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Vincent Cumberworth BSc FRCS Consultant Ear,
Nose and Throat Surgeon
Clementine Churchill Hospital Sudbury Hill Harrow Middlesex HA1 3RX
Private Secretary: Tel: 020 8872 3866 Fax: 0208872
3861
Information is supplied only upon the condition that the viewer
will make their own determination as to the suitability of the
information for its purposes prior to use. There will be no
responsibility for information that is misused or misinterpreted and
the information should not be used as a substitute for consultation
with a health care professional. It is not possible to answer
questions regarding individual cases or to enter into individual
correspondence.
Glue Ear
This refers to a build-up of fluid in the middle ear behind the
eardrum and consequently can impede the movement of the ossicles,
the bones which transmit sound across the middle ear.
Around 80% of children may have a mild episode of this prior to
their 4th birthday, but usually these problems resolve. The
underlying problem tends to be the functioning of the Eustachian
tube. This is a tube which links the middle ear, from the inside, to
the eardrum to the back of the nose to equalise pressure across the
drum. It is less efficient in children and does not require adult
function until generally after the age of 5 – 7. It also allows
potential upwards passage of naso-pharyngeal inflammation or
infection which contributes to glue ear, particularly as the medial,
inside, opening of the tube has a very small amount of lymphoid
tissue in it (Erlach’s tonsil) which can then swell and block the
tube. If the tube becomes blocked, then the air is absorbed and
ultimately fluid is secreted, possibly aided by a change in the
actual cell type in the middle ear so that more fluid is produced.
After the age of 5 – 7 the adenoids also tend to shrink; this is
lymphoid tissue, like the tonsils, which is situated at the back of
the nasopharynx on the roof and, if large, can obstruct the medial
or inside opening of the Eustachian tube. Sometimes these may need
to be removed in combination with grommet insertion if they are
large.
In addition to natural reduction of the adenoids, there is also
benefit from growth of the skull base, which also helps aeration and
contributes to the improvement in Eustachian tube function.
Other conditions may affect the function of the Eustachian tube, and
hence increase the risk of middle ear problems such as glue ear,
include secondary smoke inhalation and allergies.
Signs or Symptoms of Glue Ear
This problem can cause a hearing loss of 30 – 40dB. It is not
strictly accurate to talk of this as a percentage, as it is actually
a logarithmic scale but it is often talked about a 30%+ reduction in
hearing acuity. Can cause problems with vocabulary, pronunciation,
school progress, integration and awareness, concentration and even
occasional temper tantrums.
If there is also recurrent acute otitis media, there may be
intermittent pain and even discharge from the ear if the infection
perforates through the drum.
Diagnosis and Management
The problem may be detected by hearing screening, school or
community doctors and general practitioners and may require referral
to an ENT Specialist. In many cases the problem will settle of its
own accord and “watchful waiting”, sometimes over a period of around
3 months, can reduce the number of children undergoing ventilation
tube insertion. There is no proven efficacy for any medical
treatment but certainly a significant number will resolve
spontaneously over around a 3 month period.
The common test may be an audiogram, if the child is old enough and
able to cooperate with this, to assess hearing levels. A tympanogram
is an objective test (which does require cooperation) which can be
performed to see if there is the presence of fluid behind the
eardrum.
Grommets
A grommet is a very small silicon tube which fits in the eardrum,
being inserted through a very small incision in the drum performed
under an operating microscope, a procedure called a myringotomy,
under general anaesthesia and usually as a day case. Grommets look
like small cotton reels that sit in the eardrum and allow air into
the ear cavity or middle ear to equalise pressure across the
eardrum. They also let any fluid drain away that may have built up.
You will need to attend the Outpatient Clinic at regular intervals
until we have seen that the grommets have fallen out.
They do not cure the underlying problem but alleviate the symptoms
of hearing loss and can also be useful to reduce frequency and
severity of infections. The grommets typically stay in for a period
of 6 – 18 months and extrude naturally. It is unusual for them to
require surgical removal; they are so small that you may not see
them fall out.
A small proportion of children may develop an intermittent discharge
which generally responds well to antibiotic drops. There is also a
small risk of a permanent perforation in the drum, in the region of
around 1%. If this is the case, it is possible to get occasional
discharge from the ear but this may still heal at a later stage when
the function of the Eustachian Tube improves and enables better
ventilation and pressure equalisation across the eardrum.
Your child may go back to school as soon as he/she is well enough
and has recovered from the general anaesthetic or as your consultant
has indicated. Generally it is recommended to take the day off after
surgery.
Usually hearing improvement is either immediate or at least soon
afterwards and for most children who do require grommet insertion,
it is unlikely that re-insertion will be required.
Children now are allowed to swim but it is preferable for them to
wait until they have had their first review after surgery. A degree
of water precautions involving wearing a swimming cap or even a plug
in the ear can be helpful and certainly diving or swimming under
water is to be avoided. However, most children are able to swim
satisfactorily without any added problems at all. When washing hair,
a small plug of cotton wool smeared with Vaseline in the ear canal
may be beneficial.
It is absolutely fine to fly in an aeroplane with grommets fitted;
indeed this will help pressure equalise across the eardrum better!
Adenoids
If the adenoids are large, they can block the inside opening of
the Eustachian Tube, which is the means of ventilation of the middle
ear. Occasionally they can also act as a focus of infection for the
middle ear, with infection ascending the tube. Often, however, they
may reduce in size in relation to the post-nasal space such that
they may become less of a problem after the age of 5 to 7.
If adenoids are removed then often this also is a day case procedure
but occasionally overnight stay will be suggested. There is a small
risk of primary bleeding, bleeding can occur in the first 24 – 48
hours after surgery or secondary bleeding at around 7 – 10 days
after adenoidectomy which may require re-attendance to a hospital
although such bleeding is unusual and not occur in more than 1% of
cases.
© Vincent Cumberworth 2005 |
