Document type
Clinical pathways
Hertfordshire and West Essex ICB
Output type
Clinical Pathways
Glue in Ear | Children

Acute and Chronic Otitis Media/Glue Ear and Indications for Grommets

Pathway published: September 2023.
Next review date: September 2025. 

Acute otitis media

  • Treat pain and fever with paracetamol or NSAIDS
  • Consider no antibiotic prescribing, or a delayed antibiotic prescribing strategy
  • Offer an immediate antibiotic prescription to people:
    • Who are systemically unwell but do not require admission
    • Who are at high risk of serious complications
    • Whose symptoms have lasted for 4 days or more and are not improving

Assess for red flags , if any suspected acute complications such as meningitis, mastoiditis or facial nerve palsy discuss with ENT on-call as may require admission.

See pathway for management

Recurrent acute/ chronic otitis media with effusion/ glue ear

Routine referral of CHILDREN for an ENT opinion.

NB: 50% will spontaneously clear within 3 months and 95% will spontaneously clear within 12 months. 


  • The child has hearing loss suggestive of sensori-neural deafness (urgent referral);
  • The child has persistent hearing loss detected on two occasions separated by 3 months or more; NICE guidelines suggest a threshold of 25 dBHL or worse in the better ear;
  • The otoscopic features are atypical and accompanied by a foul smelling discharge lasting for more than 6 weeks, suggestive of cholesteatoma (urgent referral).
  • The tympanic membrane is structurally abnormal (or there are other features suggesting an alternative diagnosis).

Urgent referral:

  • Hearing loss is severe (61 dB or greater)
  • Persistent, foul-smelling discharge (cholesteatoma)
  • There is a reasonable suspicion of hearing loss plus a delay in speech or language development, poor educational progress, social or behavioral problems or another disability such as Down’s syndrome or cleft palate (should be seen soon)

Routine referral to ENT for a child who already has grommets if:

  • If symptoms of otitis media with effusion recurs despite having / had grommets;
  • Ongoing ear discharge / bleeding / or perforated TM whilst having grommets in.

Routine referral for ADULTS if they meet the following criteria:

  • Otitis media with effusion (OME) that meets the following criteria:
  • Persisting after a prolonged period of watchful waiting/active observation of at least 4 months, (NB watchful waiting is not appropriate if malignancy suspected)
  • There is a definitive diagnosis of OME and
  • It persists;


  • Severe pain-due to air pressure changes when flying or in hyperbaric treatment. The severity and frequency of flying should be discussed with the patient and balanced against the possible complications associated with grommets;


  • Re-insertion of ventilation tubes- where it’s been inserted and fallen out- a 2nd or 3rd grommet may be inserted if they still meet one of the above criteria.


  • The patient has severe retraction of the tympanic membrane, if the clinician feels this may be reversible and reversing it may help avoid erosion of the ossicular chain or the development of cholesteatoma

NB: Patients who do not meet the above criteria may be considered on an individual basis where the GP/Consultant believes exceptional circumstances may exist. In patients who suffer from subjective feelings of pressure or eustachian tube dysfunction-like symptoms, treatable underlying causes should be ruled out.