Recommendations

People have the right to be involved in discussions and make informed decisions about their care, as described in NICE's information on making decisions about your care.

Making decisions using NICE guidelines explains how we use words to show the strength (or certainty) of our recommendations, and has information about prescribing medicines (including off-label use), professional guidelines, standards and laws (including on consent and mental capacity), and safeguarding.

The recommendations in this guideline apply to otitis media with effusion, also known as 'glue ear', in under 12s. This guideline does not cover the management of acute or chronic otitis media. For guidance on antimicrobial prescribing strategy for acute otitis media (ear infection), see the NICE guideline on otitis media (acute): antimicrobial prescribing.

1.1 Information and advice

1.1.1

Ask children with suspected or confirmed otitis media with effusion (OME), and their parents and carers, about their concerns and the impact that OME is having on day-to-day living. Take this into account when agreeing a plan for investigation and treatment. [2023]

1.1.2

Give children with OME, and their parents and carers, the following information about the condition:

  • what it is

  • its cause

  • its fluctuating nature

  • its possible impact on the child's hearing, listening, language development, behaviour, and emotional and social wellbeing. [2023]

1.1.3

For children with OME without hearing loss, provide reassurance to them, their parents and carers that it will often get better on its own over time and explain that no treatment is necessary and the reasons for this. [2023]

1.1.4

For children with OME without hearing loss, advise them and their parents and carers to seek professional help again if they have future concerns about hearing. [2023]

1.1.5

Discuss management options with children with confirmed OME and hearing loss, and their parents and carers. Use the OME decision table to guide and inform the conversation, and cover:

  • the benefits, risks and practical considerations of each option (for example, monitoring and support, auto-inflation, hearing aids, and grommets [ventilation tubes])

  • supportive strategies, for example modifying the environment and listening strategies. [2023]

1.1.6

Give children with suspected or confirmed OME, and their parents and carers, information about OME that:

1.1.7

Advise parents and carers about ways they can support their child with OME and hearing loss, including in educational settings, for example by:

  • being close to and facing the child when speaking to them

  • minimising background noise

  • using visual aids

  • informing their teacher that the child has OME, and asking if adjustments can be made in school to help (for example, taking the steps above and having the child sit near the front of class)

  • preparing the child for interventions and ongoing management. [2023]

1.1.8

Give children with OME, and their parents and carers, a chance to ask questions at any stage where care or treatment options are being discussed. Allow time in discussions for this, and be willing to answer questions at later appointments after people have reviewed the information they have been given. [2023]

1.1.9

Ensure parents and carers are informed that management decisions may need to be reviewed, including the option of no active treatment, according to the changing needs of the child. [2023]

For a short explanation of why the committee made these recommendations and how they might affect practice, see the rationale and impact section on information and advice.

Full details of the evidence and the committee's discussion are in evidence review N: information for suspected or confirmed OME and evidence review A: modifiable risk factors for developing OME in children.

1.2 Recognition and assessment

1.2.1

Be aware that children with OME often present with any of the following features:

  • hearing difficulties (for example, mishearing when not looking at who is speaking, difficulty in a group, asking for things to be repeated)

  • delayed speech and language development

  • ear discomfort

  • tinnitus. [2023]

1.2.2

Be aware that the following can also be associated with OME:

  • behavioural problems (particularly lack of concentration or attention), being withdrawn, or irritability or

  • poor educational progress or

  • balance difficulties (for example, clumsiness). [2023]

1.2.3

Have a higher suspicion of OME if the child has any of the following features, but be aware the absence of these features does not rule out OME:

  • a history of:

    • upper respiratory tract infections (URTIs)

    • acute otitis media (AOM)

  • craniofacial anomalies, for example Down syndrome and cleft palate

  • asthma

  • wheezing

  • dyspnoea

  • eczema

  • paroxysmal sneezing/nasal itching

  • urticaria

  • potentially harmful sucking habits (for example finger or dummy sucking and bottle feeding,) and mouth breathing

  • conjunctivitis

  • snoring. [2023]

1.2.4

Be aware that OME is less likely in the absence of the following:

  • nasal obstruction

  • rhinorrhoea

  • current, or history of, adenoid hypertrophy. [2023]

1.2.5

If OME is clinically suspected on the basis of the child's clinical history and assessment of the presenting features in recommendations 1.2.1 to 1.2.4, refer for formal assessment. [2023]

1.2.6

Formal assessment should include:

  • clinical examination, focusing on:

    • otoscopy

    • general upper respiratory health

    • general developmental status

  • hearing testing

  • tympanometry. [2008]

1.2.7

Consider coexisting causes of hearing loss (for example, sensorineural, permanent conductive and non-organic causes) when assessing a child with OME and manage appropriately. [2008]

For a short explanation of why the committee made these recommendations and how they might affect practice, see the rationale and impact section on recognition and assessment.

Full details of the evidence and the committee's discussion are in evidence review B: presenting features associated with OME in children.

1.3 Reassessment

1.3.1

In bilateral OME (in both ears) with hearing loss, reassess hearing after 3 months. Where the OME with hearing loss is unilateral (in one ear), consider reassessment of hearing after 3 months. Advise on strategies to minimise the impact of hearing loss both at home and in educational settings (see recommendation 1.1.7 in the section on information and advice). [2023]

1.3.3

At the 3‑month audiology reassessment:

For a short explanation of why the committee made these recommendations and how they might affect practice, see the rationale and impact section on reassessment.

Full details of the evidence and the committee's discussion are in evidence review C: natural history of OME without hearing loss and evidence review D: natural history of OME-related hearing loss

1.4 Management of hearing loss

1.4.1

Consider air conduction hearing aids or bone conduction devices for children with OME-related hearing loss. [2023]

1.4.2

Consider air conduction hearing aids for children with OME-related hearing loss when:

  • their hearing loss is not fluctuating and

  • this type of device would be better tolerated or is preferred, for example by avoiding the need for a headband as is used with bone conduction devices. [2023]

1.4.3

Consider bone conduction devices for children with OME-related hearing loss when:

  • their hearing levels are known to fluctuate, or

  • there are contraindications to using an air conduction hearing aid (such as a history of otorrhea, or anatomical issues such as narrow ear canals), and this type of device would be better tolerated or is preferred (for example, to avoid the choking risk from the small parts of an air conduction device). [2023]

For a short explanation of why the committee made these recommendations and how they might affect practice, see the rationale and impact section on management of hearing loss.

Full details of the evidence and the committee's discussion are in evidence review J: hearing aids/devices for hearing loss associated with OME in children under 12 years.

1.5 Non-surgical management of otitis media with effusion

Auto-inflation

1.5.1

Consider auto-inflation in children with OME if they are able to engage with the treatment. [2023]

For a short explanation of why the committee made this recommendation and how it might affect practice, see the rationale and impact section on auto-inflation.

Full details of the evidence and the committee's discussion are in evidence review I: auto-inflation.

Antibiotics

1.5.2

Do not offer antibiotics to treat OME. [2023]

For a short explanation of why the committee made this recommendation and how it might affect practice, see the rationale and impact section on antibiotics.

Full details of the evidence and the committee's discussion are in evidence review G: antibiotics.

Non-antimicrobial pharmacological interventions

1.5.3

Do not offer oral or nasal corticosteroids for OME or OME-related hearing loss. [2023]

1.5.4

Do not offer antihistamines, leukotriene receptor antagonists, mucolytics, proton pump inhibitors and anti-reflux medications, or decongestants for OME or OME-related hearing loss. [2023]

For a short explanation of why the committee made these recommendations and how they might affect practice, see the rationale and impact section on non-antimicrobial pharmacological interventions.

Full details of the evidence and the committee's discussion are in evidence review H: non-antimicrobial pharmacological interventions for children with OME.

Other non-surgical interventions

1.5.5

Do not use the following treatments for management of OME:

  • homeopathy

  • cranial osteopathy

  • acupuncture

  • dietary modification, including probiotics

  • massage. [2008, amended 2023]

For a short explanation of why the committee made this recommendation and how it might affect practice, see the rationale and impact section on other non-surgical interventions.

Full details of the committee's discussion are in evidence review G: antibiotics. The evidence relating to the 2008 recommendation is in supplement 3: evidence from the 2008 guideline.

1.6 Surgical management of otitis media with effusion

Grommets

1.6.1

Consider grommets for the management of OME-related hearing loss in children. [2023]

1.6.2

Discuss the benefits and risks of grommets with the child and their parents and carers, and make a shared decision on their use. Cover that there is a risk of perforation of the eardrum, localised atrophy, tympanosclerosis and infection associated with grommets. [2023]

For a short explanation of why the committee made these recommendations and how they might affect practice, see the rationale and impact section on grommets.

Full details of the evidence and the committee's discussion are in evidence review E: ventilation tubes.

Adenoidectomy

1.6.3

When planning grommets for management of OME, consider adjuvant adenoidectomy unless assessment indicates an abnormality with the palate. [2023]

1.6.4

Discuss the benefits and risks of adenoidectomy with the child and their family or carers, and make a shared decision on whether to have the procedure. Include that there is a risk of haemorrhage, and velopharyngeal insufficiency. [2023]

For a short explanation of why the committee made these recommendations and how they might affect practice, see the rationale and impact section on adenoidectomy.

Full details of the evidence and the committee's discussion are in evidence review F: adenoidectomy for children with OME.

Prevention of otorrhoea

1.6.5

Consider a single dose of ciprofloxacin ear drops given intraoperatively during grommet insertion to prevent otorrhoea and tube blockage. [2023]

In August 2023, this was an off-label use of ciprofloxacin ear drops. See NICE's information on prescribing medicines.

1.6.6

Advise that water precautions should be taken to keep the ear dry (such as avoiding swimming, and taking care when bathing or washing hair) for 2 weeks after grommet surgery. [2023]

For a short explanation of why the committee made these recommendations and how they might affect practice, see the rationale and impact section on prevention of otorrhoea.

Full details of the evidence and the committee's discussion are in evidence review K: preventing otorrhoea after surgery for hearing loss associated with OME in children.

Treatment of infection after grommet insertion

1.6.7

If there is isolated otorrhoea (ear discharge) after grommet insertion, advise water precautions should be taken to keep the ear dry (such as avoiding swimming, and taking care when bathing or washing hair). [2023]

1.6.8

Advise children with recurrent otorrhoea after grommet surgery to use ear plugs or headbands if in contact with water. [2023]

1.6.9

Consider non-ototoxic topical antibiotic ear drops (such as ciprofloxacin) for 5 to 7 days for otorrhoea after grommet insertion. [2023]

In August 2023, this was an off-label use of non-ototoxic antibiotic-containing topical ear drops. See NICE's information on prescribing medicines.

1.6.10

For children with otorrhoea that is persistent and does not respond to topical antibiotics, consider removal of the grommets. [2023]

For a short explanation of why the committee made these recommendations and how they might affect practice, see the rationale and impact section on treatment of infection after grommet insertion.

Full details of the evidence and the committee's discussion are in evidence review L: treating otorrhoea after surgery for hearing loss associated with OME in children.

Follow up after surgical treatment

1.6.11

Perform a postoperative hearing test 6 weeks after surgery for OME, and:

  • If the hearing loss has resolved, discharge and:

    • advise parents and carers to seek a reassessment by the audiology service involved in their child's care if they are concerned about a possible recurrence of OME-related hearing loss at a later date or

    • consider a 1-year follow up with a hearing test if there are concerns a potential recurrence of hearing loss could be missed or

    • consider an individualised follow-up plan if the child has an increased risk of unrecognised OME with hearing loss (for example, children with a learning disability or craniofacial anomalies).

  • If there continues to be hearing loss, this needs to be investigated. [2023]

For a short explanation of why the committee made this recommendation and how it might affect practice, see the rationale and impact section on follow up after surgical treatment.

Full details of the evidence and the committee's discussion are in evidence review M: follow-up strategy after surgical treatment for OME-related hearing loss.

Terms used in this guideline

This section defines terms that have been used in a particular way for this guideline.

Bone conduction devices

A collective term that covers bone conduction hearing aids or devices as well as bone conduction hearing implants. Bone conduction devices transfer sound by bone vibration directly to the cochlea, bypassing the outer and the middle ear.

Grommets

Grommets are small plastic tubes which sit in a hole in the eardrum, and let air get in and out of the ear. Grommets are sometimes also called ventilation tubes.

Hearing loss

Normal hearing is when the quietest sound a person can hear in either ear is anywhere between 0 dB to 20 dB. Hearing loss is defined as when a person cannot hear sounds until they are above that 20 dB threshold in one or both ears. The louder a sound needs to be in dB before they can hear it, the greater their level of hearing loss (for example, someone who can only hear sounds of 50 dB or more has greater hearing loss than someone who can hear sounds of 25 dB or more).

At the time of publication this was in agreement with the World Health Organization definition of hearing loss.

Hearing tests

This can be any suitable test to assess hearing, but should always be age and developmentally appropriate for the person, and use properly calibrated equipment.

Monitoring and support

Monitoring and support is a period during which time is allowed to pass before medical interventions or therapies are used. During this period, the person may undergo tests or have check-ups. The person may also receive other forms of support during this period. This period was previously known as watchful waiting.

Otitis media with effusion

Otitis media with effusion (OME) is characterised by the presence of an effusion (fluid) within the middle ear space without signs of acute inflammation or infection. OME is different to acute otitis media (AOM), which is classified as the presence of acute inflammation in the middle ear. While AOM is associated with an effusion, it is accompanied by the rapid onset of symptoms and signs of an ear infection.