(source-National Collaborating Centre for Women's and Children's Health, UK)

In view of a lot of controversy over the management of otitis media with effusion, it is helpful to know the recommendations by a group that has studied this on basis of extensive research, randomized trials and meta analysis. These recommendations are for your information and maybe followed, with scope for modifications, but should be supported with adequate proof. In the age of consumerism, especially as a draft of these guidelines are available to the general public also, it is pertinent that we are aware of this document. A full text of this document is available at www.nice.org.uk/CG060

Otitis media with effusion (OME) is a condition characterised by a collection of fluid within the middle ear without signs of acute inflammation. It is most common in young children, with a bimodal peak at 2 and 5 years of age. Eighty percent of children will have had a least one episode of OME by the age of 10 years. At age 7–8 years, about 8% of children will have middle ear effusions. The mean duration of effusions is 6–10 weeks but some cases are more persistent. The mean duration of effusions is 6–10 weeks but some cases are more persistent.

OME is known to be a fluctuating condition with symptoms that vary with time and with age. The main symptom of OME is impaired hearing because the middle ear effusion causes a conductive hearing loss by reflection of the sound energy at the air–fluid interface. The diagnosis is based on suspicion of hearing loss, clinical history, clinical examination of the ears and appropriate audiometry and tympanometry.

While most cases of OME will resolve spontaneously, some children will need intervention because of the effects of hearing loss. This intervention may take the form of educational and social action or the provision of a hearing aid to minimise the impact of the hearing loss. No non- surgical intervention has yet been shown conclusively to be of benefit. Surgical management usually takes the form of myringotomy and insertion of a ventilation tube (grommet), with or without adenoidectomy.

Children with cleft palate are particularly susceptible to OME because of the impaired function of the Eustachian tube that results from the palatal anomaly, which in turn leads to a failure of middle ear ventilation. Similarly, children with Down's syndrome have a high incidence of OME, partly because of their impaired immunity and mucosal abnormality, with resulting susceptibility to ear infection. These groups of children need particular surveillance for OME so that proper action can be taken.

Formal assessment of a child with suspected OME should include:

• clinical history taking, focusing on:
  • poor listening skills
  • indistinct speech or delayed language development
  • inattention and behaviour problems
  • hearing fluctuation
  • recurrent ear infections or upper respiratory tract infections
  • poor educational progress
• clinical examination, focusing on:
  • otoscopy
  • general upper respiratory health
  • general developmental status
• hearing testing, which should be carried out by trained staff using tests suitable for the developmental stage of the child, and calibrated equipment
• tympanometry

Children with persistent bilateral OME documented over a period of 3 months with a hearing level in the better ear of 25–30 dBHL or worse averaged at 0.5, 1, 2 and 4 kHz (or equivalent dBA where dBHL not available) should be considered for surgical intervention. Once a decision has been taken to offer surgical intervention for OME in children, the insertion of ventilation tubes is recommended. Adjuvant adenoidectomy is not recommended in the absence of persistent and/or frequent upper respiratory tract symptoms.
Hearing aids should be offered to children with persistent bilateral OME and hearing loss as an alternative to surgical intervention where surgery is contraindicated or not acceptable. Hearing aids should normally be offered to children with Down's syndrome and OME with hearing loss. Insertion of ventilation tubes at primary closure of the cleft palate should be performed only after careful otological and audiological assessment. Insertion of ventilation tubes should be offered as an alternative to hearing aids in children with cleft palate who have OME and persistent hearing loss.