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Grommet insertion - child

What is it?

First of all, each ear is made up of three parts. There is the outer ear which you can see, and which gathers the sound. Further in, the outer ear joins the middle ear on each side of the head, which contains the ear drum. Deeper still, there is an inner ear on each side. The sound goes down the ear tube, which is part of the outer ear, into the middle ear on that side. The ear drum stretches across the deepest part of the ear tube between the outer ear and the middle ear and vibrates. The drum is about a third of an inch (0.8cm) across. It is made of thin skin, like the top of a real drum. The middle ear is an air space which connects with the back of the nose. This is why your ear drums pop when you blow your nose. The surgeon has looked into your child's outer ear and at the ear drum with a special telescope. He can see some fluid behind the ear drum. The fluid has built up in the middle ear, because it cannot drain through to the back of your child's nose. The middle ears, on each side, connect with the back of the nose along two very narrow tubes. They are called the Eustachian tubes. One of your child's Eustachian tubes has become blocked. The middle ear on that side has filled up with fluid. To start with, the fluid was thin and watery. Gradually, it has become thick and sticky, like jelly. It is sometimes called "glue ear". This fluid stops the ear drum letting the sound through properly. It is the cause of your child's hearing difficulties. The fluid behind the ear drum may also lead to infection in the middle ear. It is not known why the Eustachian tube has become blocked in this way. Both may be blocked. In some children, swollen gland tissue (adenoids) at the back of the nose will be blocking the tubes. This is not happening in your child's case. Glue ear is the commonest cause of mild deafness in school children. About one in five of all children suffer from this in their early years. This operation has very good chance of correcting your child's hearing difficulties. The condition is not the parents' fault.

 

The operation

Your child will have a general anaesthetic and will be completely asleep. The surgeon will shine a very fine microscope into your child's ear tube. He will then make a tiny cut in the ear drum (myringotomy). A very fine sucker will be placed through the hole in the eardrum into the middle ear. The sucker will draw the fluid from behind the ear drum like a miniature vacuum cleaner. He will then plug a tiny hollow plastic tube into the hole in the ear drum. This tube is called a grommet. It is shaped like a cotton reel with flanges that hold it in place in the ear drum. The grommet lets air pass from the ear tube through the ear drum and into the middle ear. Any fluid in the middle ear should now just dry up. Because your child will be asleep, he or she will not feel any pain during the operation. The operation can be done as a day case. This means that your child comes into hospital on the day of the operation, and goes home the same day. Both sides can be done at the same time if needed.


Any alternatives

If you leave things as they are, the fluid may drain away given time. This may take months or years. The deafness will continue and may hold your child back in many ways. Your child may get serious middle ear infections during this time. This can eventually lead to more and more thickening of the ear drum as well as thickening of the fluid in the middle ear and can cause irreversible hearing loss. Tablets, medicines, nose drops, and inhalers, will no longer help. Hearing aids are only a stop gap. Drawing the fluid out with a fine needle has not helped. The fluid will just build up again. The fluid may be too thick for needling. Taking out the adenoids will not help your child. You may have heard on the TV that grommets are not necessary. This may be the case for some children, but your child will almost certainly benefit.


Before the operation

Your child must have nothing to eat or drink for about six hours before the operation. This means not even a sip of water. Your child's stomach needs to be empty so that the anaesthetic can be administered safely. If your child has a cold in the week before admission to the hospital, please telephone the ward and let the ward sister know. The operation will usually need to be put off. Your child has to get over the cold before the operation can be done because by having an anaesthetic the cold could turn into a serious infection in the chest. 

Sort out any tablets, medicines, inhalers that your child is using. Keep them in their original boxes and packets. Bring them to the hospital with you. On the ward, your child may be checked for past illnesses and may have special tests to make sure that he or she is well prepared and can have the operation as safely as possible. Many hospitals now run special preadmission clinics, where you and your child visit for an hour or two, a week or so before the operation for these checks.


After - in hospital

There is very often no pain in the ear after a grommet operation. The grommet itself will cause no discomfort in the ear. If your child does have some earache after the operation, the nurses will give some medicine to take the discomfort away. Before you leave the ward, you will be given an appointment to bring your child back to the ENT (ear, nose, and throat) outpatient clinic for the doctors to check the grommet. They will make sure it is working properly. This will be a week or so after the operation. The nurses will advise about sick notes, certificates etc.


After - at home

After three or four hours on the ward, your child will be well enough to go home. Usually the doctors like your child to have something to eat or drink before leaving. Give your child a painkiller such as Calpol every six hours to control any earache or discomfort. Your child will be fit to go back to school the second day after his or her operation. With the grommet in place, the fluid will clear from behind the ear drum within six to eight weeks. Once the fluid has cleared, your child should be able to hear normally. The grommet stays in the ear drum for about a year. As the fluid problem gets better, the hole in the drum heals, and squeezes the grommet out into the ear tube. In some children, the grommets come out sooner, and in others they stay in longer. The grommet usually sticks to wax in the ear tube. The doctor in the outpatient clinic can then easily take it out. Sometimes the grommet has to be taken out with a small operation, if it does not come out by itself. It is important that you keep the ears dry. Do not allow water to get into the ears when your child is taking a bath or washing his or her hair. Protect the ear by placing a piece of cotton wool rubbed in Vaseline in the ear. Your child can swim providing that he or she has ear plugs and a tight bathing cap. Your child must not have the ear syringed if there is a grommet. It would be very painful and could cause serious infection in the middle ear. It is perfectly safe to travel by air. Air can pass freely through the grommet into the space behind the ear drum, so there will be no problems with changes in pressure.


Possible complications

As with any operation under general anaesthetic, there is a very small risk of complications related to the heart and the lungs. The tests that your child will have before the operation will make sure that he or she can have the operation in the safest possible way and will bring the risk for such complications very close to zero. 

The operation is successful in 70% of children. The remaining 30% might need the grommet re-inserted on one or more occasions. 

Occasionally children notice a popping or clicking in the ears. This is not harmful, it is expected and you should not worry about it. You may notice some clear but lightly blood stained fluid coming out of the ear for the first two days after the operation. This is expected but if it continues for more than two days and your child gets a runny ear (especially if the fluid coming out is thick, yellow and or green or smelly), it probably means that germs have passed through the grommet and have caused an ear infection. You should take your child to your doctor who will probably give antibiotics. If the infection is not getting better, he will arrange for your child to be seen in the ENT outpatient clinic. In a few children, the ear can be a bit runny without anything serious being wrong. In addition, if your child doesn't have a runny ear but gets a headache, a temperature or becomes irritable and loses his or her appetite, you should also be alert and ask for medical advice because these symptoms can be an indication for a developing infection. 

There is a 2 to 3% chance that following the insertion and removal of the grommet (especially after multiple insertions or removals as can be the case for some children) the ear drum will develop a hole that doesn't heal well. Given time most of those holes heal on their own but for some of them another operation is needed to close them.


General advice

These notes should help you and your child through the operation. They are a general guide. They do not cover everything. Also, all hospitals and surgeons vary a little. If you have any queries or problems, please ask the doctors or nurses.

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