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.

Talk to your surgeon

This transcript provides general information about myringoplasty. It is not a substitute for advice from your surgeon. Read it carefully. Some terms may require further explanation by your surgeon. Write down questions you want to ask.
Although patients should be as informed as possible about the surgery, every aspect cannot be covered in this transcript. With your surgeon, discuss diagnosis, non-surgical treatment options, and the benefits, risks and limitations of surgery.
If you are uncertain about the advice you are given, you are encouraged to seek the opinion of another specialist. This transcript should only be used in consultation with your surgeon.

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 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.

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.