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2256 pages added, reviewed or updated during the last month (last updated: 21/4/2021)


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grommets

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The function of a grommet is to ventilate the middle ear, rather than drain it. Grommets thus replace the function of the blocked eustachian tube in glue ear and improve hearing.

Post-operatively the ear should be kept dry and any further discharge mopped up and treated with antibiotic/steroid drops. If discharge continues another referral may be required.

There is controversy about swimming and other activities in the period before the grommet falls out - research seems to suggest that bathwater is the worst culprit.

The grommet will extrude after a variable period - 6 to 18 months. Repeated insertion may be necessary as 1 in 5 children requiring surgical treatment.

A horse shoe shaped thickening and calcification of the drum may follow grommet insertion, though this rarely causes hearing loss.

NICE suggest that the persistence of bilateral otitis media with effusion (OME) and hearing loss should be confirmed over a period of 3 months before intervention is considered. The child's hearing should be re-tested at the end of this time:

  • during the active observation period, advice on educational and behavioural strategies to minimise the effects of the hearing loss should be offered
  • children who will benefit from surgical intervention
    • children with persistent bilateral OME documented over a period of 3 months with a hearing level in the better ear of 25-30 dBHL or worse averaged at 0.5, 1, 2 and 4 kHz (or equivalent dBA where dBHL not available) should be considered for surgical intervention
    • exceptionally, healthcare professionals should consider surgical intervention in children with persistent bilateral OME with a hearing loss less than 25-30 dBHL where the impact of the hearing loss on a child's developmental, social or educational status is judged to be significant
    • once a decision has been taken to offer surgical intervention for OME in children, the insertion of ventilation tubes is recommended. Adjuvant adenoidectomy is not recommended in the absence of persistent and/or frequent upper respiratory tract symptoms
    • children who have undergone insertion of ventilation tubes for OME should be followed up and their hearing should be re-assessed.

Notes:

  • study evidence however suggests that the role of grommets in the management of glue ear is unclear.
    • a systematic review concerning the use of grommets in glue ear (otitis media with effusion) concluded that the benefits of grommets in children appear small (2)
      • the effect of grommets on hearing diminished during the first year
      • potentially adverse effects on the tympanic membrane are common after grommet insertion
        • ears treated with grommets had an additional risk for tympanosclerosis of 0.33 (95% CI 0.21 to 0.45) one to five years later
      • the authors recommended that an initial period of watchful waiting seems to be an appropriate management strategy for most children with otitis media with effusion
    • a study showed that, in infants and toddlers with persistent middle ear infusion, prompt insertion of tympanostomy tubes was not more effective than delayed insertion for developmental outcomes at 9-11 years (3)
        • this study provides further evidence to show that a conservative wait-and-see approach will give the best outcome in children <= 3 years of age, avoiding unnecessary operations

Reference:

  1. NICE (February 2008). Surgical management of otitis media with effusion in children
  2. Lous J et al. Grommets (ventilation tubes) for hearing loss associated with otitis media with effusion in children. Cochrane Database Syst Rev 2005; (1): CD001801
  3. Paradise JL et al.Tympanostomy tubes and developmental outcomes at 9 to 11 years of age. N Engl J Med. 2007 Jan 18;356(3):248-61.

Last reviewed 01/2018

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