Questionnaire/history: Hearing loss (e.g. 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'? Aural discharge (persistent foul smelling discharge requiring urgent referral)? Recurrent ear infections, upper respiratory tract infections or frequent nasal obstruction? 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 - Lack of concentration or attention, or being socially withdrawn?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? Past medical history? Current medication? Drug allergies? Examination: (Note: A normal-looking tympanic membrane does not exclude OME, there are usually no signs of inflammation or discharge on examination) Effusion (serous, mucoid or purulent)? Abnormal colour of the eardrum (eg yellow, amber or blue? Loss of light reflex or a more diffuse light reflex? Opacification of the eardrum (other than that due to scarring)? Air bubbles or an air/fluid level? Retracted, concave or indrawn eardrum or, less frequently, fullness or bulging? Nose and throat factors which may predispose to OME? Investigations: - Audiometry where appropriate (visual response audiometry for children aged 8 months to 2.5 years and conventional audiometry for children aged 4 years or over)? - Tympanometry where appropriate to assesses the ability of the eardrum to react to sound and may be used to improve the accuracy of a diagnosis of OME? Management: Advised: - Active observation over 6–12 weeks appropriate for most children, as spontaneous resolution is common, ideally with two hearing tests using pure tone audiometry at least 3 months apart as well as tympanometry - Following the hearing test depending on the severity of any confirmed hearing loss and suspicion of a delay in the child reaching developmental milestones referral to an ENT specialist - Re-evaluating signs and symptoms of the effusion and concerns regarding the child's hearing or language development and complications during this period to determine whether it is appropriate to continue with active observation or refer to the child to an ENT specialist - Referral to ENT specialist if signs and symptoms persist after the period of observation - Immediate referral of children with Down's syndrome or cleft palate, who are suspected to have OME - Following treatments are not recommended for treating OME, as there is no evidence to support their use: antibiotics, antihistamines, mucolytics, decongestants, corticosteroids Referral: - Hearing loss of any level is associated with a significant impact on the child's developmental, social, or educational status - Hearing loss is severe (61 dB or greater) (requiring urgent referral within 2 weeks to exclude additional sensorineural deafness) - Significant hearing loss persists on two documented occasions (usually following repeat testing after 6–12 weeks) - Tympanic membrane structurally abnormal (or there are other features suggesting an alternative diagnosis) - Persistent, foul-smelling discharge suggestive of a possible cholesteatoma (within 2 weeks) - Down's syndrome or cleft palate Resource(s): NICE CKS: Otitis media with effusion