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Otitis media with effusion in under-12s

Otitis media with effusion (OME, also known as ‘glue ear’) is very common in children. Indeed, many children (and adults) will get an effusion in the middle ear with ear infections and URTIs. However, if this persists (6w seems to be the definition used by most), it earns the label ‘otitis media with effusion’. It is of greatest clinical significance in children when it impairs hearing, which may in turn affect speech and language development, educational progress and/or behaviour.

In 2023, NICE updated its guidance on otitis media with effusion in the under-12s (NICE 2023, NG233). There are some amendments in the guidance – notably, early referral for formal audiological assessment and a recommendation against nasal steroids – which may be a change in practice for some of us. Let’s take a closer look.

This article was reviewed in January 2024.

NICE on otitis media with effusion

NICE on otitis media with effusion (NICE 2023, NG233)
When to suspect
Children often present with: Hearing difficulties. Delayed speech and language development. Ear discomfort. Tinnitus.
The presence of the following RAISES the index of suspicion: Upper respiratory tract infections or otitis media. Conjunctivitis. Atopy (asthma, eczema, wheezing, urticaria, sneezing/nasal itching). Snoring. Craniofacial abnormalities (e.g. Down’s syndrome and cleft palate). Dyspnoea. Mouth breathing, sucking habits (dummy, bottle feeding, thumb sucking).	The absence of the following REDUCES index of suspicion: Nasal obstruction. Rhinorrhoea. Adenoid hypertrophy.
The following may be associated with OME: Behavioural problems (inattention, poor concentration); being withdrawn or irritable. Poor educational progress. Balance problems and clumsiness.
When to refer
If clinically suspected, refer for formal assessment, which should include otoscopy, audiology and tympanometry.
Audiology assessment
If there is NO hearing loss, the patient may be discharged from audiology with reassurance and advice, including strategies to minimise the impact of hearing loss at home and school (see below). Where hearing loss is present, offer advice and reassess after 3 months (sooner if hearing loss is significantly affecting day-to-day living). At 3 months: If NO hearing loss, discharge with advice. If UNILATERAL hearing loss, reiterate advice and consider a further 3-month review, unless hearing loss is impacting daily living/communication, in which case move to management strategies (below). If BILATERAL hearing loss, follow management strategies (below).
Management strategies
Hearing aids	Air conduction device considered when hearing loss is not fluctuating and it would be better tolerated than/preferred over a bone conduction device. Bone conduction device used when hearing loss fluctuates or there are contraindications to the use of an air conducting device, e.g. otorrhoea, or if preferred/better tolerated.
Non-surgical options	Consider autoinflation if patient able to engage with the treatment.
Surgical options	Consider grommets. Consider adjuvant adenoidectomy. 6-week postoperative hearing test to ensure no further investigation required. Consider ‘as-required’ review or arrange a 1y follow-up hearing test if there are concerns.
NICE does not recommend…	Antibiotics. Other pharmacological interventions, e.g. oral or nasal corticosteroids, antihistamines, PPIs, anti-reflux medication, leukotriene receptor antagonists, mucolytics, decongestants. Other non-surgical treatments, including homeopathy, cranial osteopathy, acupuncture, dietary modification, probiotics, massage.

Do we really refer as soon as we suspect glue ear?

NICE suggests referring all children with suspected glue ear for formal audiological assessment rather than adopting a period of watchful waiting. The rationale is that better and earlier recognition and management of hearing impairment is likely to improve educational outcomes, child development and quality of life, which may offset the increased costs of early referral.

What advice do I give for children with glue ear?

NICE suggests that for all children with glue ear and hearing loss, we offer the following advice:

Avoid exposure to tobacco smoke.
Hearing may fluctuate and glue ear may resolve within weeks to months.
Face the child and be close to them when speaking.
Minimise background noise.
Inform teachers of hearing loss so that adjustments can be made, including the above.

Surgical management of hearing loss

Grommets

Grommets are considered for otitis media with effusion and persistent (>3m) bilateral hearing loss.
Risks include perforation, atelectasis (inward collapse of the ear drum), tympanosclerosis and infection.
The ear must be kept dry for 2 weeks following grommet surgery.
If there is recurrent otorrhoea after grommet surgery, advise to keep the ears dry and to use earplugs or headband if in contact with water.
For otorrhoea after grommet surgery, consider 5–7 days of non-ototoxic topical antibiotic (e.g. ciprofloxacin). This is an off-label use; follow GMC guidance on off-label prescribing. NICE doesn’t specify if this relates to the immediate postoperative period, longer term, or both. Is this something we should start in primary care or is it a specialist-only treatment? We may have to make a case-by-case decision.
Persistent otorrhoea not responding to topical antibiotics may require removal of grommets.

Adenoidectomy

NICE includes a new recommendation for adenoidectomy to be considered in addition to grommet insertion for children being referred for surgical intervention for glue ear.

It states that:

Adenoidectomy would present minimal additional risk in a child already having general anaesthesia.
Adenoidectomy may improve hearing over and above grommet insertion alone.
Benefits (hearing improvement) are likely to outweigh the risks.

Autoinflation devices

NICE suggests we consider autoinflation devices for children with glue ear if they are able to use them. It identified low-quality evidence that autoinflation improves hearing in the short term (under 6 weeks) compared with no intervention (Cochrane 2023;CD015253).

For those not familiar with autoinflation, it involves the child learning to blow up a balloon through their nostril rather than their mouth. As they do this, they hold open their eustachian tube, allowing pressure in their middle ear to equalise with atmospheric pressure (in effect, they are doing what divers learn to do and what you do when you yawn, but in a more sustained fashion and with immediate feedback to show they are doing it correctly).

You can prescribe special devices (e.g. Otovent) or they can be purchased relatively cheaply at a pharmacy. Otovent consists of a plastic nozzle and five balloons. I keep one in my desk drawer to show parents and children what I want them to do. The instructions say it can be used from age 3y – although not all will manage, and a fair bit of parental help may be required at this age to get them doing the technique correctly! We know 4-year-olds who have picked it up quickly and successfully. The manufacturer recommends that the device is used three times daily for 2–4 weeks. An instructional video has been produced to provide support with this, and we have included it in the useful resources box, below. Do note that the balloons contain latex.

Note that ordinary party balloons cannot be used as they do not provide consistently safe and effective pressure.

Glue ear and steroids

NICE does not recommend oral or nasal steroids for otitis media with effusion, or effusion-related hearing loss.

Its decision is based on a Cochrane review (Cochrane 2023;CD015255) which included 27 studies involving almost 3000 children. NICE concluded that:

Oral or nasal steroids may reduce otitis media with effusion in the short and very-short term.
Steroids are known to have potential long-term side-effects.
Nasal steroids can be difficult for children to use.
All evidence was of very-low quality and the benefits were not felt to outweigh the potential harms.

	Otitis media with effusion Common, but often resolves spontaneously. Hearing difficulties, poor educational progress, delayed speech and language development, behavioural problems, ear discomfort, tinnitus or balance problems should prompt you to consider it. Refer for formal audiological assessment if suspected. Consider autoinflation devices if the child can cooperate. If ongoing significant hearing loss or functional impairment, consider surgery or hearing aids. Do not offer antibiotics, antihistamines, decongestants, oral or nasal steroids, leukotriene receptor antagonists, mucolytics, proton pump inhibitors or anti-reflux medications. Do not offer acupuncture, dietary modification, homeopathy, massage or cranial osteopathy.
	Do you have an autoinflation device you could demonstrate to your patients?
	Useful resources: Videos (all resources are hyperlinked for ease of use in Red Whale Knowledge) Little Ears – nasal balloon instructions

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