

Conditional Recommendation

Moderate Quality Evidence (observational studies regarding the high prevalence of OME in at-risk children and the known impact of hearing loss on child development; expert opinion on the ability of prompt diagnosis to alter outcomes)^24-26

5. Screening healthy children

Clinicians should not routinely screen children for OME who are not at risk (Table 4) 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.

Strong recommendation (against)

High Quality Evidence (systematic review of RCTs)^27,28

6. Patient education

Clinicians should educate families of children with OME regarding the natural history of OME, need for follow-up, and the possible sequelae.

Conditional Recommendation

Moderate Quality Evidence (observational studies)²⁹

7. Watchful waiting

Clinicians should manage the child with OME who is not at risk with watchful waiting for 3 mo from the date of effusion onset (if known) or 3 mo from the date of diagnosis (if onset is unknown).

Strong recommendation

High Quality Evidence (systematic review of cohort studies)³⁰

8a.Autoinflation

Clinicians may recommend Autoinflation using a balloon more than 3 times a day as a treatment option.

Conditional Recommendation

Moderate Quality Evidence (systematic review of RCTs)³¹

8b. Steroids

Clinicians should recommend against using intranasal steroids or systemic steroids for treating OME.

Strong recommendation (against)

High Quality Evidence (systematic review of well-designed RCTs)^32-34

8c. Antibiotics

Clinicians should recommend against using systemic antibiotics for treating OME.

Strong recommendation (against)

High Quality Evidence (systematic review of well-designed RCTs)³⁵

8d. Antihistamines or decongestants

Clinicians should recommend against using antihistamines, decongestants, or both for treating OME.

Strong recommendation (against)

High Quality Evidence (systematic review of well-designed RCTs)³⁶

9. Hearing test

Clinicians should obtain an age-appropriate hearing test if OME persists for  3 months or for OME of any duration in an at-risk child.

Conditional Recommendation

Moderate Quality Evidence (systematic review of RCTs showing hearing loss in about 50% of children with OME and improved hearing after tympanostomy tube insertion; observational studies showing an impact of hearing loss associated with OME on children’s auditory and language skills)^37-40

10. Speech and language

Clinicians should counsel families of children with bilateral OME and documented hearing loss about the potential impact on speech and language development.

Conditional Recommendation

Moderate Quality Evidence (observational studies; extrapolation of studies regarding the impact of permanent mild hearing loss on child speech and language)⁴¹

11. Surveillance of chronic OME

Clinicians should reevaluate, at 3- to 6-mo intervals, children with chronic OME until the effusion is no longer present, significant hearing loss is identified, or structural abnormalities of the ear drumor middle ear are suspected.

Conditional Recommendation

Moderate Quality Evidence (observational studies)^42-44

12a. Surgery for children <4 y old

Clinicians should recommend tympanostomy tubes when surgery is performed for OME in a child less than 4 years old; adenoidectomy should not be performed unless a distinct indication (eg, nasal obstruction, chronic adenoiditis) exists other than OME.

Conditional Recommendation

Moderate Quality Evidence (systematic review of RCTs (tubes, adenoidectomy) and observational studies (adenoidectomy)^45,46

12b. Surgery for children  ³4 y old

Clinicians should recommend tympanostomy tubes, adenoidectomy, or both when surgery is performed for OME in a child 4 years old or older.

Conditional Recommendation

Moderate Quality Evidence (systematic review of RCTs (tubes, adenoidectomy) and observational studies (adenoidectomy)^47-50

13. long-term tubes

The clinician should not place long-term tubes as initial surgery for children who meet the criteria for tube insertion unless there is a specific reason based on an anticipated need for prolonged middle ear ventilation beyond that of a short-term tube.

Conditional Recommendation (against)

Moderate Quality Evidence(based on observational studies)^51-53

14. Perioperative ear drops

Clinicians should not routinely prescribe postoperative antibiotic ear drops after tympanostomy tube placement.

Conditional Recommendation (against)

Moderate Quality Evidence (Grade B, based on systematic reviews, randomized controlled trials, and before-and-after studies with a balance between benefit and harm, with a preponderance of benefit over harm)⁵⁴

15. Acute tympanostomy tube otorrhea.

Clinicians should prescribe topical antibiotic ear drops only, without oral antibiotics, for children with uncomplicated acute tympanostomy tube otorrhea.

Strong recommendation

High Quality Evidence (based on RCTs demonstrating superior efficacy of topical vs oral antibiotic therapy for otorrhea as well as improvedoutcomes with topical antibiotic therapy when different topical preparations are compared)^56-58

16. Water precautions

Clinicians should not encourage routine, prophylactic water precautions (use of earplugs or headbands, avoidance of swimming or water sports) for children with tympanostomy tubes.

Strong Recommendation (against)

High Quality Evidence (based on systematic reviews, randomized controlled trials, and multiple observational studies with consistent effects)^59,60

17. Outcome assessment

When managing a child with OME, clinicians should document in the medical record resolution of OME, improved hearing, or improved quality of life.

Conditional Recommendation

Moderate Quality Evidence (randomized trials and before-and-after studies showing resolution, improved hearing, or improved QOL after management of OME)⁶⁰