Ear drops and grommets

The relative ease with which different ear drops pass through grommets of different designs has been investigated using a laboratory model. The viscosities of the various ear drop preparations tested have also been determined. There is a considerable variation in the volume of ear drops required to penetrate ventilation tubes. Their ease of passage is determined by the size of the tube and is probably also related to the ease with which a preparation wets the surface of the grommet. There is no relationship between ease of penetration and viscosity. The penetration of ear drops through grommets during episodes of aural discharge was studied in vivo. Penetration into the middle ear was observed only when the drops were introduced using the displacement technique. It was more readily achieved when the grommet lumen was free of discharge.     

Titanium grommets: a trial to assess function and extrusion rates

Titanium grommets have been promoted as having the advantage of a slower extrusion rate than other types of ventilation tube. A prospective trial was therefore designed to compare the function and extrusion rates of these grommets with those of the widely used Shepard design of Teflon grommet in a single group of patients. Thirty-one children had one type of grommet inserted in one ear and the other type in the opposite ear. After eight months there were significantly more Titanium grommets still functioning (p less than 0.05) but after 12 and after 16 months there was no significant difference in the extrusion rates of the two types of grommet. There was a higher incidence of infection with granulation tissue formation around the Titanium grommet. Accordingly it is concluded that the extra expense of the Titanium grommet is not justified, particularly as the long-term effects of these grommets on the tympanic membrane are not known.     

Grommets versus paracentesis in secretory otitis media. A prospective, controlled study

One hundred and ninety-three consecutive children with bilateral secretory otitis media were treated by adenoidectomy, bilateral paracentesis, and evacuation of middle ear effusion, but with insertion of a grommet in the right ear only. At follow-up one to three years later, the audiometric and tympanometric results were similar in right and left ears. The primary advantage of grommet insertion was normalization of the hearing ability for as long as the grommet was functioning. Thus, only 1% of the ears with grommets had hearing losses exceeding 30 dB HL, whereas this occurred in about 20% of ears without grommets. The adverse effects of grommet insertion included periodic aural discharge during the functioning period of the grommet in 14% and tympanosclerosis of the drum in 48%. In the group of ears treated with paracentesis only, tympanosclerosis occurred in 10%. However, reinsertion of grommets was indicated in 10% of right ears, and 23% of left ears required grommets as well. Of the various pre- and perioperative factors analyzed, only a granulating mucous membrane and copious middle ear effusion could be correlated to frequent and protracted episodes of secretory otitis that required repeated treatment. The implications of these findings are discussed.     

Unilateral grommet insertion and adenoidectomy in bilateral secretory otitis media: preliminary report of the results in 91 children.

This study evaluates whether the use of grommets in the primary treatment really changes the course of secretory otitis media. The patient acts as his own control. Bilateral cases are selected and one ear is treated by a grommet, the other left intact, and all have their adenoids removed. Until now 91 children have been entered. A repeated operation was done in 13, and 6 of them had a contralateral grommet because of persisting middle ear effusion. A discharge occured from 25% of the operated ears. After the operation the intact ear showed a great improvement in the function of the Eustachian tube according to the tympanograms. The hearing level was normalized within 3 months in both intact and operated ears. In 28 children the grommets had been extruded for more than one month. By comparing the intact and the operated ears no significant statistical difference was found.     

Grommets and cholesteatoma in children

Cholesteatoma in children may be a sequel to chronic exudative otitis media with tympanic membrane retraction but the role of grommets in the possible facilitation of squamous epithelial invasion into the middle ear is not yet clear. A retrospective study was made of the history and prior treatment in 25 children who underwent mastoidectomy for cholesteatoma at St. Mary's Hospital between 1975 and 1986. Thirteen patients had undergone previous middle ear aeration procedures which included myringotomy, cortical mastoidectomy and grommets. There was no difference in the site or severity of cholesteatoma in the operated and non-operated cases. Of the seven patients with a history of multiple grommets three had primarily attic, and three had primarily mesotympanic disease. The latter had greater ossicular erosion. One patient with an intact tympanic membrane had grommet insertion subsequently developed a cholesteatoma. While cholesteatoma due directly to the presence of grommets is rare, it appears that children who require multiple grommet insertions constitute a high risk group and should be very closely monitored.     

Unilateral grommet insertion and adenoidectomy in bilateral secretory otitis media: preliminary report of the results in 91 children

This study evaluates whether the use of grommets in the primary treatment really changes the course of secretory otitis media. The patient acts as his own control. Bilateral cases are selected and one ear is treated by a grommet, the other left intact, and all have their adenoids removed. Until now 91 children have been entered. A repeated operation was done in 13, and 6 of them had a contralateral grommet because of persisting middle ear effusion. A discharge occurred from 25% of the operated ears. After the operation the intact ears showed a great improvement in the function of the Eustachian tube according to the tympanograms. The hearing level was normalized within 3 months in both intact and operated ears. In 28 children the grommets had been extruded for more than one month. By comparing the intact and the operated ears no significant statistical difference was found.     

Grommet insertion: some basic questions answered

A very large number of grommets are inserted to improve middle ear ventilation in children. A retrospective survey of 1011 admissions for myringotomy and/or grommet insertion has been used to answer some basic questions about such admissions and the fate of grommets inserted. No attempt has been made to assess the benefits of this mode of treatment. The average number of admissions per child was 1.6, with 64% being admitted only once. A child aged 3-4 years when first listed had the greatest chance of repeated admissions. Nearly 50% of the grommets had been extruded within 6 months and 80% within 1 year. Children put on the waiting list because of middle ear effusions present in summer months had a greater chance of spontaneous resolution in the subsequent few months than those listed in winter months. Significant complications occurred in 2.2% of grommet insertions.     

Management of hearing loss in Apert syndrome

BACKGROUND: Apert syndrome is one of the craniosynostosis syndromes, with a birth prevalence estimated to be between 9.9 and 15.5/million, and accounts for 4.5 per cent of craniosynostoses. Although conductive hearing loss is common in Apert syndrome there are contradicting reports regarding the cause of this hearing loss. There is also no detailed information available on the management of hearing loss in Apert syndrome. MATERIALS AND METHODS: A retrospective analysis of case notes of Apert syndrome patients seen between 1970 and 2003 at Great Ormond Street Children's Hospital, London, was undertaken. RESULTS: Seventy case notes were obtained. The incidence of congenital hearing impairment was between 3 and 6 per cent. Almost all patients had otitis media with effusion (glue ear), which tended to persist into adult life. More than 56 per cent of cases developed permanent conductive hearing loss by 10-20 years. Repeated grommet insertion was common; even though 35 per cent had trouble with ear discharge and persistent conductive hearing loss. Statistically, grommets made no difference to the risk of developing permanent hearing loss. CONCLUSION: This study, of the largest number of Apert syndrome cases assembled to date, showed that early optimization of hearing with possible hearing aids needs to be considered. Repeated grommet insertion does not help in optimizing hearing, especially if ear discharge complicates the picture.     

A comparison of audiometric performance and complications of T tubes and Shepard grommets

Since T tubes were introduced in 1972 their use in cases of chronic Eustachian-tubal insufficiency has been reported on several occasions, (Goode, 1973, 1983; Rothera and Grant, 1985). T tubes remain in-situ for longer than grommets, and they are frequently used in cases where multiple grommet insertions have failed to provide adequate middle ear ventilation. They have also been used when prolonged Eustachian-tubal insufficiency is anticipated, for instance in children with cleft palate. Shepard grommets continue to be the most commonly used type of ventilating tube for short-term use and a significant proportion of children with glue ear require repeated insertions. In an attempt to reduce the need for repeated myringotomy, and also to reduce the need for adenoidectomy in children with glue ear, it has been the recent practice of one Consultant (K.S.M.) to use T tubes routinely in all cases of glue ear. This study analyses the audiometric performance and complications of 32 children (60 ears) who underwent myringotomy and insertion of T tubes for glue ear. In all cases no previous treatment for glue ear had been undertaken. The results are compared with those of a control group who underwent myringotomy with insertion of Shepard grommets and adenoidectomy as a first-line treatment.     

The prognostic significance of the air volume in the middle ear for the tendency to recurrence of secretory middle ear condition

The incidence of recurrence of secretory middle ear conditions (SMEC) in the course of the first 3 months after extrusion of a grommet was evaluated in 172 tubulated patients in relation to a number of background variables in a stepwise logistic regression analysis. The background variables were: treatment period, 3-month period (season) of extrusion, sex, age, air volume in the middle ear, diagnosis (unilateral/bilateral, suppurative/non-suppurative and consequently antibiotics), other treatment apart from a grommet (paracentesis and/or adenoidectomy), and a history of allergy. There was a definite correlation between the incidence of recurrence and the air volume in the middle ear, as determined by physical volume test, after correction for age, recurrences being most common in ears with a small middle ear volume. In addition, there was a relationship, but not as marked, between the incidence of recurrence and age after correction for the middle ear volume, recurrences being less common in older patients. None of the other background variables played a statistically significant role when correction was made for age and middle ear volume. It is recommended to practise an expectant therapeutic strategy in SMEC in order to eliminate cases with spontaneous remission. In the event of recurrence, a more liberal reinsertion of grommets is recommended for patients with small middle ear volumes, while in those with larger volumes a different aetiology should possibly be considered.     

The use of perioperative Sofradex eardrops in preventing tympanostomy tube blockage: a prospective double-blinded randomized-controlled trial

Around 11-12% of tympanostomy tubes are reported to become blocked by middle ear secretions or blood immediately following surgery, and so no longer function. Many otologists routinely instil an antibiotic and steroid-containing solution at the time of surgery in the belief that this may reduce this complication. The aim of the study was to investigate the efficacy of instilling the antibiotic and steroid-containing solution Sofradex at the time of grommet insertion in preventing grommet blockage. Double-blind randomized-controlled trial, comparing rates of grommet blockage in ears treated with Sofradex drops against control (no drops) in patients undergoing bilateral grommet insertion. Sixty-one pairs of results were obtained. There was a significant difference between the rates of grommet blockage in the two groups. Grommets with Sofradex drops instilled perioperatively were nine times less likely to be blocked than controls [1.6%versus 13.1%, odds ratio (Sofradex/control) = 9.06, 95% confidence interval (CI): 1.04-78.82, P = 0.05]. There was no association between grommet blockage and perioperative bleeding or the nature and presence of middle ear secretions. Sofradex eardrops are effective in reducing the rate of grommet blockage when instilled perioperatively.     

Long-term Paparella II grommet use in the management of persistent childhood otitis media: a 5-year follow-up study

A comprehensive 5-year follow-up study of Paparella grommet use in UK. Study group consists of children previously treated with short-term grommets and with persistent glue ear. Mean functional period was 3.73 years with 52% being retainde for the full 5 year duration of the study. Infection and perforation rates increased with the duration of grommet in-situ and this was especially marked after 36 months. We advise the elective removal of these long-term grommets after 3 years of function to reduce compication rate.     

A 15 year follow-up of a controlled trial of the use of grommets in glue ear

The long-term natural history of secretory otitis media and the changes induced in the middle ear following grommet insertion are of importance. We report the results 15 years following the unilateral insertion of a Shepard grommet and adenoidectomy for bilateral secretory otitis media. The results suggest that grommets do not protect against attic disease of late onset and induce atrophic scars which do not resolve. Grommets confer no long-term advantages to the hearing when used in the management of childhood secretory otitis media.     

The clinical management of otorrhoea following grommet insertion: a survey of otolaryngologists and general practitioners

A postal questionnaire of all Consultant Otolaryngologists in the British Isles, and of General Practitioners within the local family practitioner committee area, was designed to compare the current practice in the management of discharge from the ear following grommet insertion. 76% of the Otolaryngologists and 52% of the General Practitioners completed the questionnaire. Between the two groups, statistically significant differences were apparent in the management of this common complication of grommet surgery. A higher proportion of Consultants took a bacteriology swab of the ear as part of their treatment, which was significantly more frequently treated by antibiotic ear drops. Within the Consultant group, significant regional variations in choice of drugs and therefore the cost of treatment were apparent. The General Practitioners more commonly prescribed oral antibiotics. This common complication of grommet surgery is managed differently by General Practitioners and Otolaryngologists without a firm rational basis. Treatment based on current knowledge is discussed. Further evaluation of the efficacy of different treatment regimens by controlled prospective trials is required.     

The use of perioperative Sofradex® eardrops in preventing tympanostomy tube blockage: a prospective double‐blinded randomized‐controlled trial

Around 11–12% of tympanostomy tubes are reported to become blocked by middle ear secretions or blood immediately following surgery, and so no longer function. Many otologists routinely instil an antibiotic and steroid‐containing solution at the time of surgery in the belief that this may reduce this complication. The aim of the study was to investigate the efficacy of instilling the antibiotic and steroid‐containing solution Sofradex^® at the time of grommet insertion in preventing grommet blockage. Double‐blind randomized‐controlled trial, comparing rates of grommet blockage in ears treated with Sofradex^® drops against control (no drops) in patients undergoing bilateral grommet insertion. Sixty‐one pairs of results were obtained. There was a significant difference between the rates of grommet blockage in the two groups. Grommets with Sofradex^® drops instilled perioperatively were nine times less likely to be blocked than controls [1.6%versus 13.1%, odds ratio (Sofradex^®/control) = 9.06, 95% confidence interval (CI): 1.04–78.82, P = 0.05]. There was no association between grommet blockage and perioperative bleeding or the nature and presence of middle ear secretions. Sofradex^® eardrops are effective in reducing the rate of grommet blockage when instilled perioperatively.     

Otitis media with effusion: An audit on the indications and outcome

One of the reasons for the variation in the number of grommet insertions amongst different hospitals could be that the indications for surgery differ amongst them. Even ENT surgeons within the same hospital may have different criteria for grommet insertion. Definitive criteria for grommet insertion in children with Otitis media with effusion (OME) were established in 1995 at the Ipswich Hospital NHS Trust. A subsequent audit was performed on children with grommets inserted between 1995 and 1996 to assess whether the indications for surgery fell within the defined disappointment were analysed. the result of the audit shows that 240 out of 245 children who grommet insertion met the preset criteria. Seventy-five percent of the children noticed an improvement of hearing at the 6 months review. The overall percentabge of children with improvement of their speech, education and behaviour was 41.6%, 33% and 20.4% respectively. Forty-seven percent of the children also noticed a reduction in the frequency of acute otitismedia. On the whole 78.5% of the parents were pleased with the operation at the 6 month review. The main reason for disappointment at 6% months was grommet extrusion or the grommet acting as a source of discharge. An erratum to this article is available at .     

Treatment of secretory otitis and pneumatization

In 33 children, median age 4 years, with bilateral secretory otitis, adenoidectomy was performed, a grommet was inserted in the right ear, and paracentesis was done on the left side. Seven years postoperatively x-rays were taken of the children's mastoid cell systems and these were measured by planimetry. A significantly larger cell system was found on the side with grommets, which is considered to support the environmental theory of pneumatization.     

Does passive smoking affect the outcome of grommet insertion in children?

Bilateral myringotomy with insertion of ventilation tube (grommet) is the most common surgical procedure done on children under general anaesthetic. A prospective study was conducted on children undergoing grommet insertion to ascertain any relationship between exposures of passive smoking to the outcome of grommet insertion. Six hundred and six children (with 1174 ears) who underwent grommet insertion for recurrent secretory otitis media were followed up till the grommets were extruded. Thirty-three children (65 per cent), whose mothers smoked when they were pregnant, had bilateral narrow external ear canals. The median survival rate of grommet was 59 weeks in children who were exposed to passive smoking as compared to 86 weeks for non-exposed children and the extrusion rate of grommet was 36 per cent higher at the end of one year if both parents smoked compared to the non-smoking group. Post-extrusion myringosclerosis was 64 per cent if both parents smoked and less than 20 per cent if neither parents smoked. It is concluded that post-operative infection rate, attic retraction, post-extrusion myringosclerosis and permanent perforations of tympanic membrane were more common in children exposed to passive smoking. The study provides further support to professional and governmental advice that passive smoking is harmful.     

Medial displacement of grommets: an unwanted sequel of grommet insertion

Grommet insertion is one of the commonest surgical procedures performed in the UK. We have come across three cases in which grommets have displaced medially in the middle ear after establishing a satisfactory post-insertion position. We suggest that an abnormally long myringotomy incision and improper placement of the grommet are responsible for this unwanted outcome.     

Late ear sequelae in cleft palate patients

This retrospective study looks at the incidence and nature of ear disease in 50 adolescent patients who had cleft palates repaired in infancy. Half of these patients had a history of grommet insertion. We found that most patients had normal hearing (81%) and middle-ear pressures (86%), although about half had tympanic membrane abnormalities. Grommet insertion did not result in better long-term hearing in this study but was strongly associated with tympanosclerosis. Cleft type did not influence the degree of ear disease although more patients with complete clefts had a history of repeated grommet insertion. Otitis media with effusion is almost universal in cleft palate infants and may influence later language, speech and educational development. At the time of palatal repair grommets should be inserted to improve hearing in these infants.