Patients Info: Surgical Information: Treatment with Grommets

TREATMENT WITH GROMMETS (MIDDLE –EAR VENTILATION TUBES)

Acute otitis media

Acute otitis media is an infection of the middle ear that can cause pain, fever and an inflamed eardrum. Occasionally the eardrum can burst, resulting in an ear discharge. Often this infection settles down quickly and requires no treatment, but sometimes antibiotic treatment is required.
Fluid in the middle ear that remains after the infection may take weeks or months to resolve.

Recurrent otitis media

Otitis media is “recurrent” when the infection occurs three or more times in six months. Repeated middle ear infections are likely to occur:

  • In children prone to upper respiratory infections
  • When fluid (“glue”) is still present in the middle ear from a previous infection
  • In some child day-care settings
  • Where the Eustachian tube does not function well enough; colds or irritants, such as cigarette smoke, can interfere with its function.

Recurrent acute otitis media has infrequently been associated with some permanent inner-ear hearing loss for high-frequency sounds.

Chronic otitis media with effusion (glue ear)

If otitis media with effusion (accumulation of fluid in the middle ear) has been present for three months or more, the condition is called glue ear. This fluid is often thick and sticky (hence the term “glue”).
Many contributing factors are associated with glue ear, most commonly:

  • poor Eustachian tube function
  • children under the age of three
  • a preceding ear infection
  • the colder seasons
  • structural factors such as a cleft palate.

If the Eustachian tube does not function properly and air cannot adequately enter the middle ear from the back of the nose, then fluid cannot drain down the Eustachian tube. The thick and sticky fluid interferes with the transmission of sound through the middle ear and can cause a mild or moderate hearing loss.
Most cases of glue ear settle down and resolve without medical treatment. However, treatment may be needed if glue ear is present for more than three months and especially if associated with:

  • hearing loss
  • damage to the eardrum
  • damage to the small bones of the middle ear.

In children, on-going glue ear may be associated with a delay in speech development, learning difficulties at school, behavioural problems, frequent earache, and some imbalance.

Complications of persistent glue ear:
Glue ear can cause the eardrum to be thinned and pulled toward the middle ear (retraction pocket). This can lead to damage of the small bones of the middle ear, further impairing the ability to hear.
If the eardrum becomes severely retracted, a “cholesteotoma” may form. A cholesteotoma is an abnormal growth of skin misplaced in the middle ear. It almost always requires surgical removal.
Children tend to grow out of glue ear and acute otitis media. In general, children older than seven or eight years are much less prone to middle ear problems than younger children.

Grommets
Grommets are small tubes about the size of a match head that are placed in the eardrum to help treat recurrent otitis media and glue ear. Also called  “ventilating tubes”, grommets allow air to flow into the middle ear, restoring an equal air pressure between the middle ear and the atmosphere, allowing the “glue” to drain down the Eustachian tube or to be reabsorbed into the tissues. This equalisation of pressure is important for good health and function of the middle ear and Eustachian tube.
Treatment with grommets may be recommended when:

  • Three or more significant ear infections occur within six months, or
  • Glue ear is present for more than 3 months, especially if hearing loss or eardrum damage is present.

Benefits of grommets

Hearing: Grommets improve hearing in most patients with a chronic glue ear that causes a
“ conductive hearing loss” (that is, hearing loss due to impairment of the passage of sound through the middle ear). Restoration of good hearing may be especially important in children with delayed speech development or learning difficulties.

Behaviour of children: Behavioural problems associated with glue ear may be improved by grommet insertion.

Stopping or slowing damage: As a grommet permits air to enter the middle ear and allows a retracted eardrum to return to its normal position, it may prevent further damage to the eardrum and to the small bones of the middle ear.

Decreasing the frequency of infections: In children who have recurrent otitis media, grommets usually decrease the frequency of infection. In some children infections stop completely while grommets are in place.
There is some debate among doctors about whether grommets are used too often. Often, fluid within the middle ear will slowly disappear without surgery or by using antibiotic (and sometimes steroid) treatment. For children six years and older, nasal balloon technique can be tried.
Other doctors believe that, after a reasonable period of observation, the immediate benefits of a grommet fully justify their use. Also, there is increasing concern about the emergence of antibiotic resistant bacteria due to antibiotics that are sometimes taken for as long as three months during non-surgical treatment.

DIAGNOSIS

The surgeon looks into the ear with a light to inspect the eardrum for any problem that may suggest glue ear.
Sometimes a test called a tympanogram is used to determine the middle ear pressure or indicate whether there is fluid in the middle ear.
A hearing test (an audiogram) may be helpful to establish the degree of hearing loss. This test measures the patient’s ability to hear sounds at different pitches and can indicate whether hearing loss is present.
For children seven months to three-and a half years of age, this is often a puppet test (visual reinforcement orientation audiometry or VROA test, which measures hearing in both ears together). For children aged from about three-and-a-half years and older, a pure tone audiogram (PTA) can measure the level of hearing in each ear separately.
Audiometry in young children can be difficult and is not always available, with long delays to schedule a test. Often grommets are inserted first, and then audiometry is done afterwards if suspicion of deafness remains.
A diagnosis of acute or recurrent otitis media or glue ear is based on physical examination, tests, the patient’s medical history and the referring general practitioner’s comments.

BEFORE SURGERY

The surgeon needs to know the patient’s medical history to plan the best treatment. Disclose all health problems your child may have had. Some may interfere with surgery, anaesthesia and aftercare.
Your surgeon needs to know about:

  • Any allergy or bad reaction to antibiotics, anaesthesia drugs or other medicines
  • Any recent or long-term illness or infection.

Give the surgeon a list of ALL medicines being currently or recently taken. Include medicines prescribed by your family doctor and those bought “over the counter” without prescription. Check with your hospital or your surgeon about fasting instructions to be observed on the day of the procedure.

ANAESTHESIA

Children are usually given a short-acting general anaesthetic. If the child has an acute respiratory infection the procedure may be deferred by the anaesthetist.
For adults, the procedure may be performed using a local anaesthetic.
Modern anaesthesia does have some risks (occasionally severe), even though complication rates are low. Ask your anaesthetist for more information.
The anaesthetist needs a list of all the medications the patient is taking or has taken, and any allergies the patient may have had with any anaesthetic.
Inform the anaesthetist about any heart murmur, respiratory disease, or any other medical condition.
It is important to follow fasting instructions.

SURGICAL PLACEMENT OF A GROMMET

Looking through an operating microscope, the surgeon inspects the eardrum and makes a small incision in it about 2 to 3 millimetres long. This is known as myringotomy. Some of the fluid in the middle ear can then be gently suctioned out.

The grommet is placed into the eardrum incision, with a flange sitting either side of the eardrum.

Normally, air ventilates the middle ear by flowing through the Eustachian tube. If the Eustachian tube is not functioning properly , placement of a grommet restores good ventilation so that the thickened and inflamed lining of the middle ear can return to normal. Fluid in the middle ear can then be absorbed into the tissues or drain away.
Grommet placement is a “day stay” procedure, usually taking about 20 to 30 minutes. The child or adult does not feel the grommet sitting in the eardrum.

 

RECOVERY AND CARE AFTER SURGERY

Most patients go home as soon as they have recovered sufficiently from the anaesthetic. They can have a light meal soon after they are awake. Any ear pain is usually mild and pain-relieving medicine is given if required. A clear or blood-tinged discharge from the ear may occur for 1 or 2 days. If necessary, the outer ear can be gently cleaned with cotton wool or a soft cloth. Do not use a cotton bud in the ear canal, as it could be harmful if it goes too far into the ear. Children can usually return to school the day after surgery.

While the grommets are in place, swimming should be on the surface of the water only.. Do not dive without ear protection.
Children with grommets should be able to travel by air without problems. With a grommet in place, the ear is not affected by changes in air pressure.
The surgeon inspects the ears six weeks after surgery.
Follow-up visits are required until the grommet falls out (or“extrudes”), as they are designed to do. The hole in the eardrum gradually heals and pushes the grommet into the ear canal, usually in 6 to 12 months (but sometimes longer than two years). The eardrum usually heals quickly as the grommet falls out. A small scar may be left on the eardrum but does not affect hearing.
The grommet may stick to wax in the outer ear canal and can be removed at a routine visit to the doctor, or it may fall out of the ear canal without being noticed. As a general rule, small grommets stay in for a shorter time, while large grommets, which have a bigger inner flange, stay in longer.
Some children require specialist follow-up for several years.

POSSIBLE COMPLICATIONS OF SURGERY

Risks of treatment with grommet

  • Infection can occur after the operation, especially when there is pus in the middle ear at the time of surgery.. As infection may be anticipated, medication may be used after surgery to decrease the risk of infection. With the grommet in place, the ear should have only a little clear or blood-tinged discharge in the first few days after the operation. If discharge occurs later see a doctor for treatment as it indicates that an ear infection may be present. Some eardrops can harm the middle ear or inner ear if not used as directed by your surgeon.
  • Perforation of the eardrum: In about 2 of every 100 children, the grommet leaves a small hole that does not heal after the grommet comes out. The hole can act like a grommet, ventilating the middle ear and helping to prevent infection and accumulation of fluid. In this case, it is common to wait for the child to outgrow the ear problems. During this time, there might be a mild hearing loss (depending on the size of the hole) and intermittent discharge. An operation to repair the hole (myringoplasty) may be needed when the child is older. This operation is successful in nine children out of 10.
  • An ear discharge due to infection may develop at any time. This may occur after an upper respiratory tract infection. This is usually not serious and typically clears quickly with treatment. Occasionally, the discharge does not respond to treatment by your specialist and the grommet may need to be removed.
  • Recurrence of glue ear or otitis media: After the grommet comes out, the condition may recur because the causes (such as a poorly functioning Eustachian tube) have not resolved. About 20 to 30 of every 100 patients may need to have second grommets inserted. A few children require numerous placements of grommets until the condition clears completely. However, by about the age of ten years, most children will have grown out of their ear problems. Repeated grommet placement may eventually cause thinning of a small part of the eardrum, which may lead to an increased chance of a hole in the drum when the grommet falls out. This may require further surgery to repair it.
  • Tissue around the grommet may become persistently infected, causing polyp formation and bleeding. Antibiotic eardrops may be prescribed. If symptoms persist, the grommet may have to be removed.
  • The hole in the grommet may become blocked, with the grommet becoming non-functional. Replacement of the grommet is needed in some cases.
  • Retention of the grommet:In about 95 patients in 100, the grommet slowly drifts outwards along the ear canal after rejection by the healing eardrum. This usually occurs between 6 and 18 months after surgery. However, occasionally the grommet is retained in the eardrum, and a second operation is needed to remove it. Removal of a retained grommet is usually not done until a few years after insertion.
  • Early displacement of the grommet: This occasionally occurs and may require reinsertion of the grommet.
  • Thinning of the eardrum at the site of the grommet insertion can occur in some patients but usually does not cause a problem. However a thin eardrum may be more easily perforated when under stress, for example, during underwater swimming and diving.
  • Calcium deposits and scarring (tympanosclerosis) of the eardrum can occur due to glue ear, recurrent otitis media or grommets. Tympanosclerosis usually does not affect hearing.
  • Of the many thousands of grommets inserted, only occasional cases have been reported where the grommet has fallen into the middle ear. If the hole in the eardrum heals and the patient has no symptoms, there may be need to remove the grommet.

Risks of not having treatment

Talk to your surgeon regarding your case if you wish to know the risks of choosing not to have the recommended treatment. Due to [persistent fluid in the middle ear, there could be:

    • On-going conductive hearing loss
    • Possibly damage to the eardrum
    • Possibly damage to the bones of hearing (hammer, anvil and stirrup).
    • A few children with frequent recurrent ear infections can develop partial high-frequency hearing loss caused by spread of inflammation to the inner ear. Such damage is permanent.