Background: Secretory otitis media (SOM) is a pathologic condition of the middle ear in which an effusion is present behind an intact ear drum without signs of acute inflammation. Untreated cases might end in serious consequences as permanent anatomical abnormalities within middle ear cleft. Diagnosis of SOM depends mainly on audiological evaluation. Tympanometry is perhaps the most useful of all tests association with SOM. Despite of high sensitivity of tympanometry in diagnosis of SOM, many cases with type “B” Tympanogram found no middle ear fluid. The Objectives of the work were to study cases with type “B” Tympanograms without middle ear effusion, clinically, ways of treatment and outcome and to compare it with the classic types of SOM. Methods: This study was conducted in El-Helal hospital, Sohag. Diagnosis of SOM was done after detailed history, Otoscopic examination, pure tone audiometry and tympanometry. All patients (200) under this study were initially treated by medical therapy. In case of failure of medical treatment, myringotomy with ventilation tubes insertion were applied in different types of SOM under the study (group without effusion, with thick mucoid fluid and lastly with thin serous fluid) and myringotomy without application of ventilation tubes was applied to 10 patients in group of otitis media without effusion as a control. Follow up was carried out for all groups at one, six, and twelve months after the operation. Results: This study included 200 patients with SOM, 126 were males (63%) and 74 were females (37%). The majority of the patients (177) were between 5-8 years (88.5%). Patients were initially given medical treatment and followed up by tympanometry and pure tone audiometry. Out of 200 patients, 55 patients (27.5%) improved and 145 patients (72.5%) had no response and underwent surgery. From 145 patients with persistent SOM, 42 patients (28.9%) had no middle ear effusion during myringotomy, from this group 10 patients were taken as a control group and underwent myringotomy alone without application of ventilation tubes and 32 patients myringotomy with ventilation tubes were inserted. Conclusions: Surgery is the treatment of choice in resistant cases and ventilation tubes should be applied even in absence of middle ear effusion in all cases with type “B” Tympanograms with conductive hearing loss.