Practice Guidelines

AAO-HNS Releases Updated Guideline on Management of Otitis Media with Effusion


Am Fam Physician. 2016 Nov 1;94(9):747-749.

Author disclosure: No relevant financial affiliations.

Key Points for Practice

• Pneumatic otoscopy should be the primary method for diagnosing OME.

• Tympanometry can confirm pneumatic otoscopy findings or be used as an alternative to otoscopy if visualization of the membrane is limited.

• An observation period of three months is recommended for OME.

• Counsel parents of infants with failed newborn screening due to suspected OME to follow up for testing to reduce the chance of a missed or delayed diagnosis of sensorineural hearing loss.

From the AFP Editors

Otitis media with effusion (OME) is defined as the presence of fluid in the middle ear in the absence of signs or symptoms of acute ear infection. More than 2 million cases of OME are diagnosed in the United States each year, and approximately 50% to 90% of children are affected by five years of age. OME is a common cause of hearing impairment in children living in developed countries, and is associated with speech and reading difficulties, limited vocabulary, and attention disturbances.

This practice guideline from the American Academy of Otolaryngology–Head and Neck Surgery (AAO-HNS) provides recommendations to improve diagnostic accuracy, identify children most at risk of developmental sequelae from OME, and educate physicians and patients on the natural history of OME and the lack of clinical benefits of medical therapy. Additional recommendations target OME surveillance, hearing and language evaluation, and management of OME detected during newborn screening. The target population is children two months to 12 years of age.

Updates from the Previous Guideline

This is an AAO-HNS update of a 2004 guideline, which was developed in collaboration with the American Academy of Pediatrics and the American Academy of Family Physicians. Some of the changes include new evidence from clinical practice guidelines, systematic reviews, and randomized controlled trials; an emphasis on patient education and shared decision making; expanded action statement profiles; additional information on pneumatic otoscopy and tympanometry for diagnosing OME; expanded information on speech and language assessment; new recommendations for managing a failed hearing screening result in newborns, evaluating at-risk children, and educating and counseling parents; a new recommendation against the use of topical intranasal steroids; a new recommendation against adenoidectomy for a primary indication in children younger than four years unless there is a distinct indication; and a new recommendation for assessing OME outcomes.

Key Action Statements


Pneumatic Otoscopy. Clinicians should document the presence of middle ear effusion with pneumatic otoscopy when diagnosing OME in a child; additionally, they should perform pneumatic otoscopy to assess for OME in a child with otalgia, hearing loss, or both.

Pneumatic otoscopy should be the primary method for diagnosing OME because reduced tympanic membrane mobility correlates most closely with the presence of fluid in the middle ear. Use of otoscopy improves diagnostic accuracy by reducing false-negative findings (from effusions that do not have obvious air bubbles or an air-fluid level) and false-positive findings (from surface changes or abnormalities in the tympanic membrane without middle ear effusion). In a systematic review of nine methods for diagnosing OME, pneumatic otoscopy had the best balance of sensitivity (94%) and specificity (80%) compared with myringotomy as the diagnostic standard. Additionally, pneumatic otoscopy is efficient and cost effective, and the equipment is readily available.

Tympanometry. Clinicians should perform tympanometry in children with suspected OME for whom the diagnosis is uncertain after performing (or attempting) pneumatic otoscopy.

Tympanometry can confirm pneumatic otoscopy findings or be used as an alternative to otoscopy if visualization of the membrane is limited. Tympanometry can also objectively assess membrane mobility in patients who are difficult to examine or who do not tolerate insufflation.

Watchful Waiting. In children with OME who are not at risk,

Author disclosure: No relevant financial affiliations.

Coverage of guidelines from other organizations does not imply endorsement by AFP or the AAFP.

This series is coordinated by Sumi Sexton, MD, Associate Deputy Editor.

A collection of Practice Guidelines published in AFP is available at



Copyright © 2016 by the American Academy of Family Physicians.
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