👂
Otitis Media with Effusion (Glue Ear) — Under 12s Fluid in the middle ear without infection · 3-month active observation · OME decision table · grommets ± adenoidectomy · NICE NG233 (2023) & CKS
Progress 0 / 9
The full reasoning pathway — glue ear = middle-ear fluid without infection. Confirm OME & hearing loss, observe for 3 months, then make a shared decision on support, hearing devices or grommets; support development, and safety-net.StartDecisionInvestigateActionReferStop / Admit
PresentationChild <12 with suspected glue ear
OME = fluid in the middle ear without infection. Suspect from hearing difficulty, ear discomfort, tinnitus, delayed speech/language, or behaviour/balance/educational concerns raised by parents, carers or professionals.
Step 1 · Safety — special groups / red flagsDown's syndrome, cleft palate, or other concern?
Children with Down's syndrome or cleft palate → refer to specialist (don't follow standard observation). Also consider co-existing causes of hearing loss: sensorineural, non-organic, permanent conductive.
Special group
ReferSpecialist / audiology
Down's, cleft palate, craniofacial anomaly, learning disability, or diagnostic uncertainty → ENT/audiology with individualised follow-up.
Otherwise healthy child
Assess & confirmOtoscopy · tympanometry · hearing test
Refer for formal hearing assessment if OME is clinically suspected. Examine: otoscopy, general development, URT health.
Step 3 · OME confirmed?
OME, NO hearing loss
No treatment — reassure
No treatment needed. Explain why; reassure they can return if hearing concerns arise.
OME + hearing loss — observe
Active observation 3 months
Reassess hearing after 3 months (was "watchful waiting"). Most resolve. Intervene earlier if hearing difficulty significantly affects day-to-day living.
Persistent hearing loss
OME decision table
Shared decision: monitoring & support, auto-inflation, hearing aids / bone-conduction devices, or grommets.
Step 7 · if surgery chosen
Step 7 · Action · surgeryGrommets ± adjuvant adenoidectomy
Insert grommets (ventilation tubes) for OME-related hearing loss. Consider adjuvant adenoidectomy unless a palate abnormality (adenoidectomy alone not recommended without persistent/frequent URT symptoms). Single intraop ciprofloxacin dose; water precautions 2 weeks. Post-op hearing test at 6 weeks.
Do NOT offerNo drugs or alternative therapies for OME
Do not offer: antibiotics, oral/nasal steroids, decongestants, antihistamines, leukotriene receptor antagonists, mucolytics, PPI/anti-reflux drugs, homeopathy, cranial osteopathy or acupuncture.
Step 8 · support & modifiable factors
Step 8 · Support & modifiable factorsHelp hearing & development while awaiting resolution
Avoid passive smoke exposure (a modifiable risk for OME). Practical communication support — face the child, reduce background noise, gain attention before speaking; inform nursery/school and consider favourable seating. Auto-inflation (e.g. nasal balloon) can help in suitable children. Reassure parents most OME resolves spontaneously and monitor speech/language.
Step 9 · review & safety-net
Step 9 · Review & safety-netReassess & when to escalate
Re-test hearing after the 3-month observation and review speech/behaviour/education. Refer to ENT/audiology if persistent hearing loss, significant impact on development or schooling, special groups (Down's, cleft palate), or diagnostic uncertainty. Post-grommet: hearing test at 6 weeks, water precautions 2 weeks; review for recurrence after extrusion. Reconsider sensorineural or permanent conductive loss if hearing doesn't recover.
⚠️ OME with no hearing loss needs no treatment — but explain why, and safety-net. Refer children with Down's syndrome or cleft palate to a specialist rather than observing in primary care. NICE NG233 (2023).
1
Safety

What OME Is — and When This Pathway Doesn't Apply

Otitis media with effusion (OME, "glue ear") = fluid in the middle ear in the absence of infection. First separate it from conditions that need a different route.

Acute otitis media (AOM) Painful ear, fever, bulging/red drum, systemic upset → that's infection, not OME → use the AOM pathway. OME is the non-infected effusion that often follows.
Down's syndrome Higher OME prevalence & persistence → refer to specialist/audiology; do not manage with standard primary-care observation.
Cleft palate Strongly associated with OME → specialist (cleft/ENT) management, not routine watchful waiting.
Cholesteatoma / chronic perforation Foul discharge, attic crust/retraction pocket, persistent discharge → urgent ENT referral; not simple glue ear.
Suspected sensorineural / permanent loss Consider co-existing sensorineural, non-organic or permanent conductive hearing loss — these change management.
Adult with unilateral effusion (Outside this under-12s pathway) — a persistent unilateral middle-ear effusion in an adult needs exclusion of a post-nasal space (nasopharyngeal) tumour → urgent ENT.
OME is defined by middle-ear fluid without the signs of acute infection — distinguishing it from acute otitis media is the first step, because the management (observe vs treat infection) is completely different. Children with Down's syndrome and cleft palate are explicitly carved out by NICE/CKS for specialist care because their OME is more prevalent, more persistent and higher-stakes for speech and language. And although this guideline is for under-12s, it's worth remembering that an unexplained unilateral effusion in an adult is a nasopharyngeal-cancer red flag.
2
Diagnose

How Glue Ear Presents — Two Feature Categories

NICE NG233 now splits presenting features into two groups. Be alert to OME in a child presenting with any of these — the child may not complain of their ears at all.

Common features
Hearing difficulties · ear discomfort · tinnitus · delayed speech and language development.
Associated features
Behavioural problems · lack of concentration or attention · clumsiness · balance difficulties · poor educational progress.
Who raises it
Concerns from parents/carers or professionals (e.g. teachers, health visitors) are a valid trigger to assess.
Often bilateral & fluctuating
Hearing can fluctuate; effusions are frequently bilateral. A child may "ignore" instructions or turn the TV up rather than report deafness.
Peaks in early childhood
Very common in pre-school children; most episodes are self-limiting, which is why active observation comes first (Step 4).
The 2023 update deliberately broadens the presenting picture beyond "hearing loss" to include behaviour, attention, clumsiness, balance and educational progress — because young children rarely articulate hearing difficulty, and OME is often first noticed as a developmental or behavioural concern. Recognising these softer signs is what prevents glue ear from being missed during the critical speech-and-language window.
3
Diagnose

Assessment & Confirming the Diagnosis

Clinical examination
Focus on otoscopy (dull/retracted drum, fluid level/bubbles, reduced mobility), general development, and general upper respiratory health.
Objective tests
Tympanometry (flat/type B trace supports an effusion) and hearing testing appropriate to age.
Refer for formal hearing assessment
If OME is clinically suspected from the history & presenting features, refer for further hearing assessment (audiology) to confirm OME and quantify any hearing loss.
Consider co-existing causes
Where there's hearing loss, consider sensorineural, non-organic and permanent conductive causes — don't assume all loss is from the effusion.
Document baseline
Record laterality (uni/bilateral), hearing levels, and the impact on day-to-day living, speech/language and schooling — this drives the management decision.
Confirmed OME =
Middle-ear effusion on examination/tympanometry, ± a confirmed conductive hearing loss on audiometry. The presence/absence of hearing loss then splits the pathway (Step 4).
OME is confirmed with otoscopy and tympanometry, but the management hinges on audiology — whether there's a hearing loss, how big, and whether it's affecting the child. Actively considering sensorineural, non-organic and permanent conductive causes prevents the error of attributing a fixed or progressive loss to a transient effusion and missing a more serious diagnosis.
4
Treat

Active Observation — The 3-Month Rule

Most OME resolves spontaneously, so the first-line approach is a period of active observation (the term that replaced "watchful waiting").

OME with NO hearing loss
No treatment reassure
Children with OME but no hearing loss do not need treatment. Explain why it isn't needed (avoids confusion/anxiety) and that they can return if hearing concerns arise.
OME + hearing loss
Reassess at 3 months
Reassess hearing after 3 months of active observation — a large proportion resolve in this window without intervention.
Significant impact on daily living
Intervene earlier don't wait
If hearing difficulties are significantly affecting day-to-day living, consider intervening earlier than the 3-month reassessment.
During observation
Support strategies + auto-inflation
Offer hearing-loss support strategies (Step 6) and consider auto-inflation as a simple measure while observing.
The 3-month active-observation period reflects the strong natural-history evidence that most OME resolves on its own, sparing children unnecessary surgery. The crucial nuances are that OME without hearing loss needs no treatment at all (just explanation and a safety-net), and that a child whose hearing loss is materially harming their daily life or development shouldn't be made to wait the full three months.
5
Treat

Do NOT Offer — Ineffective Treatments

A short, important list. None of these change OME or OME-related hearing loss, and some carry harm — actively counsel families against them.

Antibiotics No role in OME (it is not an active infection).
Oral or nasal steroids Do not offer for OME or OME-related hearing loss.
Decongestants Ineffective — do not offer.
Antihistamines · LTRAs · mucolytics Do not offer (NG233).
PPI / anti-reflux medications Do not offer for OME.
Homeopathy · cranial osteopathy · acupuncture No evidence of benefit — do not recommend.
ℹ️ The only "treatments" with a role are hearing-loss support strategies, auto-inflation, hearing aids/bone-conduction devices, and surgery (grommets ± adenoidectomy) — covered in Steps 6–8.
NICE reviewed and rejected the whole pharmacological shelf — antibiotics, steroids, decongestants, antihistamines, leukotriene receptor antagonists, mucolytics and anti-reflux drugs — because none alter the natural history of OME, and prescribing them exposes children to side effects and antimicrobial resistance for no benefit. Naming the alternative therapies (homeopathy, cranial osteopathy, acupuncture) pre-empts a common family question.
6
Lifestyle

Hearing-Loss Support Strategies

Whatever the management decision, support strategies help the child function while the effusion is present. Cover home, all settings, and education.

Be close & face the child Get down to their level and face them when speaking so they can use visual cues.
Minimise background noise Turn off TV/radio when talking; choose quieter settings for conversations.
Use visual aids Gestures, pictures and demonstration to back up spoken instructions.
Inform school staff Tell staff about the OME and the related hearing loss so they can adapt.
Classroom adjustments Ask whether adjustments can be made — e.g. sitting near the front of the class.
Prepare the child Explain interventions and what to expect in age-appropriate terms.
Consider auto-inflation A simple, low-risk measure (e.g. balloon device) that can be offered during observation.
Tailored information Give OME information tailored to the child's age, development and the family's needs/format/language.
Support strategies are the part of OME care that helps every child immediately, regardless of whether they go on to devices or surgery — and they're cheap, safe and empowering for families and schools. Auto-inflation has modest evidence but is low-risk, so NICE positions it as something to consider during the observation period.
7
Treat

Persistent Hearing Loss — The OME Decision Table

If OME-related hearing loss persists after observation (bilateral, or unilateral and impacting daily living/communication), discuss the options using the NICE OME decision table and make a shared decision.

Monitoring & support
Continue active monitoring plus the support strategies (Step 6) if the family prefers to avoid devices/surgery.
Auto-inflation
Consider as a non-invasive option, particularly as a bridge while deciding.
Hearing aids
Consider hearing aids — especially where surgery is unsuitable/declined, or for bilateral loss; reversible and non-surgical.
Bone-conduction devices
Consider bone-conduction devices (transmit sound via skull vibration, bypassing the middle ear) — useful where conventional aids aren't suitable.
Grommets (ventilation tubes)
Consider grommets for OME-related hearing loss (Step 8) — the main surgical option.
How to decide
Cover the benefits, risks & practical considerations of each option, plus support strategies, tailored to the child & family — this is the decision table conversation.
ℹ️ Historically, persistent bilateral OME with a hearing level of ~25–30 dBHL in the better ear over 3 months prompted intervention. NG233 now frames this as a shared decision using the OME decision table rather than a single dB cut-off.
The 2023 guideline's headline change is the OME decision table: instead of channelling every child with persistent loss straight to grommets, it lays out monitoring/support, auto-inflation, hearing aids, bone-conduction devices and grommets as legitimate options to weigh together with the family. This recognises that hearing aids are a reasonable, reversible alternative to surgery for many children, and that the "right" choice depends on the child's circumstances and the family's preferences.
8
Treat

Surgery — Grommets ± Adenoidectomy & Aftercare

Grommets (ventilation tubes)
Insertion of temporary grommets to ventilate the middle ear is recommended for OME-related hearing loss. Discuss risks: perforation, localised atrophy, tympanosclerosis, infection — shared decision.
Adjuvant adenoidectomy
When planning grommets, consider adjuvant adenoidectomy — unless assessment indicates a palate abnormality. Discuss its risks (haemorrhage, velopharyngeal insufficiency).
Adenoidectomy alone
Not recommended in the absence of persistent and/or frequent upper respiratory tract symptoms.
Intra-operative ciprofloxacin
Consider a single dose of ciprofloxacin given intraoperatively during grommet insertion (off-label in Aug 2023) to reduce post-op otorrhoea.
Water precautions
Keep the ear dry — avoid swimming, take care bathing/washing hair for 2 weeks after surgery.
Post-op hearing test
Perform a postoperative hearing test 6 weeks after surgery (Step 9).
Grommets ventilate the middle ear and reliably restore hearing while in place, which is why they remain the main surgical option — but the 2023 guidance stresses shared decision-making about their real risks. Adjuvant adenoidectomy is considered alongside grommets (unless the palate is abnormal) because removing the adenoids reduces the chance of OME recurrence and repeat surgery; adenoidectomy on its own is reserved for children who also have significant upper-airway symptoms.
9
Refer

Follow-Up, Special Groups & Safety-Netting

Post-op hearing test at 6 weeks
If hearing loss has resolved → discharge, and consider follow-up options. If hearing loss continues → investigate and manage appropriately.
Follow-up options
Advise parents/carers to seek reassessment if they're worried about recurrence; or consider a 1-year follow-up hearing test; or an individualised plan for higher-risk children.
Refer to specialist
Down's syndrome and cleft palate → specialist/audiology pathways (not routine observation). Also craniofacial anomalies & learning disability → individualised follow-up (higher risk of unrecognised OME-related loss).
Persistent unilateral loss
Persistent unilateral OME-related hearing loss impacting daily living or communication warrants the same options discussion (Step 7) as bilateral.
Persistent otorrhoea post-grommet
Otorrhoea that persists and doesn't respond to topical antibiotics → ENT may consider grommet removal.
Safety-net
Tell families OME can recur and to return if hearing, speech, behaviour or school progress deteriorates — re-refer for hearing assessment as needed.
The 6-week post-op test closes the loop: it confirms the grommets worked, and any continuing loss is investigated rather than assumed resolved. Higher-risk groups — Down's syndrome, cleft palate, craniofacial anomalies, learning disability — get specialist pathways and individualised follow-up because their OME is more likely to be persistent and to be missed, with bigger consequences for speech, language and learning if it is.
Educational use only. Pathway based on: NICE NG233 Otitis media with effusion in under 12s (August 2023) & its OME decision table · NICE CKS Otitis media with effusion · BMJ 2023 visual summary of updated NICE guidance (bmj.com/infographics). Orange-box items reflect 2023 changes from the 2008 guideline. This is not a validated clinical decision aid — refer for formal audiology assessment and always individualise to the child & family.