Healthy Child, Happy Family

Grommet surgery (as a treatment for Glue Ear)

Grommets are little tubes that are inserted into the ear drums to attain a more normal air flow behind the ear drum to equalise pressure and encourage fluid to drain. This is usually done under general anaesthetic in children and is a treatment most often used in the case of glue ear that has not resolved with time and/or antibiotic treatment. Glue Ear – as discussed in an earlier post – is a common childhood disorder involving a build up of thick fluid behind the ear drum and can affect one or both ears. It is the major cause of transient hearing problems in young children (1). My little boy underwent this surgery at 1 year old (on his first birthday, mean Mummy!) after glue ear being reported by our Gp at 3 separate visits followed by an ear infection that required 3 courses of antibiotics to clear. The hearing test done by the ENT surgeon’s office showed moderate hearing loss at only 9 months old.

Guidelines on when to see a specialist from the American Academy of Paediatrics and the American Academy of Otolaryngology (ENT physicians) are:

  1. If your child has three or more infections prior to six months of age.
  2. If your child has four infections in six months or
  3. If your child has six or more infections in a year.
  4. If your child has fluid that lasts more than three months with associated hearing loss.
  5. If your child has signs of significant hearing loss.
  6. If your child has delayed speech (2).

 

The decision to insert grommets as a treatment for unresolved glue ear/recurrent ear infections is one that should be made in consultation with an ENT surgeon after a full assessment of the child and their medical history and is usually offered after the child has had glue ear that has not responded to antibiotics or fluid that will not clear after an appropriate amount of time (more than 3 months in most cases) with/without infection. As chronic fluid behind the ear drum can cause hearing loss, a hearing test is usually conducted during the assessment and the result of this can be a factor in the treatment offered, particularly if there are associated speech delays (2). The insertion of grommets, and the resulting drainage of fluid from behind the ear drum, can reverse any hearing loss suffered and, as a result, assist to correct any speech delay, although Speech therapy may still be required. (A list of Speech therapists in Metro WA can be found here).

Insertion of grommet surgery can be done as a public or private patient but the process is much the same regardless.

Grommets are inserted under general anaesthetic in children and this will require a day stay in hospital or a private clinic with hospital-grade facilities.The anaesthetic required for Grommet insertion is very quick, often only 5-10 minutes, and usually having a ‘drip’ put in for IV fluids is not necessary (2). Unfortunately there is still a need for your child to fast for 6 hours in preparation for the anaesthetic, this can make for a very grumpy child! Each hospital or clinic will have their own guidelines around fasting for an operation and you will be informed of these in your letter to inform you of the date and time of admission, most letters will also state the last times that your child can eat or drink on the day of admission.

On the day of admission the nurse assigned to look after you and your child will check information such as the child’s name, date of birth, address etc as well as allergies, medical problems, medications and record ‘baseline observations’ such as heart rate, blood pressure, respiratory rate, temperature and weight. He/she will also tell you what to expect during your stay and answer any questions you may have. The anaesthetist will visit pre-operatively to speak with you and your child in order to make sure that your child is healthy and well that day – for example no fever – to record any allergies, medical problems or medications and to explain the risks that are associated with any anaesthetic. Your doctor, or one of the ENT team, will also speak with you and your child prior to surgery to answer any questions and ask you to sign a consent form, if this has not been done previously.

When it is time for your child to go for surgery, you and your child will be escorted to the anaesthetic room, just outside the operating theatre. More often than not, one parent will be allowed in to the anaesthetic room with your child (this does differ from site to site but is not dependent on whether you are a private or public patient at a public hospital). The reason that only one parents is allowed is due to space and safety. Once in the anaesthetic room, the staff in the room will explain to you and your child what they are doing, such as attaching a monitor to record oxygen saturations/heart rate and blood pressure cuff. This can be quite frightening for your child so it is important that you as the parent can remain calm in order to calm your child. When a child is having surgery, particularly one as quick as Grommet insertion, a gas induction is used to anaesthetise the child. This will involve a mask being put over the child’s mouth and nose to inhale the anaesthetic gas, which will sometimes smell of strawberries, until they fall in to a sleep-like state. It is not uncommon for children to make some jerking movements when this is happening. If you have a young child being anaesthetised, you will often be able to hold them on your lap while this is being commenced. once the anaesthetist is happy that they are ‘asleep’ they will help put your child on the bed, ask you to give your child a quick kiss and you will then be escorted out to the waiting area. Procedures within the anaesthetic room will vary depending on anaesthetist.

The insertion of Grommets itself involves a small hole being made in the ear drum, usually of both ears, and the grommet (tube) is inserted in to the hole through which the air will flow.

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The ear drum will heal around the grommet and they normally fall out within 6-12 months. Antibiotic ear drops or oral antibiotics are prescribed post-op to reduce the incidence of infection and there can be a risk of a perforated ear drum (3).

Once the surgery has been completed, your child will be taken to a recovery area to wake up, one parent will be escorted in to that area once your child is awake and once the recovery nurse is happy, you and your child will be taken back to the ward area. The length of time until your child can be discharged will depend on the hospital/clinic you are at. Often your child will need to stay anywhere from 1-4 hours post op and will need to drink/eat and may be required to pass urine prior to discharge.

Occasionally there will be  a need to remove Adenoids (a lymph node at the back of the throat that, when enlarged can contribute to glue ear by blocking the eustachian tubes(2)) at the same time as inserting Grommets, this will call for a longer post-op stay in hospital but is usually still a day stay surgery. Care upon discharge is also slightly different when Adenoids are removed.

Care of a child post grommet insertion will involve ensuring that adequate pain relief, such as Panadol or Nurofen, is given, usually for 1-2 days post op as your child may have earache. There may be oozing of fluid or a small amount of blood from the ear(s) for 1-2 days. This is normal and will resolve itself. It is okay to clean any discharge from the outer ear but nothing should be put inside the ear (3). More specific instructions will be given by the clinic/hospital upon discharge.

Your child will need to avoid getting water inside the ear(s) while the grommets are in (3). They can still have baths/wash hair/swim with the help of ear plugs. These can be in the form of cotton wool covered in vaseline inserted into the outer ear – this is best used for bathing rather than swimming. Putty-like ear plugs can be bought from most pharmacies and are best used with a special headband to prevent them falling out while in the water. These are also available from the PMH shop (Princess Margaret Hospital) and online from sites like Littlegrommets.

In most cases a follow up appointment with your surgeon or ENT team as an outpatient will be required approximately 6 weeks post surgery and a hearing test will be conducted if there was hearing loss prior to surgery.

A review of previous research in to the effectiveness of grommets on resolving chronic effusion (fluid), lasting more than 3 months and associated with hearing loss, found that the benefit gained from having grommets lasted approximately 6 months post surgery but that the effect diminished after that time. Glue ear has often resolved itself by this time if a wait and see approach has been taken. No evidence could be found to show a benefit to speech and language development but no study has been performed in children with established speech, language, learning or developmental problems (1).

Anyone interested in taking part in research into why some children suffer from recurrent or chronic ear infections can help Telethon Kids Institute in their Family study of Ear infections or through the

Dornase Alpha Study:
The Telethon Kids Institute will trial the use of Dornase alfa (Pulmozyme®) medication which is commonly used in cystic fibrosis patients. The medication is administered in the ear at the time of grommet insertion to see if it breaks down the sticky “glue” in the middle ear and if it increases the effectiveness of antibiotic drops used for children with chronic and recurrent middle ear infections. Taking part in the study will help us to determine if this treatment will work to reduce the number of complications following grommet surgery and ultimately if it can prevent the need for grommet reinsertion.

Children between 6 months and 5 years of age who are in general good health and undergoing their first grommet insertion for otitis media and has had fluid in both ears for 3 months or longer.

CONTACT
Vaccine Trials Group
Phone: 9340 8542
Email: vtg@telethonkids.org.au
Website: vaccine.telethonkids.org.au

1) Grommets (ventilation tubes) for hearing loss associated with otitis media with effusion in children. Browning, Rovers, Williamson, et al (2010). Retrieved 2015 from http://onlinelibrary.wiley.com/doi/10.1002/14651858.CD001801.pub3/abstract

2) Otitis media (ear infections) and complications. Perth ENT centre 2015. Retrieved 2015 from http://www.entkids.com.au/education

3) Treatment of glue ear with grommets. Great Ormond Street Hospital, London, UK, 2014. Retrieved 2015 from http://www.gosh.nhs.uk/medical-information/procedures-and-treatments/treatment-of-glue-ear-with-grommets/

 

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