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 (Otitis Media with Effusion, OME)

In this condition there is a build-up of fluid in the middle ear behind the eardrum, in the absence of infection, and the movement of the ossicles (the bones which transmit sound across the middle ear) and the eardrum itself (the tympanic membrane) is impeded, resulting in a conductive hearing loss.

Around 80% of children may have a mild episode of this prior to their 4th birthday, but most experience spontaneous resolution.  The underlying problem tends to be malfunctioning of the Eustachian tube.  This tube links the middle ear to the back of the nose to equalise pressure across the drum. The “pop” experienced in the ears when swallowing, or sometimes descending on a flight, is a manifestation of the tube opening.  It is less efficient in children and does not reach adult function until generally after the age of 5 – 7.  It also allows potential lateral passage of naso-pharyngeal inflammation or infection which can contribute to glue ear – particularly as the medial opening of the tube bears a very small amount of lymphoid tissue (Erlach’s tonsil) which can then swell and block the tube.  If the tube becomes blocked air is absorbed and 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 posterosuperiorly in the nasopharynx and, if large, can obstruct the medial or inside opening of the Eustachian tube at the Fossa of Rosenmuller.  Adenoidectomy may need to be combined 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; this 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; these include glue ear, secondary smoke inhalation and allergies.

Glue ear can occur in adults, following viral illness resulting in Eustachian tube dysfunction, but does not persist commonly and if this is the case review by an ENT specialist is mandatory to exclude and post-nasal pathology, which can sometime be dangerous untreated. 

Signs or Symptoms of Glue Ear

This problem can cause a hearing loss of 30 – 40dB.  It is not strictly accurate to report this as a percentage, as it is actually a logarithmic scale but it is often described in terms of a 30%+ reduction in hearing acuity.  Glue ear cause problems with vocabulary, pronunciation (frequently!), school progress, integration, awareness, concentration and occasionally temper tantrums, balance and coordination problems.

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.

Long term Eustachian tube problems can be associated with thinning and atrophy of the drum head, even “adhesive otitis media”, where the drum remnant is adherent to the medial wall of the middle ear and can partially or completely obliterate the middle ear space.  This occurs due to a loss of tensile strength of the middle (fibrous) layer of the eardrum.  It must be said that grommet insertion cannot be guaranteed to prevent long-term drumhead complications; some feel that the procedure offers no protection against such problems but should be considered solely as offering the opportunity to correct the associated conductive hearing loss, and that only for the duration of the ventilation tube remaining in the drumhead. 

Diagnosis and Management

Concerns about a child’s hearing, vocabulary, pronunciation, school progress (or even ear infections in the case of recurrent acute otitis media) may give rise to referral and 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 a 3 month period.  A hearing aid may be prescribed as a temporary measure pending a decision about the necessity or not for surgery.  Other managements can include a trial of a steroid nasal spray or use of a nasal balloon to attempt to inflate the Eustachian tube.  The National Institute for Health and Clinical Excellence (NICE) have published helpful guidelines for the management of glue ear: www.nice.org.uk

The commonest test is a pure tone audiogram, if the child is old enough and able to cooperate with this, to assess hearing levels.  A tympanogram is an objective test  (which requires cooperation), performed to identify the presence of fluid behind the eardrum.

Grommets

A grommet is a very small silicon tube which sits in the eardrum, being inserted through a very small incision in the drum performed under an operating microscope.  The procedure is a myringotomy, performed under general anaesthesia and is usually a day case.  A grommets looks like a small cotton reel that sits in the eardrum and allows air into the ear cavity or middle ear to equalise pressure across the eardrum and also permits any fluid to drain away that may have built up.  It is necessary to attend the Outpatient Clinic at regular intervals until the grommets have been seen to extrude, hopefully accompanied by healing of the drum and return of hearing (as tested by an audiogram) to normal.

Grommets do not cure the underlying problem but alleviate the symptoms of hearing loss and can also be useful to reduce frequency and severity of recurrent acute middle ear 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 they may not be seen to extrude.

A small proportion of children may develop an intermittent discharge which has an unpleasant smell and 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.

A child may go return to school as soon as he/she is well enough and has recovered from the general anaesthetic or as the consultant has indicated.  Generally it is recommended to take the day off after surgery, also considering that there may be some residual effect from the general anaesthetic for up to 24 hours post-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.  The presence of Down’s Syndrome, Cleft Palate, immune deficiency syndromes, sinusitis, adenoiditis or passive smoke inhalation increases the risk of recurrence of glue ear and the possible need to reinsert grommets.  A small proportion of children may ultimately require reinsertion of grommets even without these co-morbidities – occasionally up to 3 sets may be required and – very rarely – long-term ventilation tubes, although these are generally best avoided because of a higher rate of residual tympanic perforation.

Children now are allowed to swim with grommets in-situ 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 best avoided.  However, most children are able to swim satisfactorily without any added problems.  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!

Complications can include a persistent hole in the eardrum after the grommet extrudes; this will require prolonged follow-up and can rarely need a future grafting procedure (myringoplasty).  There is a possibility of post-operative ear infection which can manifest as a discharge, sometimes with an unpleasant smell, which can require topical antibiotics (ear drops).

Adenoids

If the adenoids are large, they can block the medial opening of the Eustachian Tube, which then impairs 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, such that they may become less of a problem after the age of 5 to 7.

If adenoids are removed then often this also performed as a day case procedure but occasionally overnight stay will be suggested.  There is a small risk of primary bleeding (within in the first 24 – 48 hours after surgery) or secondary bleeding (typically at around 7 – 10 days after surgery) which may require re-attendance to a hospital although such bleeding is unusual.  Primary bleeding should not occur in more than 1% of cases and secondary bleeding in less than 10% of cases.

In the event of any post-operative bleeding of concern it is best to attend the A and E department of your nearest hospital or ENT department.