Introduction
Chronic otitis media (COM) is a prevalent medical condition, characterized by persistent inflammation of the middle ear with or without tympanic membrane perforation, effusion, or ossicular erosion [1]. COM affects up to 330 million individuals globally and remains a significant cause of acquired conductive and mixed hearing loss in both adult and pediatric populations [1]. COM is estimated to impact 2%–4% of children worldwide, with prevalence rates notably higher among Indigenous groups and those from socioeconomically disadvantaged backgrounds [2,3]. The condition is strongly associated with conductive hearing loss (CHL), present in up to 86% of those affected, especially those with persistent middle ear effusion or tympanic membrane abnormalities [4,5]. In addition to CHL, patients with COM are up to three times more likely than the general population to experience sensorineural hearing loss, emphasizing the importance of comprehensive audiological evaluations that assess both types of hearing impairment [6,7].
COM is complex and challenging to treat, involving a spectrum of middle ear, mastoid, and Eustachian tube pathologies. Tympanic membrane perforation, ossicular damage, chronic infection, and cholesteatoma can result in long-term hearing loss affecting communication, social engagement, work effectiveness, and quality of life [8-11]. Hearing loss imposes further societal costs by increasing education needs, limiting academic and career opportunities, and reducing long-term productivity [12].
Management of COM typically prioritizes achieving a safe, dry ear. Hearing loss, which may persist even after successful surgery [11], is frequently under-recognized and insufficiently addressed [13]. A recent multicentre study found that over 65% of COM patients with a persistent 25–30 dB air-bone gap (ABG) showed little or no hearing improvement after tympanoplasty, with many experiencing no change or progression of hearing loss over time despite multiple surgeries [11]. Historically, COM management has prioritized infection control and anatomical repair, while hearing restoration, an essential aspect of comprehensive care, has often been undervalued and overlooked in clinical practice [13,14]. The lack of focus on hearing in COM patients highlights the need for hearing-centered management, including early audiological monitoring and timely access to rehabilitation. Conventional air-conduction hearing aids are often ineffective solutions in this population. Recurrent otorrhea, ear canal discomfort, occlusion, pain, and unstable fit associated with chronic middle ear pathology can significantly compromise both device performance and user compliance. These limitations highlight the importance of considering alternative rehabilitation strategies, such as bone conduction (BC) hearing solutions, particularly in patients with persistent symptoms and/or large ABGs. BC hearing solutions bypass the middle ear by transmitting sound via the bone to the cochlea, making them particularly well-suited for patients with described conditions [15]. As BC hearing solutions leave the ear canal open, they offer improved comfort and reduced risk of recurrent infection, providing an effective hearing rehabilitation for patients with COM and reduced symptoms as otorrhoea [16-18]. Research demonstrates that patients with large ABGs greater than 30–35 dB often achieve better hearing outcomes with BC hearing solutions compared to conventional hearing aids [19,20]. BC hearing solutions can be surgically implanted or used in non-implanted forms such as headband applications, making them particularly well suited for temporary or fluctuating hearing conditions. Despite this, BC hearing solutions are often considered only after (often multiple) surgical approaches have failed, delaying meaningful hearing intervention. Early adoption offers the advantage of immediate auditory rehabilitation.
The treatment pathway for COM-related hearing loss needs reframing. Early identification of patients with persistent ABGs should prompt timely trials of hearing devices as part of comprehensive care. While surgery remains vital for achieving a dry, infection-free ear, management must also prioritize functional hearing by assessing hearing aid suitability and introducing BC hearing solutions early when large ABGs or middle ear disease limit conventional amplification. By integrating the perspectives of surgeons, audiologists, and a patient, this expert opinion presents statements and treatment recommendations that advocate for earlier integration of BC hearing solutions in COM-related hearing loss management.
Subdivisions
Research plan
This expert opinion paper was developed using a structured, multi-phase approach to synthesize interdisciplinary clinical expertise, the patient perspective, and literature-informed insights on hearing rehabilitation in patients with COM. The core team comprised two professionals (M.K.H. and H.A.S.) with extensive clinical expertise, academic contributions, and leadership roles in otology and audiology healthcare. Over a 6-month period, the core team developed a statement document based on research retrieved from COM and hearing loss focused literature searches as well as drawn from their own experience and expertise. The COM patient perspective was integrated into the expert opinion through a patient interview by an audiologist and review of the drafted statements, ensuring their lived experience was reflected in the final result.
Selection of panel of international experts.
Expert panellists consisted of the core team, M.K.H. and H.A.S., a patient stakeholder representative, and members of the Healthy Hearing Ears (HHE) initiative, an international working group of experts in otology and audiology (see https://healthyhearingears.org/ for more information). The HHE group has sought to improve the care pathway for the management of COM and related hearing loss. Core to the HHE mission is to determine best practices in management and to address systemic barriers in the delivery of hearing healthcare to those suffering from COM.
The expert panel comprised 14 members of the HHE steering committee representing expertise in otology, neurotology, and audiology across multiple geographic regions. Members of the HHE steering committee were selected based on their recognized clinical and/or research expertise in otology, hearing loss, and hearing rehabilitation, as well as their active involvement in the HHE initiative and representation of different international healthcare settings. A summary of the panel composition is provided in Supplementary Table 1 (in the online-only Data Supplement).
Methods
The statement document was shared with all 14 HHE members (referring to the full HHE steering committee involved in developing this statement) and the patient representative via electronic distribution for review. A face-to-face roundtable discussion, moderated by M.K.H. and H.A.S., was held in Vienna on September 2nd, 2025. Twelve of the 14 members participated in the face-to-face meeting. The two members who were unable to attend contributed through electronic review and feedback during the subsequent document revision stage. Discussions were structured using a two-stage “Think–Pair–Share” format; participants first reviewed the three expert opinion statements in small breakout groups, followed by plenary discussion. Each statement aimed to define the minimum acceptable standard achievable under optimal conditions, serving as a baseline for best practices rather than an upper limit of care. Discussion prompts guided the evaluation of each statement, including clarity, evidentiary support, gaps or areas of concern, agreement with the content, and suggestions for refinement. Consensus was defined a priori as unanimous agreement (100%) among all participating experts (n=14). Following the initial think dash pair dash share discussion, statements were refined iteratively and redistributed via e-mail for final review period. Any dissenting feedback was addressed through additional clarification and revision of the statements, followed by repeat circulation until full agreement was achieved across all panel members. Email review allowed all 14 members to confirm and comment on the final wording.
Expert opinion refinement and finalization
A detailed record of the discussions was maintained, capturing key points, emerging themes, and areas of disagreement. These insights were used by M.K.H. and H.A.S. to systematically revise and refine the statements ensuring they accurately reflected the panel’s collective reasoning and iterative expert discussion. The updated version of the statement document was subsequently circulated via email to the expert panellists and patient stakeholder for final input and consensus one month after the roundtable discussion. All 14 members, including the two who did not attend the face-to-face meeting, had the opportunity to provide comments, and any dissenting views were considered in the final version. The expert opinion was finalized following incorporation of this additional feedback. The following three statements on why and how early BC interventions should be considered for COM patients were collaboratively developed by the panel of experts.
Statement 1
“In patients with COM, proactive and earlier management of hearing loss with (nonsurgical) BC hearing solutions is essential in supporting speech, language, and developmental outcomes in children, and to promote communication, social participation, and occupational functioning in adults.”
Early identification and intervention in hearing loss have been shown to improve outcomes and may also reduce healthcare use and educational resource demand [21]. Hearing loss from early childhood otitis media can disrupt speech and language development, contribute to behavioural challenges, and increase the risk of long-term academic and developmental delays [22-24]. In adolescents and adults, persistent hearing is critical to prevent prolonged auditory deprivation, which may negatively affect psychosocial health and long-term functional outcomes [25].
When conventional hearing aids, often the first option for hearing rehabilitation, are ineffective, poorly tolerated, or not suitable due to anatomical or clinical factors, non-surgical BC hearing solutions offer a valuable alternative [26]. These solutions can be introduced early, either as a trial to assess benefit before considering a permanent BC hearing solution implant, or as an interim option between surgeries when no other hearing rehabilitation is feasible. Proactive use of non-surgical BC hearing solutions helps prevent auditory deprivation, reduces the psychosocial burden of hearing loss, and supports better quality of life outcomes [27]. This is especially important in children, as any delay in hearing rehabilitation risks irreversible language and developmental consequences; early BC hearing solution assessment and intervention should therefore be standard practice. In adults, timing may allow for initial surgical management, but prompt BC hearing solution evaluation is warranted when hearing loss remains functionally limiting. While patient-centered care and shared decision-making are increasingly emphasized in otolaryngology, many patients, including those with COM, may have limited involvement in clinical decisions [28]. In this context, discussions with clinicians that clearly outline both surgical and nonsurgical options can help patients make more informed choices about BC hearing solutions [29].
From the patient’s perspective, there is often an expectation that surgery will fully restore hearing. Sub-optimal hearing outcomes may cause frustration and disappointment [30]. As many patients and caregivers remain unaware of BC hearing solutions options early in the treatment journey, they may later express frustration over missed opportunities for timely intervention, particularly when hearing aids prove unsuitable due to infection or altered ear canal anatomy. This highlights the importance of proactively introducing and discussing (non-surgical) BC hearing solution alternatives earlier in the care pathway, rather than reserving them as the next step or even a last resort. Treatment recommendations based on this statement can be seen in Table 1 [1,8-11,13,14,19,20,31-33].
Statement 2
“The care pathway should ensure hearing rehabilitation is initiated and managed simultaneously with the treatment of the underlying pathology; if hearing restoration is incomplete after reconstructive surgery, immediately start with (non)surgical BC hearing solutions to ensure hearing is treated concurrently.” In a systematic review, a cohort of 1,370 COM patients with hearing loss, 29.3% did not achieve ABG closure within 20 dB post-tympanoplasty, leaving a significant portion of patients underserved in terms of hearing restoration [31]. These patients may have benefitted from earlier consideration of BC hearing solutions, which are often delayed or overlooked. Despite being a major cause of hearing loss, COM is still managed with a focus on infection control, e.g., with surgeries only, while hearing rehabilitation is often overlooked [11,13]. Most postoperative audiograms also report only pure-tone audiometry thresholds at 0.5, 1, and 2 kHz, which may overestimate the success of ABG closure, as 4 kHz often remains more challenging to close effectively [34]. Despite evidence supporting BC hearing solutions for patients with COM who exhibit persistent ABG [16,17,35], such interventions are often delayed or disregarded. This hesitation may stem from outdated views about BC hearing technology, such as concerns about aesthetics, invasiveness, or long-term use, that are not always aligned with patient perspectives. Moreover, when clinical teams work in silos, candidacy evaluation becomes fragmented. Neither Ear, Nose, and Throat surgeons nor audiologists consistently take the lead in advocating for BC hearing solutions, often leaving patients with persistent ABG after tympanoplasty in a state of clinical limbo. Evidence shows that patients with COM who receive BC hearing solutions report clinically meaningful improvements in health-related quality of life [16]. As such, early BC hearing solutions offer a patient-centred alternative to revision tympanoplasty, enabling more proactive and effective hearing rehabilitation. In summary, discuss proactively with your patient before surgery (part of informed consent) that hearing rehabilitation should proceed in parallel with disease management. When surgery leaves a persistent ABG, start hearing rehabilitation with conventional hearing aids if applicable and if not, the BC hearing solutions, surgical or nonsurgical, should be initiated immediately. In patients with cholesteatoma, where disease control comes first, any residual hearing loss must still be addressed promptly after surgery.
From the patient perspective, hearing loss may begin as manageable but may worsen over time, becoming a significant barrier to education, employment, and social participation [1]. Hence, timely identification and intervention are critical to prevent years of avoidable disability and reduced quality of life. Equally important is early, clear communication of all hearing rehabilitation options, including BC hearing solutions, to ensure patients are fully informed and able to make appropriate decisions from the outset. Providing this information early helps align expectations, supports acceptance of BC hearing solutions, and reduces the risk of delayed or missed opportunities for effective treatment. For the treatment recommendations related to the second statement, see Table 2 [1,11,20,31,32].
Statement 3
“Conduct structured monitoring of hearing and hearing related quality of life status in patients with COM to allow timely adjustment of interventions based on benefit and medical status.”
Continuous follow-up of hearing across the entire COM care pathway is essential to ensure hearing rehabilitation is initiated and remains responsive and patient-centered [36]. The NICE guidelines for assessment and management in adults with hearing loss suggest follow-up within 6–12 weeks after device fitting to support adaptation and reduce the risk of abandonment [36]. The panel suggested that COM with hearing loss patients as needed should be monitored and receive timely assessments, reassessments, and clear pathways to engage with ENT- and audiology services to have discussions about hearing rehabilitation. Monitoring should incorporate both audiological outcomes and disease progression to guide timely adjustments, such as introduction of hearing aids, or if not appropriate, BC hearing solution counselling and trial, upgrading or transition of implant, e.g., from softband to implant, or revisiting surgical options, ensuring care remains responsive and personalized. A postoperative audiologic assessment should occur ultimately within 12 weeks as a minimum standard for monitoring hearing status. This interval is intended for surveillance of hearing outcomes and does not preclude earlier intervention with non-surgical BC solutions when hearing loss persists. In addition to hearing outcomes and hearing monitoring, the panel suggested that broader functional and quality-of-life impact of hearing loss also should be considered. Hence, monitoring may include both objective measures [36], such as speech perception in noise, and subjective patient-reported outcome measures (PROMs) like the Client-Oriented Scale of Improvement and the Chronic Otitis Media Outcome Test (COMOT-15), which capture patient-perceived benefit and daily challenges that PTA may overlook [37]. While generic PROMs provide valuable overall insight, disease-specific PROMs like COMOT-15 are especially important as they address the unique impact of COM on patients’ quality of life and treatment outcomes.
Systematic patient follow-up and maintaining outcome datasets are vital for continuous quality improvement [38]. Such real-world data provide clinicians with objective insights into outcomes, enabling more responsive evaluation of treatment strategies over time. Beyond supporting individual clinical decisions, such feedback can drive broader improvements in COM care and strengthen the evidence base needed to influence policy change.
The patient perspective also emphasized the importance of hearing assessments and structured follow-up and noted that persistent hearing problems may go unnoticed and become “normalized” in daily life. Ongoing evaluation helps patients feel heard, ensures their hearing rehabilitation remains appropriate, verifies that BC hearing solutions are functioning effectively, and allows timely interventions, such as external sound processor upgrades, when needed. Table 3 outlines treatment recommendations for the third statement [16,37,39-44].
Discussion
This expert opinion paper presents three alignment-driven statements followed by recommendations designed to enhance the hearing treatment pathway and overall care for patients with COM. Effective management of COM requires a shift from the traditional, surgically dominated paradigm toward a more dynamic, patient-centred approach that simultaneously prioritizes hearing outcomes throughout the care continuum. The expert panel emphasized the critical importance of positioning hearing rehabilitation at the core of COM treatment strategies, rather than as an afterthought, through coordinated collaboration between surgeons, audiologists, and the patient.
A key theme emerging from this work was the importance of early treatment with BC hearing solutions in cases of persistent CHL, particularly where tympanoplasty fails to yield satisfactory auditory benefit. Research indicates that patients with COM who underwent primary tympanoplasty but were left with a persistent, clinically significant ABG had an average of 1.6 surgical procedures over a 7-year period, yet achieved minimal to no meaningful hearing improvement [11]. The surgical-first mindset, especially after a failed tympanoplasty, frequently delays appropriate intervention and overlooks the sustained burden of untreated hearing loss, which can significantly impact quality of life, educational attainment, and social participation. To address these gaps, the expert panel advocates for interdisciplinary care pathways that embed systematic hearing and quality of life outcome checkpoints throughout the COM management timeline. Such an approach supports proactive identification of hearing rehabilitation candidates and prevents prolonged auditory deprivation.
Early use of BC hearing solutions not only provides functional benefit but also facilitates informed patient choice, combats stigma through firsthand experience, and lays the groundwork for potential long-term adoption. These devices should not be reserved for end-stage scenarios but introduced earlier, even as interim options during medical management or between surgical interventions. One of the expert panel’s recommendations is for trial use of non-surgical BC hearing solutions as a routine step in pre-operative e assessment of patients with unresolved ABG, especially after failed tympanoplasty. Beyond offering practical experience of BC hearing solutions, such trials can empower patients to make informed decisions, points echoed by Powell, et al. [45], who identified lack of exposure and clinician familiarity as barriers to BCD uptake.
Moreover, ongoing hearing monitoring throughout the COM care pathway is critical to ensure that hearing outcomes remain a central focus alongside disease control. Follow-up should go beyond standard audiograms to include real-world assessments of hearing function, such as speech perception in noise and validated PROMs, to offer a more comprehensive understanding of patient satisfaction and everyday hearing performance. This marks a move away from the traditional focus on PTA toward a more functional and patient-centred approach to evaluating hearing outcomes. Structured, longitudinal assessments allow clinicians to track the effectiveness of interventions over time, make timely modifications, and reinforce patient engagement in their own care. Hence, embedding outcome evaluations at routine intervals in the post-operative pathway could support earlier consideration of BCD, rather than relegating them to last-resort status. Yet, as evidence suggests, such multifaceted follow-up is still uncommon, highlighting the need for changes in clinical practice to support more complete hearing evaluations [37].
The expert panel also emphasized the need for improved communication with patients and caregivers, as many remain unaware of BC hearing solutions until late in their care, if at all. This is partly due to limited awareness or confidence among general healthcare providers to discuss BC hearing solutions as a hearing solution. Closing this awareness gap requires cross-disciplinary education, standardized care pathways, and earlier inclusion of audiological expertise in COM management. Clearer interdisciplinary protocols could reduce these delays and prevent the status quo, in which patients with long-standing hearing deficits remain undertreated for years [13]. Cultural and attitudinal barriers continue to limit BC hearing solution adoption, despite clear evidence of functional benefits, particularly improved speech recognition in patients with significant ABG [20]. This underscores the need to prioritize real-world outcomes and patient-centred care over traditional audiometric benchmarks. From the patient perspective, early identification, timely intervention, personalized device selection, structured follow-up, and addressing individual needs and concerns are all critical to successful hearing rehabilitation. For patients in under-resourced or insurance-restricted settings with high rates of COM and limited access to timely surgery and follow-up [46], BC hearing solutions could offer a viable and accessible alternative for persistent hearing loss. However, challenges such as the high cost of devices, limited availability of trained surgeons and audiologists [46], and lack of public awareness hinder widespread adoption. Pragmatic strategies, such as maximizing access to non-surgical softband trials, implementing structured referral pathways, and leveraging community- or government-supported hearing programs, could help overcome these barriers and facilitate early intervention even where resources are limited.
Conclusion
In conclusion, this expert opinion supports a shift towards earlier integration of BC hearing solutions in the management of COM, emphasizing a dual focus on infection control and hearing rehabilitation. By introducing structured reassessment points and patient-centered outcome measures, the proposed approach aims to reduce prolonged hearing loss, improve quality of life, and minimize the need for repeated surgeries, ultimately promoting more functionally driven and personalized care for COM patients. Future research should focus on comparing hearing outcomes and cost-effectiveness of early BC hearing solution intervention versus revision surgery, identifying predictors for poor surgical outcomes, and assessing the societal impact of improved clinical protocols on referrals and patient outcomes. Global studies are urgently needed to improve access, equity, and early adoption of BC hearing solutions in COM patients. This need underscores a broader shift in clinical practice, from viewing a “safe ear” and a “hearing ear” as sequential objectives to embracing a new standard of care that delivers a safe, dry, and hearing ear simultaneously.
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