Documentation: clinicians should document the laterality, duration of effusion, and presence and severity of associated symptoms at each assessment of the child with OME

This recommendation is based on observational studies and strong preponderance of benefit over harm.

Documentation in the medical record facilitates diagnosis and treatment and communicates pertinent information to other clinicians to ensure patient safety and reduce medical errors. Management decisions in children with OME depend on effusion duration and laterality plus the nature and severity of associated symptoms. Therefore, these features should be documented at every medical encounter for OME. Although no studies have addressed documentation for OME specifically, there is room for improvement in documentation of ambulatory care medical records.

Ideally, the time of onset and laterality of OME can be defined through diagnosis of an antecedent AOM, a history of acute onset of signs or symptoms directly referable to fluid in the middle ear, or the presence of an abnormal audiogram or tympanogram closely after a previously normal test. Unfortunately, these conditions are often lacking, and the clinician is forced to speculate on the onset and duration of fluid in the middle ear(s) in a child found to have OME at a routine office visit or school screening audiometry.

In ∼40% to 50% of cases of OME, neither the affected children nor their parents or caregivers describe significant complaints referable to a middle-ear effusion. In some children, however, OME may have associated signs and symptoms caused by inflammation or the presence of effusion (not acute infection) that should be documented, such as

- Mild intermittent ear pain, fullness, or “popping”

- Secondary manifestations of ear pain in infants, which may include ear rubbing, excessive irritability, and sleep disturbances

- Failure of infants to respond appropriately to voices or environmental sounds, such as not turning accurately toward the sound source

- Hearing loss, even when not specifically described by the child, suggested by seeming lack of attentiveness, behavioral changes, failure to respond to normal conversational-level speech, or the need for excessively high sound levels when using audio equipment or viewing television

- Recurrent episodes of AOM with persistent OME between episodes

- Problems with school performance

- Balance problems, unexplained clumsiness, or delayed gross motor development

- Delayed speech or language development

The laterality (unilateral versus bilateral), duration of effusion, and presence and severity of associated symptoms should be documented in the medical record at each assessment of the child with OME. When OME duration is uncertain, the clinician must take whatever evidence is at hand and make a reasonable estimate.