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Recurrent middle ear infection and grommets

Infant and Children | January 14, 2015 | Author: The Super Pharmacist

Children, ENT

Recurrent middle ear infection and grommets

Middle ear infections are divided into two categories: those that occur in the external ear canal (otitis externa), and those which occur in the middle ear (otitis media). Ear infections are most prevalent in young children, primarily as a result of natural development: as they grow older and bigger, the gap between the Eustachian tube (the tube linking the pharynx to the middle ear) and the pharynx itself becomes narrower. Increased coughing and sneezing closes it shut, causing the build up of fluid and infection. As such, ear infections most commonly follow a cold or flu in young children, and are more prevalent in the winter months. It is estimated that almost 70% of children will experience otitis media before the age of three, with many experience recurrent infection (1).

The most common form of infection is known colloquially as ‘glue ear’, where the space that is usually filled with air in the middle ear is instead filled with an effusion (fluid), impacting on the ability to hear. Glue ear does occur in adults, although it is far less common than in children. As such, the majority of literature and treatment guidelines that do exist regarding infections and grommets are focused on younger children.

Grommets as a treatment option

Grommets are often considered as a last resort for patients who experience persistent middle ear infections that do not respond to any other treatment methods.

Before seeking formal medical treatment, many people first try a decongestant to clear their glue ear, such as pseudophedrine or oxymetazoline, which are widely available as over the counter medications. However, there is very little evidence to suggest that such decongestants are effective in the treatment of glue ear, as the majority of cases will clear without any medical intervention.

A systematic review of randomised controlled trials comparing decongestants with placebo treatments showed no discernible different in symptom relief after they had been administered (2).

Similarly, there is no evidence to support the use of oral steroids, nasal steroids or antihistamines to alleviate the symptoms of middle ear infections (3). A further systematic review of twelve medical databases revealed no controlled studies in regards to what constitutes the best medical treatment for adults with middle ear infections, largely due to it being both a rare medical occurrence and an under researched area (4).

Whilst it is suggested that the repeated use of antibiotics for recurrent glue ear is a beneficial treatment, there does not appear to be much formal evidence to support this course of action. This is largely due to the fact that the majority of middle ear infections are viral.

Grommets are recommended if glue ear doesn’t go away, or someone experiences repeated bouts of glue ear and hearing loss in both ears that significantly impacts on their day to day life. The odds of glue ear getting better by itself are lower in people who have Down’s syndrome or a cleft palate, in which case grommets will often be considered earlier than usual (5).

There are a number of other options offered alongside grommets such as hearing aids, removal of the adenoids and laser surgery of the eardrum. However, grommets are the preferred first line treatment for persistent ear infections. Most guidelines recommend grommets in the following circumstances (6):

  • Chronic infection with persistent effusion (fluid) for six months in one ear or three months in both ears
  • Ongoing eustachian tube dysfunction
  • Three ear infections in six months, or four infections over the course of a year

What is a grommet?

What is a grommet?A grommet is a small tube that is inserted surgically into the eardrum to help drain away fluid from the middle ear and maintain air pressure. It is known by a number of other names, including a tympanostomy tube, pressure equalization tube, vent and myringotomy tube.

The surgical procedure for grommet insertion involves making a small cut in the eardrum, between 2-3 millimetres (myringotomy).

The fluid that has built up and caused glue ear, or other infections, is then drained and the grommet tube is laid across the eardrum, letting air into the middle ear.

Hearing almost always improves immediately. Grommets fall out of the ear as the eardrum grows, usually between 4-12 months: they are small enough for most patients not to notice when this happens. There is strong evidence to suggest that grommets play a significant role in the reduction of glue ear, and other acute otitis media, within six months of being implanted (7).

The large majority of individuals who are fitted with grommets report much less frequent infections, although the limitations of the existing literature makes it difficult to consider their impact in the longer term. More cohort studies, either prospective or retrospective, are required to determine the role of grommets in reducing infection over a greater period of time. In the shorter term, a further systematic review of studies found that, on average, children fitted with grommets spent 32% less time with glue ear in the first year after they had been fitted (8).

Do grommets decrease the risk of long term hearing abnormalities?

The research that exists regarding the longer term efficacy of grommets rarely differentiates between their role in reducing long term hearing abnormalities and repeat incidence of ear infection.

Do grommets decrease the risk of long term hearing abnormalities?A randomised controlled trial, comparing speech and language development in children who had received grommets for glue ear with children who had glue ear but received no treatment, found no discernible difference in hearing levels over a three year period (9). The results appear to be relatively robust, with all children undergoing both an inner ear examination and an audiometric test.

However, there are many confounding variables that contribute to a child’s development, and many of them have not been controlled for, or acknowledged, in this particular study. As such it is difficult to draw conclusions on these long term potential implications.

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References

1. Taylor S, Marchisio P, Vergison A, et al. (2012). Impact of pneumococcal conjugate vaccination on otitis media: a systematic review. Clin Infect Dis 54(12):1765-73

2. Lildholdt T, Cantekin EI, Bluestone CD, Rockette HE. (1982). Effect of a topical nasal decongestant on Eustachian tube function in children with tympanostomy tubes. Acta Otolaryngol 94(1-2):93-7

3. Rettig E, Tunkel DE. (2014). Contemporary concepts in management of acute otitis media in children. Otolaryngol Clin North Am 47(5):651-72

4. Llewellyn A, Norman G, Harden M, Coatesworth A, Kimberling D, Schilder A, McDaid C. (2014). Interventions for adult Eustachian tube dysfunction: a systematic review. Health Technol Assess 18(46):1-180

5. Maris M, Wojciechowski M, Van de Heyning P, Boudewyns A. (2014). A cross-sectional analysis of otitis media with effusion in children with Down’s Syndrome. Eur J Pediatr 173(10):1319-25

6. National Institute of Care Excellence: Otitis Media with Effusion Clinical Knowledge Summary. Available online at http://cks.nice.org.uk/otitis-media-with-effusion (last accessed 3rd January 2015)

7. McDonald S, Langton Hewer CD, Nunez DA. (2008). Grommets (ventilation tubes) for recurrent otitis media in children. Cochrane Database Syst Rev 8(4):CD004741

8. Lous J, Burton MJ, Felding JU, Ovesen T, Rovers MM, Williamson I. (2005). Grommets (ventilation tubes) for hearing loss associated with otitis media with effusion in children. Cochrante Database Syst Rev 25(1):CD001801

9. Johnston LC, Feldman HM, Paradise JL, Bernard BS, Colborn DK, Casselbrant ML, Janosky JE. Tympanic membrane abnormalities and hearing levels at the ages of 5 and 6 years in relation to persistent otitis media and tympanostomy tube insertion in the first 3 years of life: a prospective study incorporating a randomized clinical trial. Pediatrics 114(1):e58-67

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