Grommets (Ventilation tubes)

The relevant anatomy of the ear

The middle ear is connected to the back of the nose by the Eustachian (pronounced you-
stay-shun) tube. This tube helps to maintain an equal pressure inside and outside the
middle ear, and so allows the eardrum to vibrate efficiently.

The tube opens to allow the pressure equalise in the middle ear space. This may cause the
click or pop which can experience when swallowing, or when flying. These pops are
evidence of a working Eustachian tube.

If the Eustachian tube does not work properly or is blocked by inflammation, the air in the
middle ear is absorbed but cannot be replaced. This causes the air pressure in the middle
ear to be less than the air pressure in the ear canal.
The negative pressure (partial vacuum) in the middle ear causes the eardrum becomes
progressively more indrawn and eventually the body responds by filling the space with fluid
to protect the eardrum and middle ear contents. This is the common condition called glue
ear.

Glue ear is very common in children younger than 6 years old, but it dissipates
spontaneously in the majority of cases, usually within three months. The longer fluid
remains trapped there though, the thicker egg white like and more tenacious the
secretions become, and spontaneous resolution becomes less likely.

Grommets (Ventilation tubes)

Grommets are tiny little plastic tubes, which are inserted into the Tympanic Membrane
eardrum.
The grommet does the work that the poorly functioning Eustachian tube should be doing.
Therefore ventilating aerating the middle ear, reducing secretions, allowing better eardrum
vibration function and giving the middle ear a chance to recover from infections.
In America grommets are simply known as ventilation tubes.


A grommet is seen in the eardrum


Grommets are used for one of three main reasons:

1)Persistent middle ear effusions, or fluid trapped behind the eardrum glue ear. This may
cause considerable hearing loss deafness, and sometimes earache and slight imbalance.
2)Recurrent otitis media middle ear infections. These are painful recurrent ear infections,
which may be accompanied by a high temperature, poor appetite and general lethargy.
3)The (very unusual) case where the vacuum in the middle ear threatens to damage the
eardrum or the contents of the middle ear. (Picture below)



A permanently damaged eardrum, known as end-stage adhesive otitis media
What causes these ear problems?

Something about the working of the Eustachian tube is very commonly amiss in children up
to about the age of 7. We are not certain what the cause is despite huge amount of
research.

Sometimes the cause is adenoiditis, with enlargement and infection of the adenoids causing
obstruction of the Eustachian tube (a tube like structure that connects the middle ear to the
back of the nose/upper throat).

Rare causes include sinusitis, cleft palate, immune deficiencies and bottle-feeding. Parental
smoking is also a potent cause of both acute and chronic ear problems in young children.

Grommet insertion surgery

This is a quick (10-15 min) procedure usually performed under general anaesthesia. In
adults, who are not considered suitable for general anaesthesia, grommet insertion may be
performed under local anaesthesia (a special anaesthetic cream in the ear) with little
discomfort.
This is a day case procedure and patients usually go home on the same day.
A microscope is used to visualise the tympanic membrane eardrum.
A tiny slit cut is made in the eardrum (myringotomy). Fluid glue within ear is drained by
suction. A grommet is then inserted through the hole made in the eardrum to keep middle
ear ventilated and healthy.
In a child, if adenoids are enlarged and the child is having the second or third sets of
grommets inserted, the surgeon may also remove the adenoids.

Complications of the grommet surgery

This is a relatively safe operation, however no surgery is totally free of any risk.

1) Infection- grommet may cause ear infection and even rarely be significant enough to
require the removal of the grommet. However it is usually is to treat with antibiotics.

2) Persistent eardrum perforation- most grommets fall out of ears spontaneously after an
average of 9 months. When they do, most eardrums heal up, by scarring however in about
2% of patients, the eardrum fails to heal or leave a smaller residual perforation hole. Some
of these patients may require a further operation in future to repair the remaining hole, of
course only if it causes any problem.
You should discuss with your surgeon about possible alternatives to surgery
Expectations and advice following grommet insertion surgery

This is usually a day case surgery, but if other procedures need to be carried out as well
(e.g. tonsillectomy) an overnight stay may be required in some cases.

A follow up appointment will be arranged for about 6 weeks after surgery.

Avoid getting water into the ears as this may easily cause infection in the ears. This applies
to showers, bathing, washing hair as well as swimming. Swimming is only permitted after
the follow-up appointment has given the all clear. Avoid diving with a grommet in the ear.
Earplugs must be used for all these activities. Alternatively, cotton wool heavily smeared
with Vaseline is an excellent and sometimes more comfortable alternative.

You may get a bloodstained discharge after the surgery for couple of days.

If ear discharge persists, smells foul or there is increased pain seek help as this suggests
infection and treatment with antibiotic eardrops will be required.

Pain is normally fairly minimal and can be controlled with simple painkillers.

Avoid poking of ear buds, matches, keys or a dirty finger. This can introduce infection.
Clean ear with a damp cloth around the outside.

Grommets usually fall out of ear in about 9 months. They spontaneously grow out and are
ejected by the eardrum and therefore very rarely have to be removed. Usually they fall out
of the ear and may be found on the pillow upon awaking. The eardrum usually heals up
where the grommet was sited.

If your grommet falls out early do not panic. You do not need to contact your doctor
immediately. You should continue keeping your ear waterproof and attend the outpatient
clinic as planned.

Sometimes (20%- 25% chance) repeat sets of grommets are needed if the fluid re-
accumulates. A hearing test will indicate if this is the case. The older a child gets, the less
likely this will be. In a way, grommets buy time by maintaining hearing and preventing
serious eardrum damage until the child is older when the Eustachian tube function often
starts working properly, and fluid does not readily recur.

Do not drive for 48 hours (because of the effect of the general anaesthetic).

Flying is allowed.

We advise at least 24 hours off school/work. If adenoids and/or tonsils have been
removed longer will be required.


In case of Emergency...

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Whilst every effort has been made to ensure that the information contained on this
website is accurate you should always discuss the risks, limitations and
complications of your specific operation with the relevant surgeon.

Mr Behrad Elmiyeh MRCS DO-HNS
What are grommets?
Grommets, also called tympanostomy or ventilation tubes, are tiny plastic tubes
which are inserted into a small slit in your child's ear drum in a short operation.

You can see how tiny a grommet is when it's placed on an adult finger, or next to a
millimetre ruler.



The following diagram and photo show a grommet in place in an ear drum. (The diagram uses the terms ear tubes and tympanostomy tubes to refer to grommets). See Acknowledgements.



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How do grommets work?
Grommets maintain normal middle ear pressure by allowing air into the space
on the other side of the ear drum, from the outside. This reduces the risk of
fluid building up in that space. If an ear infection does occur, the resultant pus
flows out through the grommet, limiting the pain your child suffers. If your
child develops an ear infection with grommets in place, your doctor can use
topical treatments (such as prescribed ear drops which are put directly into the
ear) rather then oral antibiotics. Studies have shown that topical treatments are
more effective than oral antibiotics in treating discharging ears.

Grommets are a temporary measure and will buy time until hopefully your
child's Eustachian tubes grow to a sufficient size to work naturally. The
Eustachian tubes connect the space behind the ear drum (middle ear) of each
ear to the back of the nose. (See Who gets ear infections? for an explanation
about why children's Eustachian tubes don't work as well as in older children
and adults).

Most grommets usually stay in place for about six to 18 months and come out
by themselves.

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When might my child need grommets?
Grommets may be recommended for glue ear that won't clear up or for frequent
episodes of acute middle ear infections; as a general guideline, if your child has
had:
middle ear fluid (glue ear) for more than three months, depending on the
degree of hearing loss
six acute ear infections in one year, especially if the infections have occurred in
both ears
repeat infections through the summer months, when such infections should be
less likely to occur
previous complications because of ear infections
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How successful is the operation?
With grommets in place, any hearing loss caused by the pre-existing fluid in
the space behind the ear drum will be reversed.

Parents often report a better quality of life for their children after grommet
insertion with better sleeping and overall behaviour.

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Who will perform the operation?
A specialist ENT (ear nose and throat) surgeon (also known as an
otolaryngologist or ORL surgeon) will perform the operation.

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What happens to my child during the
operation?
your child will require a brief general anaesthetic
a small slit is made in the drum and the grommet is inserted into this
the surgery usually takes about ten to 15 minutes
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How long will my child need to be in hospital
after the operation?
When your child has recovered and is wide-awake, they are usually allowed to
go home. This is often an hour or so after the operation.

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What can my child expect after the operation?
There is not usually any pain in the ears after grommet insertion. Although your
child may be a little unsettled at first, they are usually back to normal after a
few hours. They can usually return to school the following day.

Many parents notice an immediate improvement in their child's hearing.
Travelling home with hands over ears because of the loud noises is not
uncommon.

Some children will have discharge from their ears after grommets have been
inserted. This is not usually painful and is usually treated with ear drops. See
your family doctor if this happens. If your child's ear discharge continues, your
family doctor may send your child to an ear nurse specialist or ENT specialist.

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Are any precautions necessary once my child
has grommets in place?
Doctors vary in their recommendations about ear protection for your child in
water (when swimming, shampooing, showering and bathing). Some children
get ear infections and resultant discharge. Ask your surgeon about this at the
time of the operation. You can also discuss this with your family doctor or ear
nurse.

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Will my child need to have repeat surgery?
Some children continue to have ear problems (glue ear and / or recurrent ear
infections) once the grommets come out. They may require a further set(s) of
grommets.

Sometimes removal of the adenoids is recommended. There is some evidence
that removing the adenoids is helpful in those children who require a second or
subsequent grommet insertion. The adenoids sit at the end of the Eustachian
tubes at the back of the nose and can block the tubes if they become swollen.

See:
Tonsillectomy and adenoidectomy on this website
What does the inside of the ear look like? for a diagram which includes
adenoids (bottom right corner of the diagram)
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What are the possible complications?
A grommet may occasionally block. If this happens, your child will need ear
drops to help clear it.

A small number of children may have persistent or frequently recurring
discharge from their ears.

A small but significant risk exists of a persisting hole in the eardrum after the
grommets come out. If this happens, an operation to repair the hole may be
necessary when your child is older, usually around eight to ten years of age.

In a small number of children, grommets may not come out by themselves
within three years. If this is the case, your child may need a further brief general
anaesthetic to remove the grommets. The decision to remove working
grommets must be weighed up against the possible risk of the return of ear
infections and glue ear. You can discuss this with your family doctor and / or
ear specialist.

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When should I seek help?
See your family doctor or ear nurse if your child has any discharge from their
ears. Your family doctor may take a swab. This will identify any potential
bacterial cause for the discharge so that your child can receive targeted
treatment - usually ear drops.

Some areas have mobile children's ear clinics which visit schools and early
childhood education centres. If your area has a mobile clinic, you could also
talk to the ear nurse specialists who staff these. They are specially trained to
diagnose, treat, monitor and refer for children with middle ear problems.

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Where to go for more information
On this website
Ear infections - brief version or detailed version
Glue ear - brief version or detailed version
Hearing and vision tests, a section in the fact sheet Well Child / Tamariki Ora
services for under fives

The National Foundation for the Deaf Inc (NFD) www.nfd.org.nz
See the NFD website for:
Your child's speech and hearing milestones
- See more at: http://www.kidshealth.org.nz/grommets-
tympanostomy-or-ventilation-tubes#sthash.QNfpd5cM.dpuf
Myringoplasty/ Tympanoplasty
Myringoplasty is an operation carried out to repair a chronic (non-healing) hole in the
eardrum.

A hole in the eardrum may lead to repeated ear infections with pain, discharge and hearing
loss. If this is the case, surgery is recommended to close the perforation and put and end to
these infections.


PERFORATED EAR DRUM


REPAIRED EAR DRUM FOLLOWING MYRINGOPLASTY

Aims of the surgery

1) Prevent recurrent ear infections.

2) Improve hearing, if there is a conductive hearing loss due to eardrum perforation.

3) Enable patients to swim or get ear wet without facing infection as a consequence.
Myringoplasty surgery

The operation is performed under general anaesthesia, and it usually takes about 1-2
hours. It involves taking a layer of scalp fascia usually behind ear in the hairline to use as
a graft. This graft is then slipped behind the drum to cover the perforation.
There are two approaches to the eardrum. One is the approach to the eardrum through the
ear canal endaural approach. The second approach is to make an incision cut behind the
ear and flipping it forward post-auricular approach.
This is decided depending on the site and the type of the eardrum perforation, the reason
for the surgery and surgeons preference.
At the end of the surgery, the ear is packed with special ribbons.

Complications of Myringoplasty

1) Infection- it could potentially cause graft failure and therefore failure to heal the eardrum.

2) Bleeding- very unlikely, however small bloodstained discharged can be expected within
the first couple of days after the surgery.

3) Graft failure- graft success can be as high as 80%. However the success rate varies
depending on many factors such as the indication for surgery, the size and the site of
perforation, presence of chronic infection and general patients health e.g. diabetic.

4) Hearing loss- this is very rare, but potentially with any ear surgery there is small risk of
deteriorating the hearing rather than improving it.

Expectations and Advice following Myringoplasty/ Tympanoplasty surgery

You may wake up with a head bandage around your head. If so, this will be removed the
following day.

You can go home the day after the surgery or later the same day.

There will be some packing inside your ear. Do not remove any pack from your ear.

The ear pack must be removed within 2-3 weeks. You should have an outpatient
appointment before the end of this period.

Do expect sensations of ear blockage and pressure while having the pack in your ear.

Do expect mild dizziness/ instability of balance.

You may have a small bloodstained discharge ooze in the first 24-48 hrs.

Do not expect any improvement in hearing before the ear pack is removed or even the first
few weeks after packs are removed.

There should be no increase in pain, discharge or bleeding.

Avoid getting water on the wound or in the ear.

Off work/ school for about 10 days. A sick note will be provided.

Please contact your GP during the working hours or contact the hospital where the surgery
took place for any further advice or assistance.

Trauma to a nose may cause a shift of the nasal bones. This may cause an obvious
deformity of the nose bent nose and some degree of nasal blockage.
It is best to reassess the situation about a week after the injury, when most of the swelling
has settled.
Fractured nasal bones heal about 2-3 weeks following trauma. There is more chance of a
successful manipulation (moving) the fractured nasal bones back to the original position in
the second week following the injury.
The aim of the surgery is to correct the nasal deformity back to its original shape and
improve the nasal blockage symptom caused by the fracture.




MUA (Manipulation Under Anaesthesia) of fractured nose - The Surgery

The procedure is usually performed under general anaesthesia. It involves manipulation or
pushing and slipping of the nasal bones back to their original position.
On occasions, the surgeon may use surgical instruments in order to improve the cosmetic
result or to correct nasal septal nose partition deformity.

Complications of MUA of fractured nose

There are rarely significant surgical complications.
1) Bleeding- There is a small risk of bleeding if there is a need to use surgical instruments.
Even then, only a small minority of patients may require any form of nasal packing.

2) Infection- a very rare complication. Even then, more likely if there is also a laceration or a
cut to the skin of the nose.
3) Nasal deformity- there may be a remnant deformity or even no cosmetic improvement
after the operation. This is more likely if there has been any previous nasal trauma or
surgery.
Expectations and advice following surgery

Correction of your nasal deformity is more likely if the surgery is performed before the
bones heal and if the deformity is significant in the first place.

There may be a splint or a plaster placed on the nose if the bones appear unstable after
the operation. If so, this is usually removed at the clinic after 1 week to 10 days.

You may get a small blood stained nasal discharge for 10 days

Avoid contact sports or nose injury for 6 weeks.

Do not drive for 48 hours (because of the effect of the general anaesthetic).

You may return to work/school the day after the surgery.

The swelling/bruising will settle slowly over 6 weeks after the surgery. If you are not
satisfied with the outcome of your surgery, after this time, please contact your GP. If your
GP feels appropriate, we will review the situation in the ENT outpatient department.
If appropriate, you may then be offered a relatively more significant surgery such as
rhinoplasty or septorhi nopl asty to improve the appearance and function of your nose.