Tympanometry, audiometry, and middle ear assessment — collectively referred to here as Otitis Media with Effusion (OME) monitoring tools — are the clinical instruments that determine whether otitis media with effusion is resolving, persisting, or causing conductive hearing loss significant enough to influence the management pathway.

How do tympanometry and audiometry support OME monitoring?

Tympanometry and audiometry support OME monitoring by providing objective, reproducible evidence of middle ear function and hearing impact — complementing otoscopy and enabling clinicians to track whether effusion is resolving, persisting, or beginning to affect hearing in ways that influence management decisions.

Pneumatic otoscopy remains the primary tool for identifying middle ear effusion. Tympanometry adds an objective dimension: it measures eardrum compliance across a range of air pressures and produces a waveform — the tympanogram — that reflects middle ear status without relying on patient cooperation or clinician visual interpretation alone.

In OME, the most clinically relevant tympanogram findings are:

  • Type B (flat): No compliance peak across the pressure range. In the context of a normal ear canal volume, this pattern is strongly associated with middle ear effusion. It is the most common tympanometric finding in confirmed OME.
  • Type C: Compliance peak shifted to negative pressure, consistent with Eustachian tube dysfunction and negative middle ear pressure — a precursor to effusion or a sign of partial resolution.
  • Type A: Normal compliance peak at or near atmospheric pressure — suggests the middle ear is well-ventilated and effusion has resolved or is absent.

Audiometry documents whether effusion has crossed the threshold into clinically significant conductive hearing loss. The AAO-HNSF 2016 OME guideline recommends formal age-appropriate hearing testing at or before three months of known effusion duration in children with bilateral OME. In infants under six months, high-frequency tympanometry (1000 Hz probe tone) is recommended over standard 226 Hz tympanometry to avoid false-positive results.

How can conductive hearing loss influence OME follow-up?

Documented conductive hearing loss in the context of OME changes the follow-up trajectory — from routine surveillance to active assessment of developmental impact, hearing burden, and whether the threshold for non-surgical or surgical intervention has been reached.

Middle ear effusion can cause conductive hearing loss ranging from mild to moderate. The AAO-HNSF guideline notes that OME-related hearing loss averages 10 to 15 decibels, though the range extends to 45 dB in more significant cases. Even at the lower end, this degree of hearing loss is clinically meaningful in young children during critical periods of speech and language development.

When audiometry confirms conductive hearing loss in a child with persistent bilateral OME, the management pathway shifts. Several clinical considerations are triggered:

  • Duration plus hearing loss together — not effusion duration alone — is the primary indication for discussing tympanostomy tube insertion under the AAO-HNSF 2022 tympanostomy tube guideline
  • Unilateral conductive hearing loss in a child warrants the same documentation and follow-up as bilateral — unilateral OME can cause meaningful functional hearing asymmetry
  • At-risk children — those with Down syndrome, cleft palate, autism spectrum disorder, or existing developmental concerns — warrant earlier and more aggressive hearing assessment regardless of effusion duration

Conductive hearing loss from OME is typically reversible when fluid clears. However, persistent or recurrent hearing loss during developmentally sensitive windows carries cumulative risk that should inform the pace and intensity of follow-up.

What can an audiogram show in conductive hearing loss related to OME?

In conductive hearing loss related to OME, an audiogram typically shows elevated air conduction thresholds with normal or near-normal bone conduction thresholds — producing an air-bone gap that reflects the degree of middle ear sound transmission impairment.

Understanding the audiogram pattern in OME-related conductive hearing loss requires two concepts:

Air conduction measures how well the entire hearing pathway — outer ear, middle ear, and inner ear — transmits sound. In OME, fluid in the middle ear dampens eardrum and ossicular movement, raising the threshold at which sound is heard through air conduction.

Bone conduction bypasses the outer and middle ear entirely by transmitting sound vibration directly to the cochlea through the skull. In pure conductive hearing loss, bone conduction thresholds are normal — the inner ear and auditory nerve are intact.

The air-bone gap is the difference between these two thresholds. In OME-related conductive hearing loss, a consistent air-bone gap across multiple frequencies is the hallmark finding. The gap typically ranges from 10 to 30 dB in OME. A flat audiometric pattern — where hearing loss is relatively consistent across low, mid, and high frequencies — is characteristic of middle ear effusion, in contrast to the configuration seen in sensorineural loss (typically sloping downward at high frequencies).

In practice, a flat tympanogram (Type B) combined with an air-bone gap on audiometry provides strong, convergent evidence of middle ear effusion with conductive hearing loss. When these findings are bilateral and persistent, the clinical threshold for discussing intervention is reached.

For children unable to complete standard pure-tone audiometry, visual reinforcement or conditioned play audiometry are age-appropriate alternatives.

When should monitoring findings inform the broader OME management pathway?

Monitoring findings should inform the broader OME management pathway when tympanometry and audiometry together confirm persistent bilateral effusion with conductive hearing loss — the primary indication for moving from surveillance to active discussion of non-surgical or surgical options.

The following monitoring findings should prompt a management discussion rather than continued observation:

  • Bilateral Type B tympanograms at or beyond three months from known OME onset, combined with audiometric hearing loss
  • Any duration of effusion with confirmed hearing loss in an at-risk child
    Progressive or worsening conductive hearing loss on serial audiometry
  • Unilateral effusion in an adult without a clear precipitating cause — requires ENT evaluation to exclude a nasopharyngeal mass
  • Monitoring findings that contradict a parent or teacher reporting significant hearing difficulties — the functional report should carry weight alongside the audiometric threshold

Monitoring also provides reassurance when findings are stable or improving. A Type C tympanogram that resolves to Type A on follow-up — with audiometric thresholds returning to normal limits — supports continued observation rather than escalation.

When monitoring findings indicate persistent bilateral OME with hearing loss, the next step is a shared decision-making conversation about management options. Non-surgical options — including autoinflation — can be initiated at any point in the monitoring period and do not need to wait for the three-month threshold. For a structured overview of the full OME management pathway, see [Pediatric OME Clinical Management: Monitoring, Treatment Pathways, and Escalation].

How Earflo supports clinician-led OME conversations

When tympanometry and audiometry confirm negative middle ear pressure or persistent effusion, Earflo provides clinicians with a guideline-endorsed, non-surgical option to offer families during the monitoring period — and a meaningful response to parents who find watchful waiting difficult to accept without active treatment.

Earflo is FDA-cleared for the management of negative middle ear pressure and OME in patients from age two, and is equally applicable in adults with Eustachian tube dysfunction presenting with conductive hearing loss from middle ear pressure.

The mechanism: Earflo uses swallow-coordinated autoinflation — delivering a precisely timed puff of air during the natural opening of the Eustachian tube that occurs with every swallow. Unlike conventional autoinflation methods that require forceful blowing against a closed tube, Earflo works at significantly lower pressure, eliminates aspiration risk, and causes no discomfort. There is no technique to learn and no risk of the overpressurization associated with nasal balloon devices.

Training and compliance tools: A built-in light indicator provides real-time feedback on correct technique and successful swallow detection. A companion app tracks compliance and reinforces technique over time. These tools contributed to the 99% objective compliance rate in both published clinical studies — substantially higher than compliance rates reported for conventional nasal balloon autoinflation in children (Webster et al., Cochrane 2023).

The evidence: Two published clinical studies (Soto et al., OTO Open 2025; Hura et al., American Journal of Otolaryngology 2026) confirmed 99% compliance, an average 12.9–14.2 dB hearing improvement at two weeks, 91% tympanometric improvement during active use, and 89% of children avoiding tympanostomy tube surgery. No adverse events were reported.

It can be introduced at the first monitoring visit where effusion and pressure findings are confirmed — giving families something active and evidence-based to do, reducing pressure to prescribe antibiotics that are not indicated, and running alongside continued tympanometric and audiometric surveillance.

Key takeaways

  • Tympanometry and audiometry together provide the objective evidence needed to determine whether OME is resolving, persisting, or causing clinically significant conductive hearing loss
  • A Type B tympanogram combined with an air-bone gap on audiometry is the hallmark finding in OME-related conductive hearing loss — bilateral persistence of these findings is the primary indication for discussing intervention
  • Conductive hearing loss in OME is typically reversible, but persistent hearing loss during developmentally sensitive periods carries cumulative risk that should inform the pace of follow-up
  • Audiometric patterns in OME-related conductive hearing loss show elevated air conduction with normal bone conduction — a flat configuration across frequencies, in contrast to the high-frequency slope of sensorineural loss
    Monitoring findings do not need to reach the three-month threshold before non-surgical options are offered; Earflo can be recommended at any point in the observation period
  • Earflo’s swallow-coordinated mechanism eliminates aspiration risk, requires no technique, works at lower pressure, and provides light and app-based feedback to confirm correct use and track complianceLearn more about Earflo for clinicians →

Contact us to discuss clinical integration →

About the Author

Dr. Peter Santa Maria, MD, PhD Professor & Division Chief of Otology and Neurotology Vice Chair of Translational and Clinical Research, University of Pittsburgh

Dr. Santa Maria is an ear surgeon-scientist specializing in advanced ear disease, hearing loss, and Eustachian tube disorders. He is the principal investigator of the two published clinical studies on swallow-coordinated autoinflation cited in this article, and co-founder and Chief Medical Officer of Earflo, Inc.

Disclosure: Dr. Santa Maria is a co-inventor of Earflo and holds equity in the company.

References

 

  1. Rosenfeld RM, Shin JJ, Schwartz SR, et al. Clinical Practice Guideline: Otitis Media with Effusion (Update). Otolaryngology–Head and Neck Surgery. 2016;154(1 Suppl):S1–S41.
  2. Rosenfeld RM, Tunkel DE, Schwartz SR, et al. Clinical Practice Guideline: Tympanostomy Tubes in Children (Update). Otolaryngology–Head and Neck Surgery. 2022;166(1_suppl):S1–S55. doi:10.1177/01945998211065662.
  3. Soto MJ, Hura N, Oldakowska I, Oldakowski M, Bumbak P, Santa Maria PL. Feasibility of a Novel Autoinflation Device to Treat Pediatric Otitis Media With Effusion At-Home. OTO Open. 2025;9(2):e70128. doi:10.1002/oto2.70128. PMID: 40370996.
  4. Hura N, Soto MJ, Lalwani Z, Oldakowska I, Oldakowski M, Bumbak P, Santa Maria PL. A novel autoinflation device for persistent pediatric otitis media with effusion: A prospective single-arm cohort study. American Journal of Otolaryngology. 2026;47(4):104862. doi:10.1016/j.amjoto.2026.104862. PMID: 42296786.
  5. Webster KE, Mulvaney CA, Galbraith K, Rana M, Marom T, Daniel M, Venekamp RP, Schilder AGM, MacKeith S. Autoinflation for otitis media with effusion (OME) in children. Cochrane Database of Systematic Reviews. 2023;(9):CD015253. doi:10.1002/14651858.CD015253.pub2. PMID: 37750500.
  6. Katz J, Chasin M, English K, Hood L, Tillery KL, eds. Handbook of Clinical Audiology. 7th ed. Baltimore: Wolters Kluwer; 2015. [Air-bone gap and audiometric patterns in conductive hearing loss.]
  7. National Institute for Health and Care Excellence. Otitis media with effusion in under 12s (NG233). August 2023.
  8. Stanford Health Care. Conductive Hearing Loss: Overview and Diagnosis. stanfordhealthcare.org. Accessed October 2026.