Changes

July 2026 — reviewed. A literature search was conducted in June 2026 to identify evidence-based guidelines, UK policy, systematic reviews, and key randomized controlled trials published since the last revision of the topic. There have been no major changes to the recommendations. A new section on signs of hearing loss in infants and children has been added.

Update

Goals

To support primary healthcare professionals to:

• Make a diagnosis of otitis media with effusion (OME).
• Offer appropriate initial and subsequent management.
• Refer children with OME to an audiology or ear, nose, and throat (ENT) specialist when appropriate.

Outcome measures

No outcome measures were found during the review of this topic.

Audit criteria

QOF indicators

QIPP - options for local implementation

No QIPP criteria were found during the review of this topic.

NICE quality standards

No NICE quality standards were found during the review of this topic.

What is otitis media with effusion (OME)?

• Otitis media with effusion (OME), also known as 'glue ear', is a condition characterized by a collection of fluid within the middle ear space without signs of acute infection.
• Synonyms include ear fluid and secretory, serous, or non-suppurative otitis media.
• OME may be associated with significant hearing loss, especially if it is bilateral and lasts for longer than 1 month. 

[Rosenfeld, 2016; Blanc, 2018; Simon, 2018]

What are the causes of otitis media with effusion (OME)?

• Otitis media with effusion (OME) may occur during an upper respiratory infection, or as an inflammatory response after acute otitis media, or spontaneously due to poor eustachian tube function.
  • The eustachian tube is key in balancing middle ear pressure and removing secretions. In young children, the eustachian tube is less effective than it is in older children and adults due to its length and angle.
• Bacteria are identified in the middle ear fluid of around one-third of cases, although there is little evidence that treatment with antibiotics has benefit in terms of resolution of OME or hearing issues.
• Genetic factors are involved, with heritability estimates of 40–70%. These are not yet fully understood, but there appears to be genetic susceptibility to OME, with some involved genes identified as those contributing to regulation of the immune and inflammatory response, as well as ciliary structure and function.
• Development and persistence of OME are affected by a number of risk factors.
• There may be an association between gastro-oesophageal reflux disease and OME, although there is no evidence of causation.
• There is also evidence of association with allergy, but no evidence of causation.

[Rosenfeld, 2016; Simon, 2018; Wu, 2021; Mulvaney, 2023; Yu, 2026]

What are the risk factors for otitis media with effusion (OME)?

• Otitis media with effusion (OME) is more common in children with the following:
  • Cleft palate (causing impaired function of the eustachian tube) or other craniofacial malformation.
  • Down's syndrome (impaired immunity and mucosal abnormality increasing susceptibility to infection).
  • Primary ciliary dyskinesia (dysfunction of cilia lining the middle ear and eustachian tube impacts clearance of fluid).
  • Allergies, chronic rhinitis, asthma, urticaria, eczema, and adenoidal hypertrophy. (Association with allergy found but no evidence of causation.)
  • Gastroesophageal reflux disease (association found but no evidence for causation).
• Younger children are more at risk, with peak incidence between the age of 6 months and 4 years.
• Other risk factors which may increase the chance of children developing OME include:
  • Acute otitis media (AOM) — OME often occurs after an episode of AOM. For more information, see the CKS topic on Otitis media - acute.
  • Viral or bacterial upper respiratory tract infection. (Having 5 or more coughs, colds or episodes of breathing problems in the past year has been shown to increase risk.)
  • Immune deficiency.
  • Adenoid hypertrophy.
  • Exposure to other children, such as through attendance at a nursery.
  • Sibling history of OME.
  • Household smoking — passive smoking increases the risk of the child developing OME.
  • Low socioeconomic group.
  • Families with more than four members per household.
  • Bottle feeding — feeding with unventilated or under-ventilated bottles can generate negative pressure in the middle ear. Also, other potentially harmful sucking habits, such as finger or dummy sucking, and mouth breathing.
  • Winter months.
• Risk factors for developmental delay as a complication of OME include comorbidities such as:
  • Permanent hearing loss from other cause.
  • Autism spectrum disorder and other pervasive developmental disorders or delays.
  • Downs syndrome.
  • Craniofacial disorders which include cognitive, speech or language delay.
  • Blindness.
  • Cleft palate.

  [Rosenfeld, 2016; Simon, 2018; Norhafizah, 2020; Goutaki, 2023; NICE, 2023; Paing, 2024]

What is the prevalence of otitis media with effusion (OME)?

• Otitis media with effusion (OME) is most common in children between the ages of 6 months and 4 years. 
• OME is the most common cause of hearing impairment in childhood.
• More than 50% of children will experience OME in the first year of life; up to 80% by the age of 4.
• 1 in 8 primary school children aged 5–6 years, when screened, have fluid in one or both ears.
• Prevalence of OME in children with Down syndrome or cleft palate is 60–85%.
• OME is most common in the winter months.

[Rosenfeld, 2016; Simon, 2018; Mulvaney, 2023]

What is the prognosis for children with otitis media with effusion (OME)?

• Otitis media with effusion (OME) usually resolves spontaneously within 3 months.
• Children with OME without hearing loss usually recover spontaneously and need no treatment. 
• Children with OME following an episode of untreated acute otitis media have a 59% rate of resolution by one month, increasing to 74% by 3 months. In children with newly diagnosed OME of unknown duration, 28% are resolved by 3 months, and up to 42% by 6 months.
• Around 35% of children will have more than one episode of OME, and 5–10% of episodes will last for more than one year.
• Persistence is more likely when a greater number of contributory factors are present, such as younger age, bilateral OME, winter months, and/or a personal or sibling history of acute recurrent otitis media.

[Simon, 2018; MacKeith, 2023; Mulvaney, 2023; NICE, 2023]

What are the complications of otitis media with effusion (OME)?

• Conductive hearing loss.
  • Otitis media with effusion (OME) is the most common cause of hearing impairment in developed nations.
  • The hearing loss is usually mild, but if it is more severe it may have a significant impact on the child, especially if the disorder is bilateral and persists for a longer period of time. 
  • 50% with a diagnosis of OME have a loss of 20 dB, 20% have up to 35 dB loss, and 5–10% have a loss of up to 50 dB.
• Ear discomfort and tinnitus.
• Educational, developmental, behavioural, and social difficulties.
  • Speech and language development and communication skills may be affected.
  • Poor educational progress may be associated.
  • Balance problems, disturbed motor function, and clumsiness have been reported. 
• Chronic damage to the tympanic membrane.
  • Tympanic membrane atrophy may be caused by persistence of the effusion in the middle ear. This may lead to retraction pockets or cholesteatomatous change.

[Rosenfeld, 2016; Blanc, 2018; Simon, 2018; NICE, 2023]

How should I assess a child for suspected otitis media with effusion (OME)?

• Be aware that children with otitis media with effusion (OME) often present with any of the following features:
  • Hearing difficulties.
  • Delayed speech and language development.
  • Ear discomfort.
  • Tinnitus.
• Be aware that the following can also be associated with OME:
  • Behavioural problems (particularly lack of attention or concentration), being withdrawn, or irritability, or
  • Poor educational progress, or
  • Balance difficulties.
• Take a detailed history, and ask about:
  • The result of the newborn hearing screening test.
  • Hearing loss — this is usually the presenting symptom, although this is often missed in infants and young children.
    • See the section on Signs of hearing loss in infants and children for more information.
  • Mild intermittent ear pain with fullness or 'popping' may occur.
  • Tinnitus. 
  • Aural discharge — persistent foul-smelling discharge requires urgent referral.
  • Recurrent acute otitis media infections, upper respiratory tract infections, or frequent nasal obstruction or rhinorrhoea. 
  • History of allergy, eczema, asthma or urticaria.
  • Paroxysmal sneezing or nasal itching. 
  • Potentially harmful sucking habits (for example, finger or dummy sucking and bottle feeding). 
  • Snoring. 
• 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.
  • Changes in behaviour.
  • 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 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 to assess for factors that may predispose the child to OME, including:
  • Craniofacial anomalies, for example, Down syndrome and cleft palate.
  • Adenoid hypertrophy.
  • Asthma (including the presence of wheeze or dyspnoea).
  • Eczema or urticaria.
  • Conjunctivitis. 
• Refer a child with clinically suspected OME for formal assessment and investigations including hearing testing and tympanometry. 

What investigations should be considered to confirm a diagnosis of otitis media with effusion (OME)?

• Following local pathways, refer a child with suspected otitis media with effusion (OME) to an audiology or paediatric ear, nose and throat (ENT) service for formal assessment and investigations:
  • Audiometry should be carried out by trained staff, using tests suitable for the developmental stage of the child to determine the level of hearing loss.
    • Visual reinforcement audiometry is used to assess children aged 8 months to around 2.5 years. 
    • Play audiometry may be used between the ages of 30 months and 4 years.
    • Pure tone audiometry is usually appropriate for children aged 4 years or over. 
  • Tympanometry assesses the ability of the eardrum to react to sound and may be used to improve the accuracy of a diagnosis of OME.
    • There is good sensitivity (90–94%) but lower specificity (50–75%) for diagnosing OME using tympanometry.
  • Specialist clinical examination focused on otoscopy, general upper respiratory health and general developmental status.
    • Pneumatic otoscopy, where available, can be used to diagnose OME.

What else might it be?

• Other causes of ear discomfort include:
  • Acute otitis media (AOM).
    • This often precedes otitis media with effusion (OME) with symptoms of shorter duration. It can often be distinguished on clinical grounds.
      • Ear pain is more common in AOM than OME, and there may be systemic symptoms such as fever, malaise, irritability, vomiting and anorexia. Children with OME are more likely to present with more subtle symptoms and signs such as hearing issues or sequelae of poor hearing. There may be a sensation of fullness in the ear, popping sounds or tinnitus.
      • On examination, a red and bulging eardrum is seen in AOM; a cloudy or opaque eardrum may be seen in OME.
    • For more information, see the CKS topic on Otitis media - acute.
  • Mastoiditis — a potentially serious complication of AOM which may precede OME.
  • Otitis externa.
    • This is more common in swimmers and adults.
    • Pain or itching are the main symptoms, with or without discharge, and there are inflammatory changes in the ear canal or surrounding skin. Movement or pressure on the pinna is usually painful.
    • For more information, see the CKS topic on Otitis externa.
  • Foreign body in the ear canal.
  • Referred pain (from teeth; temporomandibular joint; enlarged lymph nodes; salivary glands; sinuses; or laryngeal, pharyngeal, and neck problems) — relatively rare in children, but they may have erupting molars. Bilateral pain virtually excludes the possibility of referred causes.
  • Otitic barotrauma — usually seen in people who have recently travelled by aeroplane, been scuba diving, or received a blow to the ear.
• Other causes of hearing loss include:
  • Foreign body in the ear canal.
  • Impacted earwax. For more information, see the CKS topic on Earwax.
  • Perforated tympanic membrane.
  • Sensorineural hearing loss.
  • Note: coexisting causes of hearing loss (such as sensorineural, permanent conductive and non-organic causes) should be considered and managed appropriately when a diagnosis of OME is made.
• Other causes of developmental problems include:
  • Intellectual or cognitive disability from various causes.
  • Speech and language disorders, such as dyslexia, dysarthria, and neurological disorders.
  • Behavioural disorders, such as school refusal and truancy, and conduct disorders.
  • Autism. For more information, see the CKS topic on Autism in children.
  • Inattention due to attention deficit hyperactivity disorder (ADHD) and learning difficulty. For more information, see the CKS topic on Attention deficit hyperactivity disorder.
  • Visual impairment.
  • Balance disorders and conditions causing difficulties in motor coordination.
  • Metabolic issues including hypothyroidism, mitochondrial diseases, severe deficiencies, and rare congenital conditions.

Scenario: Management

From birth to 12 years.

Search strategy

Scope of search

A literature search was conducted for guidelines, systematic reviews and randomized controlled trials on primary care management of otitis media with effusion.

Search dates

May 2021 - June 2026

Key search terms

Various combinations of searches were carried out. The terms listed below are the core search terms that were used for Medline.

• exp Otitis Media with Effusion/, (otitis media$ adj3 effusion$).tw, (middle ear adj3 effusion$).tw, glue ear$.tw, ((serous$ or secretor$) adj3 otitis media$).tw
• exp steroid/
• exp antibacterial agents/

Sources of guidelines

• National Institute for Health and Care Excellence (NICE)
• Scottish Intercollegiate Guidelines Network (SIGN)
• Royal College of Physicians
• Royal College of General Practitioners
• Royal College of Nursing
• NICE Evidence
• World Health Organization
• Guidelines International Network
• TRIP database
• Agency for Healthcare Research and Quality
• National Health and Medical Research Council (Australia)
• Royal Australian College of General Practitioners
• British Columbia Medical Association
• Canadian Medical Association
• Alberta Medical Association
• Michigan Quality Improvement Consortium
• Singapore Ministry of Health
• National Resource for Infection Control
• RefHELP NHS Lothian Referral Guidelines
• Medline (with guideline filter)
• Driver and Vehicle Licensing Agency
• NHS Health at Work (occupational health practice)

Sources of systematic reviews and meta-analyses

• The Cochrane Library:
  • Systematic reviews
  • Protocols
  • Database of Abstracts of Reviews of Effects
• Medline (with systematic review filter)
• EMBASE (with systematic review filter)

Sources of health technology assessments and economic appraisals

• NIHR Health Technology Assessment programme
• The Cochrane Library:
  • NHS Economic Evaluations
  • Health Technology Assessments
• Canadian Agency for Drugs and Technologies in Health
• International Network of Agencies for Health Technology Assessment

Sources of randomized controlled trials

• The Cochrane Library:
  • Central Register of Controlled Trials
• Medline (with randomized controlled trial filter)
• EMBASE (with randomized controlled trial filter)

Sources of evidence based reviews and evidence summaries

• Drug and Therapeutics Bulletin
• TRIP database
• Central Services Agency COMPASS Therapeutic Notes

Sources of national policy

• Department of Health
• Health Management Information Consortium (HMIC)

Patient experiences

• Healthtalk
• BMJ - Patient Journeys

Sources of medicines information

The following sources are used by CKS pharmacists and are not necessarily searched by CKS information specialists for all topics. Some of these resources are not freely available and require subscriptions to access content.

• British National Formulary (BNF)
• electronic Medicines Compendium (eMC)
• European Medicines Agency (EMEA)
• Medicines and Healthcare products Regulatory Agency (MHRA)
• REPROTOX
• Scottish Medicines Consortium
• Stockley's Drug Interactions
• TERIS
• TOXBASE
• Micromedex
• UK Medicines Information

Stakeholder engagement

Our policy

The external review process is an essential part of CKS topic development. Consultation with a wide range of stakeholders provides quality assurance of the topic in terms of:

• Clinical accuracy.
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Evidence exclusion criteria

Our policy

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Studies identified during literature searches are reviewed to identify the most appropriate information to author a CKS topic, ensuring any recommendations are based on the best evidence. We use the principles of the GRADE and PICOT approaches to assess the quality of published research. We use the principles of AGREE II to assess the quality of published guidelines.

Standard exclusions for scoping literature:

• Animal studies
• Original research is not written in English

Possible exclusions for reviewed literature:

• Sample size too small or study underpowered
• Bias evident or promotional literature
• Population not relevant
• Intervention/treatment not relevant
• Outcomes not relevant
• Outcomes have no clear evidence of clinical effectiveness
• Setting not relevant
• Not relevant to UK
• Incorrect study type
• Review article
• Duplicate reference

Organizational, behavioural and financial barriers

Our policy

The CKS literature searches take into consideration the following concepts, which are discussed at the initial scoping of the topic.

• Feasibility
  • Studies are selected depending on whether the intervention under investigation is available in the NHS and can be practically and safely undertaken in primary care.
• Organizational and Financial Impact Analysis
• Studies are selected and evaluated on whether the intervention under investigations may have an impact on local clinical service provision or national impact on cost for the NHS. The principles of clinical budget impact analysis are adhered to, evaluated and recorded by the author. The following factors are considered when making this assessment and analysis.
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  • Current interventions
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  • Impact on other costs
  • Condition-related costs
  • In-direct costs and service impacts
  • Time dependencies
• Cost-effectiveness or cost-benefit analysis studies are identified where available. 

We also evaluate and include evidence from NICE accredited sources which provide economic evaluations of recommendations, such as NICE guidelines. When a recommended action may not be possible because of resource constraints, this is explicitly indicated to healthcare professionals by the wording of the CKS recommendation.

Declarations of interest

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Clarity Informatics requests that all those involved in the writing and reviewing of topics, and those involved in the external review process to declare any competing interests. Signed copies are securely held by Clarity Informatics and are available on request with the permission of the individual. A copy of the declaration of interest form which participants are asked to complete annually is also available on request. A brief outline of the declarations of interest policy is described here and full details of the policy is available on the Clarity Informatics website. Declarations of interests of the authors are not routinely published, however competing interests of all those involved in the topic update or development are listed below. Competing interests include:

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Competing interests declared for this topic:

None.