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Summary for primary care

Otitis Media with Effusion in Under 12s

Overview

This Guidelines summary for primary care covers treatment of children younger than 12 years of age who have otitis media with effusion, also known as ‘glue ear’. Recommendations included are on information and advice, recognition and assessment, reassessment, and non-surgical management.

Reflecting on your Learnings

Reflection is important for continuous learning and development, and a critical part of the revalidation process for UK healthcare professionals. Click here to access the Guidelines Reflection Record.

Information and Advice

  • 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 into account when agreeing a plan for investigation and treatment. 
  • 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.
  • 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.
  • 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.
  • 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.

Table 1: Information for Healthcare Professionals to use when Discussing Management Options for Otitis Media with Effusion (OME) with Children, Parents and Carers

QuestionsMonitoring and SupportHearing Aids
What is the intervention?The child will have check-ups during the 3-month review period to monitor changes in their OME. During this time it may resolve on its own, or if it worsens another management option may be advised. 

During this period parents or carers can actively support the child at home and at nursery or school by using simple strategies to help them to hear and listen more effectively, for example getting the child’s attention first, being close to them, speaking clearly and reducing background noise.

Autoinflation devices may also be recommended as part of monitoring and support if the child has no ear pain and is able to coordinate use. 
Hearing aids make speech more audible and so improves speech understanding, or speech access in younger children. There are 2 different types of hearing aids available: air conduction or bone conduction.

Air conduction hearing aids are usually worn behind the ear and deliver sound into the ear canal.

Bone conduction devices are worn on a headband and transmit sounds using vibration through the bones of the skull.

Both types are removable.
How effective is the intervention?In some cases OME can resolve within a few weeks or months. 

Monitoring can help form a better picture of hearing loss impact, and identify any patterns to changes in hearing, to inform choices for other interventions when OME does not resolve in the short term. Support strategies can help to alleviate the frustration and fatigue of listening to muffled sound, promote good communication and help engagement.
Hearing aids allow the child to hear quieter speech when set up and used correctly. Some types of hearing aids may be less effective if hearing levels change, which can occur with OME.
How soon can the intervention take place?Information on strategies can be provided straight away, and this can be shared with teachers or carers outside of the family at nursery, school or at home.The child may need an initial audiology appointment to fit the aid or device, and explain to parents, carers and the child how to use and maintain it.
What day to day issues are there for children and parents or carers? Support strategies work best when they are used consistently, at all times and across all settings. People caring for or teaching the child need to correctly understand the child’s hearing levels and how they might change over time (better and worse), and how to best use effective strategies to help the child cope.Hearing aids need to be put on daily and removed for sleep: some older children will be able to do this themselves, but younger children may need help.

Periodic changing of batteries, charging, and cleaning are needed. Air conduction hearing aid moulds need replacing as the child’s ears grow, and the tubing replaced when it deteriorates.

Children may take time to get used to the device and close monitoring may be necessary as hearing changes. Parents, carers and children could be asked to monitor changes in hearing at home and report any changes, such as reactions to sounds, sound sensitivity, loudness or discomfort. 
What are the risks or complications involved in the intervention?With a mild or moderate hearing loss, the child will still respond to many environmental sounds and to speech but they may not be hearing all of the sounds of speech clearly.

Careful monitoring and discussion between parents and carers and healthcare professionals is needed. This is to ensure that reduced hearing is not adversely impacting on the child’s speech and language development, and that decisions to intervene further can be made at the right time.

OME can also fluctuate, and parents and carers need to be mindful hearing can periodically worsen. 
While hearing aids can help the child’s hearing loss, hearing loss may fluctuate in OME so the hearing aids’ settings may sometimes need to be changed.

The batteries and small components in hearing aids can be choking hazards, or cause a risk of serious harm to the bowel if swallowed.

Some children may not tolerate some types of hearing aids, and a change of type used may be needed. Some children may not tolerate either type of hearing aid. 
What follow up appointments are involved?There is often a 3-month period between hearing tests while healthcare services establish whether the OME may resolve on its own, or other interventions are needed.Regular hearing aid checks will be needed, but the frequency will depend on the individual needs of the child and type of hearing aid.

Air conduction aids may need more frequent appointments for new mould impressions to be made as the child’s ears grow.
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Note: for information on grommets, refer to the full guideline.
  • Give children with suspected or confirmed OME, and their parents and carers, information about OME that: 
  • Advise parents and carers about way 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, having the child sit near the front of class)
    • preparing the child for interventions and ongoing management.
  • 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.
  • 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.
  • Advise parents and carers to avoid exposing their child to tobacco smoke because it may increase their risk of developing OME (see also the first recommendation in the section, Using Medicinally Licensed Nicotine-containing Products, in the NICE guideline on tobacco: preventing uptake, promoting quitting and treating dependence).

Recognition and Assessment 

  • 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.
  • 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).
  • 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.
  • Be aware that OME is less likely in the absence of the following: 
    • nasal obstruction
    • rhinorrhoea
    • current, or history of, adenoid hypertrophy.
  • If OME is clinically suspected on the basis of the child’s clinical history and assessment of the presenting features in the previous four recommendations, refer for formal assessment.
  • Formal assessment should include:
    • clinical examination, focusing on: 
      • otoscopy 
      • general upper respiratory health 
      • general development status 
    • hearing testing 
    • tympanometry. 
  • Consider co-existing causes of hearing loss (for example, sensorineural, permanent conductive and non-organic causes) when assessing a child with OME and manage appropriately.

Reassessment 

  • 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 the seventh recommendation in the section, Information and Advice).
  • In children who are experiencing hearing difficulties that significantly affect day-to-day living, consider intervening earlier than the 3 month reassessment: see the section, Management of Hearing Loss, and the sections on non-surgical management of otitis media with effusion and surgical management of otitis media with effusion in the full guideline.
  • At the 3-month audiology reassessment:
    • If OME is present but with no associated hearing loss, discharge. If future concerns about hearing develop, advise parents and carers to seek reassessment by the audiology service involved in their child’s care.
    • If there is unilateral hearing loss:
      • continue with the strategies in the first recommendation in this section, and
      • consider reassessment of hearing after a further 3 months, or
      • if hearing is impacting daily living or communication, see the section, Management of Hearing Loss, and the sections on non-surgical management of otitis media with effusion and surgical management of otitis media with effusion in the full guideline.
    • If there is bilateral hearing loss, see the section, Management of Hearing Loss, and the sections on non-surgical management of otitis media with effusion and surgical management of otitis media with effusion in the full guideline.

Management of Hearing Loss 

  • Consider air conduction hearing aids or bone conduction devices for children with OME-related hearing loss.
  • 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.
  • 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).
  • Advise children, parents and carers about the risk of harm from coin/button batteries in hearing aids and other hearing devices. Also see the NHS National Patient Safety Alert on the risk of harm to babies and children from coin/button batteries in hearing aids and other hearing devices.

Non-Surgical Management of Otitis Media with Effusion

Auto-Inflation

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

Antibiotics

  • Do not offer antibiotics to treat OME.

Non-Antimicrobial Pharmacological Interventions

  • Do not offer oral or nasal corticosteroids for OME or OME-related hearing loss.
  • Do not offer antihistamines, leukotriene receptor antagonists, mucolytics, proton pump inhibitors and anti-reflux medications, or decongestants for OME or OME-related hearing loss.

Other Non-Surgical Interventions

  • Do not use the following treatments for management of OME: 
    • homeopathy 
    • cranial osteopathy
    • acupuncture
    • dietary modification, including probiotics
    • massage.

For recommendations on surgical management of otitis media with effusion, refer to the full guideline.


References


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