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Surgical management of otitis media with effusion in children – NICE guideline: what paediatricians need to know
  1. M Atkinson
  1. Maria Atkinson, Nottingham University Hospital NHS Trust, Nottingham, UK; maria{at}

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Why you should be interested

Both surgical management and non-surgical management of otitis media with effusion (OME) are reviewed. In addition, specific conditions in which paediatricians are closely involved in the management of are discussed in detail.

What the guideline covers

  • There is a helpful care pathway for the diagnosis and management of children with otitis media with effusion.

  • There are also care pathways and tailored management strategies for children with cleft palate and for children with Down's syndrome.

  • Indications for surgery and the most appropriate interventions are discussed.

Otitis media with effusion (OME) is characterised by a collection of fluid within the middle ear without signs of acute inflammation. It is common in childhood and most cases are self-limiting. Persistent cases, in particular those with hearing loss, may require intervention, which ranges from educational support and hearing aids to surgery.


Surgical treatment of OME is a “short” clinical guideline; it addresses a smaller part of a care pathway and produces fewer recommendations. The methodology is slightly different to that used in a standard NICE guideline; full details can be found in the Guideline manual.1 At present, NICE does not grade recommendations but the full guideline2 contains detailed descriptions of the papers and the level of evidence assigned to each one. An economic evaluation and an information leaflet for parents/carers are also included as part of the guideline.


The guideline consists of three care pathways: one for assessment of children with suspected OME and separate care pathways for children with Down's syndrome and cleft palate.


Care pathway 1 (fig 1) is taken from the full version of the guideline produced by the National Collaborating Centre for Women’s and Children’s Health. It summarises the key recommendations for children without Down's syndrome or cleft palate. The care pathway gives the paediatrician pointers to help identify children with OME and a method for formal assessment to ensure children undergo appropriate investigations. It stresses the importance of active follow-up in children with OME and hearing loss, without the requirement for immediate referral to an otologist as the condition naturally resolves in many cases.

Figure 1

Care pathway 1. Children with suspected otitis media with effusion.


  • The following treatments are not recommended for the management of OME: antibiotics, topical or systemic antihistamines, topical or systemic decongestants, topical or systemic steroids, homeopathy, cranial osteopathy, acupuncture, dietary modification including probiotics, immunostimulants and massage.

  • The persistence of bilateral OME and hearing loss should be confirmed over a period of 3 months before intervention is considered. The child’s hearing should be re-tested at the end of this time.

  • 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.


The guideline makes specific recommendations for children with Down's syndrome. These children are prone to OME which typically occurs at an earlier age. They also suffer from a higher incidence of sensorineural hearing loss.

  • Children with Down's syndrome should be regularly assessed for OME (see formal assessment in care pathway 1 shown in fig 1) by a multidisciplinary team with expertise in assessing and treating children with Down's syndrome.

  • Hearing aids should normally be offered to children with Down's syndrome with OME and hearing loss.

  • Before ventilation tubes are offered as an alternative to hearing aids for treating OME in children with Down's syndrome, the following factors should be taken into consideration:

    • The severity of the hearing loss

    • The age of the child

    • The practicality of ventilation tube insertion

    • The risks associated with ventilation tubes: most children with Down's syndrome will suffer from persistent otorrhoea if tubes are inserted

    • The likelihood of early extrusion of ventilation tubes.


As in Down's syndrome, children with cleft palate are highly susceptible to OME which presents at an early age and has a prolonged course and a high rate of recurrence.

  • The care of children with cleft palate who are suspected of having OME should be undertaken by the local otological and audiological services with expertise in assessing and treating these children in liaison with the regional multidisciplinary cleft lip and palate team.

  • 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.


OME is a fluctuating condition and there is a lack of prospective studies on its presentation and management. The available evidence suggests that OME most commonly presents as a result of parental concern (although parental reports in general have a low sensitivity for hearing loss).3 Various methods of diagnosing OME in children were assessed for their predictive accuracy. There is limited evidence to support the use of otoscopy for diagnosis of OME; however, its inclusion was felt to be essential to diagnose other conditions.

Children with a persistent hearing loss documented over 3 months need referral to an otolaryngologist. The guideline does not state which group of specialists should look after children undergoing “formal assessment” and “active observation”. It would not be practical to state this as it will be influenced by a number of factors including the set-up of local services, clinical expertise and access to the diagnostic tests required. It is likely that these children will be looked after by a mixture of paediatricians and otolaryngologists.

The evidence for treatment of OME in Down's syndrome is limited: there are three prospective studies and one retrospective case note review.46 These studies demonstrate the difficulties in the management of this group of children. After ventilation tube insertion, the cure rate and mean hearing levels are lower than in children without Down's syndrome. Tubes are also more likely to fall out and be associated with complications. Hearing aids may not be well accepted by either children or parents and some may see surgery as a better option. As always, it is essential to assist the patient and family in making a fully informed decision, taking into account individual needs and preferences. Use of the parent/carer information leaflet which accompanies this guideline will help in this process. There is little evidence for the optimal treatment of OME in children with cleft palate, so the guideline development group felt treatment should be based on the individual needs of the child.


In conclusion, the guideline provides important information to support children, families and health professionals when they have concerns about a child’s hearing. It provides guidance for paediatricians to diagnose and manage children with OME prior to referral to ENT services. It is important that this guidance is referred to by the wide range of health professionals who encounter children with hearing problems.

This guideline can be used in conjunction with the already published SIGN guidance on the diagnosis and management of childhood otitis media in primary care ( The latter covers the diagnosis and management of OME and acute otitis media but not surgical interventions or children with genetic or facial abnormalities.



  • Competing interests: None.