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.     

Audit of the incidence of persistent perforation of the tympanic membrane following grommet removal or extrusion

The incidence of persistent perforation following grommet removal or extrusion in 210 ears was assessed, and found to be zero per cent. Collar button grommets were retained longer than Shepard grommets, and the percentage of ears requiring two or more tube insertions was 51.9 per cent.     

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 .     

Hearing loss due to mannosidosis and otitis media with effusion. A case report and review of audiological assessments in children with otitis media with effusion

A case of a child with mannosidosis and bilateral otitis media with effusion (OME) is reported here along with some discussion of relevant literature to emphasize the need for age appropriate audiometric assessment before and after insertion of grommets for glue ear (OME). There is a need for multidisciplinary teamwork in the management of children with hearing loss. If OME is treated surgically, age-appropriate hearing assessment is required before and after insertion of grommets. The need for audiological assessments will be relevant even if children had passed the newborn hearing screening test.     

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.     

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.     

Accurate consent for insertion and later removal of grommets

Each year in the UK over 30,000 patients undergo insertion of grommets. The grommet insertion may cause many problems like persistent otorrhoea, scarred drum, retraction pockets and retention. The grommets may be extruded from the middle ears by the normal epithelial migration mechanism once they have served their purpose. These may become infected and require removal. We have analysed the Department of Health Hospital Episode Statistics relating to the insertion and removal of grommets (ventilation tubes). We have shown that 7.6 per cent of patients who have grommets inserted will have grommets removed.     

Short-term benefits of grommet insertion in children

It is commonly acknowledged that otitis media with effusion (OME) can cause behavioural disturbances and that this can be relieved by grommet insertion. However, this widely-held perception has not been documented in the literature. In this study parents were asked to complete a short behavioural questionnaire on the day of the admission and 6 weeks later. A total of 32 children admitted to the Day Care Unit for insertion of grommets at The Royal National Throat, Nose and Ear Hospital, London, UK, were recruited. There was a significant behavioural change, evident by the difference in the scores before and after grommet insertion (P < 0.001).     

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.     

Three-year follow-up (1983-1986) of children undergoing bilateral grommet insertion in Sheffield

A retrospective study with review, after 3 years, of 43 children between the ages of 4 and 13 years, who had bilateral otitis media with effusion treated surgically purely by the insertion of grommets is described. The results shows that the younger the child at initial grommet insertion, the greater the likelihood of more than 1 grommet insertion being required (P less than 0.05). A younger patient is likely to make a greater number of outpatient visits (P less than 0.05), and the number of outpatient visits correlates with the number of grommets inserted (P less than 0.01). At 3 years, 49% of children remained on regular outpatient follow-up, while 34% of children had persisting effusion in 1 or more ears. Whilst grommets are in place, otorrhoea is not adversely influenced by swimming. The role of adenoidectomy in the management of otitis media with effusion is not assessed by this study.     

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.     

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.     

Adult-onset otitis media with effusion: results following ventilation tube insertion.

The outcome of otitis media with effusion (OME) in children is generally good. However, it is less clear in adults. All adult patients who had a ventilation tube inserted for OME at the Ipswich Hospital between 1996 and 1997 were studied. Of 53 patients studied, 28 had had a previous history of ventilation tube insertion. Furthermore, at 15-27 months following ventilation tube insertion, the ventilation tube had already extruded in 31 patients and the OME had already recurred in 19 of these. Endoscopic examination revealed that many patients still had evidence of inflammation at the lateral nasal wall (26.4 per cent) and at the eustachian tube orifice (51 per cent). There is also a strong history of atopy in the studied group and the skin prick test was positive in 57 per cent of the patients. This study shows that many patients with adult-onset OME have underlying pathology that could lead to recurrence of OME following ventilation tube extrusion.     

Otitis media with effusion: a study of 346 cases in an outpatient clinic

We treated 346 patients with otitis media with effusion (OME) and 30 (127 episodes) with recurrent acute suppurative otitis media at our outpatient clinic in the 6 years from October 1994 to September 2000. Of these, children under 15 years old numbered 185, mostly boys at a ratio of 1.4: 1.0, while patients aged 15 years or older numbered 161, mostly females at a ratio of 1.3: 1.0. In children, 24 were excluded due to a lack of diagnostic follow-up, 65 (40%) patients improved in conservative management of medication with and without repeated tubal inflation, 79 (49%) improved by paracentesis, and 18 (11%) recovered with the use of pressure equalization tubes (grommets). Of cases aged 15 years or older, follow-up was not possible in 28. Three (2%) were free of OME by conservative treatment, 116 (87%) improved by paracentesis, and 9 (7%) by using tubes. The mean durations of tube insertion was 11.3 months in children and 7.2 months in adults, but 5 adults (4%) continue being treated of this writing. Bilateral cases were 30% of children and 8% of adults with 73% of children affected bilaterally having persistence or recurrence. Acute purulent otitis media progressed to OME in 22% of children but only in 3% of patients aged 15 or older. In 36% of children and 26% of patients aged 15 or older, acute upper respiratory tract infection coincided with or predisposed to OME. Rhinosinusitis was seen in 19% of children and 14% of adults. Coincident allergic rhinitis was seen in 14% of children and 12% of adults with OME. Nasopharyngeal infection and allergy are likely related to OME development. The peak incidence of OME was similar to that of recurrent suppurative otitis media in children, so a seminal precipitating factor appears to result in these 2 conditions.     

Three-year follow-up (1983–1986) of children undergoing bilateral grommet insertion in Sheffield

A retrospective study with review, after 3 years, of 43 children between the ages of 4 and 13 years, who had bilateral otitis media with effusion treated surgically purely by the insertion of grommets is described. The results shows that the younger the child at initial grommet insertion, the greater the likelihood of more than 1 grommet insertion being required (P < 0.05). A younger patient is likely to make a greater number of outpatient visits (P < 0.05), and the number of outpatient visits correlates with the number of grommets inserted (P < 0.01). At 3 years, 49% of children remained on regular outpatient follow-up, while 34% of children had persisting effusion in 1 or more ears. Whilst grommets are in place, otorrhoea is not adversely influenced by swimming. The role of adenoidectomy in the management of otitis media with effusion is not assessed by this study.     

Timing for removal of tympanic ventilation tube in children

The medical records of 220 ears of 137 pediatric patients (85 male and 52 female) in which three kinds of ventilation tubes were inserted for treating otitis media with effusion (OME) were reviewed. The tubes selected were the Shepard grommet (75 ears), Goode-T (39 ears), and Paparella type II tube (106 ears). The criteria for tube placement were as follows: (1) continuous conductive hearing loss with over 25 dB air-bone gap, (2) resistance to conservative therapy for over 6 months, and (3) retracted and glue-colored tympanic membrane with type B tympanogram. The tubes that remained in place for over 18–24 months were removed intentionally in combination with a freshening of the perforation edge and tape-patch technique using Steri-Strip™ tape (3M) for preventing permanent eardrum perforation, because the incidence of persistent perforation became higher after long-term intubation. Shepard grommets tended to be extruded earlier, while Paparella type II tubes tended to stay longer. The OME recurrence rate decreased 12 months or more after tubal insertion. There was a tendency for the recurrence rate to decrease the longer the tube stayed in the eardrum. The number of recurrences decreased when the patient's age at the tube removal or extrusion was 7–8 years old. Adenoidectomy did not influence the recurrence rate of OME. Although the Goode-T and Paparella tube II tubes showed high perforation rates, the perforation rate after extrusion or removal of the tube was decreased by the use of the tape patch technique in combination with a freshening of the perforation edge. From these findings, it was concluded that the appropriate intubation period for the treatment of OME in children is over 12 months with the use of a long-term tube, and that if the patient's age at the time of tube insertion was below 6 years, it might be better that the removal of the tube is postponed until the patient is 8 years of age.     

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.

     

Goode T-tubes: do the benefits of their use outweigh their complications?

In this retrospective study of 130 ears over a 5-year period, the effect of intubation with the Goode T-tube was evaluated. The tubes improved the hearing in 86% of ears with a conductive loss secondary to a middle ear effusion to an average 5 dB airbone gap. They improved the early stage retracted tympanic membrane but had no effect on the established postero-superior retraction pocket. They were successful in treating barotrauma. The main complication with their use was otorrhoea which occurred in 28% of ears, and persistent perforation occurring in 6% of the ears. Seventy-seven per cent of tubes were in place after 36 months. Extrusion was significantly related to infection in the ear, and also to the presence of glue on insertion but there was no correlation between the number of previous grommets or the age of the patient. The Goode T-tube is advocated for use in middle ear effusion refractory to conventional grommet insertion or that due to cleft palate.     

Otitis media with effusion: treatment by autoinflammation using a balloon

Resolution of negative middle ear pressure is important in treating otitis media with effusion (OME). We treated 34 children and 21 adults with OME by autoinflammation using a nose tube and balloon in the 16 months from June 2001 to September 2002. Of these, 7 children and 5 adults had been treated for 3 years or longer, and had had grommets inserted. In 49 ears of 27 early cases of children, 34 ears (69%) improved in tympanometric findings converting to type A from type B, C2 and C5, and 9 ears (18%) of type B converted to type C1. In 23 ears of 16 early cases of adults, 12 ears (52%) improved converting to type A from type B, C2, C5 and C1, and 3 ears (13%) to type C1 from type B. However, 4 ears of 4 children and 5 ears of 5 adults did not recover by autoinflammation. In 7 children with prolonged OME in whom grommets had been inserted, 5 recovered due to autoinflammation, whereas only one of 5 adults recovered. Of 6 patients who had not recovered, 2 were associated with asthma and nasal polyposis and eosinophils infiltrated into the middle ear effusion. In other 2 patients, even when the middle ear effusion disappeared by grommets insertion, they had still dysfunction of the Eustachian tubes confirmed by sonotubometric examination. It seems no beneficial effects of autoinflammation were maintained if patients had tubal dysfunction due to intensive inflammatory changes of the middle ear and tubal mucosa or other unknown origin. Two patients used the device irregularly and rarely. There is a theoretical risk associated with this maneuver of causing baroinjury and forcing infected nasopharyngeal secretions into the middle ear, but we found no complications.     

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.