tympanostomy tubes (grommets) in recurrent acute otitis media

Last edited 09/2023 and last reviewed 11/2023

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 (1).

• consider grommets for the management of OME-related hearing loss in children (2)
• when planning grommets for management of OME, consider adjuvant adenoidectomy unless assessment indicates an abnormality with the palate (2)
• perform a postoperative hearing test 6 weeks after surgery for OME, and (2):
  • if the hearing loss has resolved, discharge and:
    • advise parents and carers to seek a reassessment by the audiology service involved in their child's care if they are concerned about a possible recurrence of OME-related hearing loss at a later date or
    • consider a 1-year follow up with a hearing test if there are concerns a potential recurrence of hearing loss could be missed or
    • consider an individualised follow-up plan if the child has an increased risk of unrecognised OME with hearing loss (for example, children with a learning disability or craniofacial anomalies)
    • if there continues to be hearing loss, this needs to be investigated

Notes:

• a systematic review with respect to grommets in OME suggests (3):
  • review found that in children with bilateral glue ear that had not resolved after a period of 12 weeks and was associated with a documented hearing loss, the beneficial effect of grommets on hearing was present at six months but diminished thereafter
    • in children with OME the effect of grommets on hearing, as measured by standard tests, appears small and diminishes after six to nine months by which time natural resolution also leads to improved hearing in the non-surgically treated children
      • tympanosclerosis was seen in about a third of ears that received grommets
      • otorrhoea was common in infants, but in older children (three to seven years) occurred in < 2%of grommet ears over two years of follow up
• use of tympanostomy tubes in children with recurrent otitis media
• randomly assigned children 6 to 35 months of age who had had at least three episodes of acute otitis media within 6 months, or at least four episodes within 12 months with at least one episode within the preceding 6 months, to either undergo tympanostomy-tube placement or receive medical management involving episodic antimicrobial treatment
• in intention-to-treat analysis (n=250; age 6-35 months), the rate of episodes of acute otitis media during a 2-year period was not significantly lower with tympanostomy-tube placement than with medical management (involving episodic antimicrobial treatment) (mean 1.48 vs 1.56 episodes per child/year, respectively; p=0.66) (4)
  • editorial (5) notes that although frequency of episodes of acute otitis media was similar in the two groups, a significant difference was observed in a per-protocol analysis (1.47 vs. 1.72, respectively), and it might be expected that qualitatively the episodes of acute otitis media were substantially different between the two groups. It adds that despite this, the results of this trial are very useful for shared decision making with caregivers; they can be informed that:
    • the present course of medical management may be continued with no greater likelihood of antimicrobial resistance than if a surgical option is selected.
    • in a child older than 2 years of age, it is predicted that infections will be fewer in the coming year and that medical treatment should be continued.
    • in the younger child, there is a nearly 50% likelihood that the frequency of infections will continue; the child is likely to have fewer and less severe episodes of acute otitis media with less exposure to antibiotics if tympanostomy-tube placement is undertaken, with only occasional development of persistent otorrhoea.

Reference:

1. NICE (February 2008). Surgical management of otitis media with effusion in children
2. NICE (August 2023).Otitis media with effusion in under 12s .
3. Browning GG, Rovers MM, Williamson I, Lous J, Burton MJ. Grommets (ventilation tubes) for hearing loss associated with otitis media with effusion in children. Cochrane Database of Systematic Reviews 2010, Issue 10. Art. No.: CD001801. DOI: 10.1002/14651858.CD001801.pub3.
4. Hoberman A et al. Tympanostomy Tubes or Medical Management for Recurrent Acute Otitis Media.N Engl J Med 2021; 384:1789-1799
5. Wald ER. Management of Recurrent Acute Otitis Media. N Engl J Med 2021; 384:1859-1860