• Glue ear and recurrent acute otitis media are part of the same spectrum of suppurative otitis media, and as such are considered together.
• It is possible for the presenting complaint to be with glue ear (hearing loss) or recurrent ear infections (pain/ fever) by themselves, or these problems can occur together.
• When the symptoms are severe  and persistent over a prolonged period for any of these clinical scenarios, grommet insertion becomes an option.

• The middle ear is normally an air-filled space between the ear drum and the inner ear (cochlea).
• It contains the bones of hearing which connect the ear drum to the inner ear.
• Infections enter the middle ear form the back of the nose via the eustachian tube, causing pain, fever and loss of hearing. The ear fills with pus.
• If the eustachian tube is blocked over a prolonged period, the middle ear fills with thick mucus (“glue ear”) causing hearing loss, because the ear drum cannot vibrate properly

• Acute otitis media is a painful infection of the ear which is common in young children.
• It usually follows a viral infection, and probably relates to secondary infection from bacteria including Streptococus pnumoniae, and Haemophilus influenzae.
• A few middle ear infections per year may be part of normal development, and are usually treated with antibiotics.
• If infections are too frequent, then grommet insertion is likely to help the situation.

• A middle ear infection – is associated with significant pain, fever and an unwell child. It represents an abscess (pus) behind the eardrum.
• Glue ear – can occur after an infection, or can occur without a clear history of ear infection. It thick mucus, or golden fluid behind the ear drum It is not painful, and the child is well. It is associated with hearing loss.

• Middle ear problems are experienced at some stage by majority of children.
• There is a natural fluctuation of middle ear issues, related to the seasons, and an improvement with age (seen between 4-6 for most children).

• Too many infections leave a child constantly having fevers, being run down, sleeping poorly and requiring multiple trips to the doctors and courses of antibiotics.
• Ear infections are very disruptive to lives of children and their families who often have to take a lot of time out of their routine schedule, with time off kindy, school or work.

• Pain
• Fever
• Reduced hearing

• Ear symptoms can vary with age but behaviour associated with a painful middle ear in a young child can include:
  • Abnormal irritability
  • Feeding difficulties
  • Consistent presence of fever
  • Ear tugging
  • Disturbed sleep.
  • A miserable and unwell child

• Typically, glue ear will present as a mild-to-moderate hearing loss, similar to walking around with your fingers blocking your ears.
• The best possible hearing in children is often substantially better than what is considered “normal“ in the adult population. This mean there is a degree of reserve.
• A child’s hearing will typically still hear one-on-one but will struggle in more challenging auditory environments.
• In many cases, the hearing loss is very obvious to parents, carers and teachers.

• The first stage is pain and fever
• The acute infection may:
  • Resolve spontaneously with time, with the ear returning to normal.
  • Resolve with the help of antibiotics
  • Burst the ear drum with pus discharge from the ear. In most cases the pain will then improve, and the hole in the ear drum will heal.
  • The infection may settle, but the patient is left with glue ear (thick mucus behind the ear drum), which causes hearing loss.

• In rare cases where no action is taken there may be severe complications including meningitis and brain abscess.
• There may be permanent structural damage to the ear drum if multiple recurrent ear infections occur without appropriate treatment.
• If infections are too frequent or too severe, antibiotics are no longer enough and grommets will be required to improve the child’s wellbeing.

• Children have immature eustachian tubes and immune systems leaving them more susceptible to the upper respiratory infections which we all encounter through the year.
• This sets the scene for a secondary infection with nasty bacteria (eg Streptococci, Haemophilus) which cause ear infections.
• Children become less prone to infections once they reach school age (4-6).
• For the worst cases ear infections may continue beyond this age group.

• Most young children will have ear infections from time to time. This is more common when they are in kindergarten or day care, and over the winter months.
• Once the infections are “back to back”, with frequent antibiotics and visits to the local doctor consideration should be given to a specialist ENT referral.
• There may be associated hearing loss with glue ear, and part of the assessment will probably include a hearing test.
• In the circumstance of severe recurrent ear infections, grommet insertion can dramatically improve your child’s quality of life and substantially reduce the requirement for antibiotics.

• Impact from Middle Ear Infection can include:
  • Delay in educational development.
  • Frequent middle ear infections cause ongoing misery for a child and their family.
  • Lifelong problems caused by hearing loss.

• Hearing testing is routine in children with suspected middle ear problems, and helps to predict which children would be helped by an operation.
• Various hearing tests can determine if there is hearing loss at a level that will compromise a child’s educational development.

• • Middle ear disease can be diagnosed by your doctor when the history is taken. Middle ear disease is indicated when a child presents with:
    • ear pain
    • fever
    • unsettled child, poor sleep
    • deafness
    • language delay
    • other ENT symptoms such as blocked nose, thick snot, cough , tonsillitis, snoring

  During an examination your doctor will possibly see:

  ●      characteristic red, swollen ear drum in middle ear infections (below)

  

  Figure: the red drum of acute otitis media

  • golden or dull ear drum with fluid
  

  Figure: the golden drum of glue ear

• Grommet implant surgery requires a general anaesthetic in one of the local hospital and is a day-only procedure.
• It is a very simple procedure with very pleasing results. We usually expect a dramatic improvement in hearing, ear infections or both.
• Even if there are ear infections after grommet insertion, they are usually much less severe.
• Your child will be back to normal activities by the next day in most cases.
• When grommet surgery is performed as a stand alone procedure, the only downtime is the day of surgery. If it is combined with other procedures (eg tonsillectomy), more time off will be required.

• The hospital will be in touch the day prior to surgery to confirm fasting information, where to park, how to get to the appropriate part of the hospital, what time to turn up and what to bring/ wear bracket omitted here.

• There is minimal pain postoperatively, and the child is usually discharged several hours after the procedure.
• Hearing improvement will often be noticed immediately
• Ciloxan ear drops will be used to both ears for 5 days.
• The first review appointment is at about 2 weeks.
• The ears should be kept dry for the first 2 weeks.
• Earplugs are not necessary in the first couple of weeks but will be discussed at the first postoperative review with a view to returning to full water activities.

• Until the post operative review 2 weeks after the Grommet procedure the ears should be kept dry. This means:
  • No Submerging the head in bathwater.
  • Hair washing is not a problem if the hair is rinsed with fresh water from the tap or a shower.
  • Swimming should be avoided until the first postoperative review.

• • With or without ear protection, infections are still possible.
  • There is controversy about earplug usage between ENT surgeons, but most who are located in areas where there is a high frequency of swimming and other water sports recommend their use.
  • If ear plugs are well-tolerated, Dr Smith recommends their use when swimming. The ear plugs should be reinforced with a headband, or swimming cap.
  • At bath time, plugs are not necessary, but it is important that the head not be put under the water in the bath, and that the hair is rinsed with fresh water from the tap or shower.
  • There are different options are available for ear plugs:

  (1)  Blu Tack is favoured by many parents, and with good reason. It is easy to use, cheap and replaceable. The Blu Tack should be moulded to fill the bowl of the ear, with a tail into the outside part of the ear canal.

  (2)  Doc’s Proplugs is a good solution for some kids. A size can be found to fit most kids. They stay in the ear well, in many cases.

  (3) Custom ear plugs (GN Resound) may be superior in some (but not all) patients.

  • Doc’s Proplugs, custom plugs and neoprene headbands for children are all available through our audiology service, both in the Miranda and Annandale offices.

After Grommet surgery Dr Smith recommends the following schedule:

• • • Two Weeks are surgery
    • Every 6 months until the grommets have come out.
    • In the event of discharge (mucky fluid coming out of the ear), more frequent review may be necessary.
    • These appointments usually last for 1-2 years.
    • The most common pathway is that the ears remain relatively problem free for the life span of the grommets.

• The grommets, on average, will last between 12 and 24 months. When they come out, the child’s ears have often returned to normal.
• In most cases, the Grommets come out by themselves and the eardrum heals.
• Often, at this stage, the ear will have returned to normal.
• In some cases, another set of grommets may be required or surgery may be required to fix a persistent hole in the ear drum.
• Occasionally, a grommet will need to be removed when it has been in the ear for too long (>3 years).
• The grommet may need to be removed if it causes problems such as uncontrolled discharge from the ear.
• The grommet can also come out early <6 months (in rare cases) If there are still middle ear issues at this stage, a further set of grommets may be required.