Suspected Otitis Media with Effusion (children under 12) Care Pathway

Review in progress


Disclaimer: The guidance contains helpful primary care information for management of referrals and up to date referral criteria. These guidelines are locality specific to best reflect local services. This guidance does not override or replace the individual responsibility of healthcare and social care professionals involved in the delivery of care to make informed professional judgements appropriate to the circumstances of the individual.

Scope

This guidance refers to:

  • Children (under 12) with suspected otitis media with effusion (OME)

This guidance does not refer to:

  • Acute Otitis Media
  • Children over 12

Commissioning Statement:

Assessment

History & Examination

  • Take a detailed history,and ask about:
    • Hearing loss — this is usually the presenting symptom, although this is often missed in infants and young children.
      • It may present as mishearing, difficulty communicating in a group, asking for things to be repeated, or listening to the television at excessively high sound levels.
      • Mild intermittent ear pain with fullness or 'popping' may occur.
    • Aural discharge — persistent foul smelling discharge requires urgent referral.
    • Recurrent ear infections, upper respiratory tract infections, or frequent nasal obstruction.
  • Assess the severity of the hearing loss and the impact on the child's life and developmental status by asking about the following:
    • Fluctuations in hearing.
    • Lack of concentration or attention, or being socially withdrawn.
    • Listening skills and progress at school or nursery.
    • Speech or language development.
    • Balance problems and clumsiness.
  • Examine the ears with an otoscope.
    • A normal-looking tympanic membrane does not exclude otitis media with effusion (OME).
    • There are usually no signs of inflammation or discharge on examination.
    • An effusion can be serous, mucoid, or purulent and is more likely if one or more of the following features are present:
      • Abnormal colour of the drum, such as yellow, amber, or blue.
      • Loss of light reflex or a more diffuse light reflex.
      • Opacification of the drum (other than that due to scarring).
      • Air bubbles or an air/fluid level.
      • A retracted, concave, or indrawn drum or, less frequently, fullness or bulging.
  • Examine the nose and throat to assess for factors which may predispose the child to OME

Red Flags

Seek immediate or urgent specialist advice/treatment if:

  • Suspicion of cholesteatoma (atypical features and persistent foul discharge)
  • OME is complicating sensorineural deafness (eg with excessive hearing loss) or is delaying diagnosis
  • The patient has treatment with aids or cochlear implants (this would be an indication for immediate grommets)

Investigations

Undertake the following to aid diagnosis, inform management or prior to referral:

  • If hearing test required refer children via eRS to diagnostic measurement/audiological assessment.

Management

Advise to avoid passive smoking around the children via parents/carers or others

At least 50% of OME causing bilateral hearing loss of at least 20dB will resolve spontaneously within 3 months therefore a period of watchful waiting for at least 3 months is required

  • During this period, it is essential to re-evaluate signs and symptoms of the effusion and concerns regarding the child's hearing or language development, and to look for any complications, as this will determine whether it is appropriate to continue with active observation or refer to the child to an ear, nose, and throat (ENT) specialist
  • Ideally, this should include two hearing tests using pure tone audiometry at least 3 months apart as well as tympanometry
    • Following the hearing test, the decision to refer to an ENT specialist will depend on the severity of any confirmed hearing loss and suspicion of a delay in the child reaching developmental milestones
  • However, if a parent thinks their child is having difficulties and glue ear is identified the child can be referred to ENT without a hearing test
  • If signs and symptoms persist after the period of observation, refer the child to an ENT specialist- see referral section

During the watchful wait period, advice on educational and behavioural strategies to minimise the effects of hearing loss should be offered. The child's hearing should be re-tested at the end of this time.

Reassure parents that:

  • Otitis media with effusion (OME) has a very good prognosis.
  • Active observation for several months rarely results in long-term complications.
  • There is no proven benefit from treatment with any medication, or any complementary, or alternative therapies

The following treatments are not recommended for the management of OME by NICE:

  • antibiotics
  • topical or systemic antihistamines
  • topical or systemic decongestants
  • topical or systemic steroids
  • homeopathy
  • cranial osteopathy
  • acupuncture
  • dietary modification, including probiotics
  • immunostimulants
  • massage

Referral

Referral Criteria

  • Red Flags
  • If signs and symptoms persist after the period of observation, refer the child to an ENT specialist
  • If referral is for Myringotomy/Grommets this should be a per commissioning policy:
    • There has been a period of at least three months watchful waiting* from the date of diagnosis
    • OME persists after three months
    • The child suffers from persistent bilateral OME with a hearing level in the better ear of 25 dBHL (averaged at 0.5, 1, 2, and 4 kHz) or worse, confirmed over three months
    • OR Persistent bilateral OME with a hearing level better than 25 dBHL (averaged at 0.5, 1, 2, and 4 kHz) in the better ear but where the impact of the hearing loss on a child's developmental, social, or educational status is judged to be significant

Referral Requirements

  • Documented evidence that the patient meets the above criteria
  • For those patients who do not meet the eligibility criteria evidence of prior approval authorisation is required

Commissioning Statement:

Referral Instructions

  • e-consultation is not currently available for this specialty
  • Referrals should be made via ICG to TRISH (if training has been undertaken) - See user guides (EMIS & S1) for further information.
  • For those Practices who have not received ICG training referrals should be made via eRS
  • Please identify speciality and clinic type

Supporting Information

Shared Decision Making

  • Patients have a right to make decisions about their care and should be fully informed about the options they face. They should be provided with reliable evidence-based information on the likely benefits and harms of interventions or actions, including any uncertainties and risks, eliciting their preferences and supporting implementation. Signpost patient to Decision Making aid Glue Ear decision making aid – this can be printed off for the patient if required

Patient information/Public Health/Self Care

Evidence/additional information

Assurance & Governance

  • This guidance was developed on: 09.2017
  • This guidance was ratified by: The OSCAR Assurance Group
  • Date ratified: 10.2017
  • Publication Date: 10.2017
  • Review Date: 09.2019
  • Ref No: ENT5 - 09.2017
Any feedback or suggestions to improve this guidance should be sent to: oscaradmin@this.nhs.uk
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