Wax removal under GA in Children: Jubilee Hospital, Trivandrum, Kerala, India: Dr.K.O.Paulose FRCS, Consultant ENT Surgeon.
Glue Ear is a build-up of fluid behind the eardrum, in the middle ear causing conductive hearing loss-deafness. Glue ear is a middle ear disease, associated with poor Eustachian tube function. Most children get glue ear at some stage in their lives.
Glue ear with fluid level behind right eardrum. The fluid may be thick and sticky, or thin and watery. Either way it stops the ear drum and ossicles vibrating easily, so quieter sounds are not heard. Glue ear is the commonest cause of deafness in children. Adults can also be affected. Other names for glue ear are middle ear effusion and chronic secretory otitis media-SOM..
It often follows after a cold or ear infection. The Eustachian tube is small and blocks easily. It then fails to ventilate the middle ear. Sticky secretions can’t drain away, so fluid builds up in the middle ear. Movement of the eardrum and ossicles is impaired, causing partial deafness.
Most cases get better quickly after the cold resolves. A minority persist for months or years. Occasionally glue ear is caused by flying with a cold – the Eustachian tube is unable to equalize pressure during descent .Diving with a cold is very likely to cause glue ear.
Persistent glue ear
Common reasons for persistent glue ear in children are due to large adenoids at the back of the nose. Less common reasons for persistent glue ear include Cleft palate and Down’s syndrome .Rarely, glue ear in an adult is caused by a tumor at the back of the nose. Often, no particular cause is found.
Symptoms of glue ear
Conductive Deafness of mild to moderate degree. Hearing loss often varies from week to week, being worse after a cold. Speech may be delayed, especially if deafness occurs early in childhood. Unclear speech and constant shouting are common. Later, education may be affected.
Sometimes deafness is not suspected, but the child is thought to be inattentive, slow or lazy. Concentration may be poor. The child often seems to be “in a world of his own”. Some sufferers get frequent earaches, usually worse at night. Repeated ear infections, with high temperature in some cases leading to fits.
Poor balance and clumsiness may feature. Older children and adults often complain of noises in the ears – tinnitus
The fluid frequently goes away by itself, so a policy of watchful waiting is usually advised. Blowing up balloons to try and force air up the Eustachian tube, may help but the published results are very short term and not many children will persist with this treatment.
Antibiotics and painkillers can be used for associated ear infections. Decongestants e.g. Sudafed are often prescribed but have never been proven effective.
Other medical treatments including antihistamines steroids, medicines to try and thin sticky mucus have all been used.
Treatment of glue ear
If deafness persists for longer than 3 months, an operation is usually needed. The decision to operate is always individual, based on all the factors in that particular case. For immediate relief, myringotomy and grommets insertion is highly effective. Removal of the adenoids may be recommended if the adenoids are enlarged, and where glue ear recurs after initial grommet insertion.
What is a grommet ?
A grommet is a tiny plastic tube, shaped like a miniature cotton reel, about 2mm diameter. It is fitted through a small cut in the eardrum (myringotomy).The tension of the eardrum grips the grommet around its waist. The cotton-reel shape stops it falling in or out, like a shirt stud in a button hole. The grommet allows air from the outer ear directly into the middle ear. Provided the grommet remains in position and is not blocked, the hearing returns to normal almost immediately. The grommet does not drain fluid out; it lets air into the middle ear. Another name for a grommet is a ventilation tube, sometimes abbreviated to tube.
The standard Shah grommet is designed to stay in position for about 9 months. Then the opening in the eardrum heals over and the grommet is pushed out. Longer term ventilation tubes are sometimes fitted. It is important to understand that a grommet does not cure the underlying cause of glue ear. A grommet does provide highly effective and immediate relief of deafness and earaches, while it is in position and working. This buys time, and allows normal education. Meanwhile the child has a chance to grow out of it.
Grommets insertion is normally a quick and simple day-case procedure.
It is very delicate and normally done under general anesthetic (patient fully asleep) the anesthetic is usually given by injection into a vein in the back of the hand, or by gas. To prevent the needle from hurting, a local anesthetic cream is applied about an hour beforehand.
A microscope provides a magnified view of the eardrum. A small cut (myringotomy) is made in the eardrum, and the fluid in the middle ear is sucked out. The cut is like a tiny button hole in the eardrum. Sometimes, if the glue is very thick and sticky, like treacle, a second cut is needed. The second opening allows air in to the middle ear while the glue is sucked out. Sometimes ear drops have to be pumped in to thin the glue in order to suck it out.
The grommet is fitted. It is held in position by the tension of the eardrum gripping it around the waist. The grommet’s shape stops it falling in or out, like a shirt stud in a button hole. If the eardrum is badly thinned, stretched and damaged, it might not have the strength to hold a standard grommet in place. A bigger grommet (long term ventilation tube) might be used in such a case.
Some eardrops are usually applied at the end of the procedure.
If the adenoids are to be removed, this is normally done under the same anesthetic. The adenoids are removed via the mouth.
What happens after the operation
Children recover very rapidly from grommets insertion and should be able to return to school after a day or two.
The hearing normally improves immediately, but don’t worry if there is still some difficulty in the first weeks as it can take time in some cases.
There may be a very slight earache, treated easily with Calpol or paracetamol for older children. There may be slight bleeding from the ear in the first few days. This is normal and nothing to worry about.
Swimming with grommets
No swimming for the first two weeks. After that, surface swimming is allowed without earplugs. Bath water should not be allowed in the ears. The head should not be submerged in the bath. For hair washing, either use earplugs, or a piece of cotton wool dipped in Vaseline to provide a waterproof seal.