Grommets in Children: Clinical Practice Guidelines

March 6th, 2015 by admin in Ear Clinic, Paediatric Otolaryngology Comments Off on Grommets in Children: Clinical Practice Guidelines

Clinicians should distinguish the child with OME who is at risk for speech, language, or learning problems from other children with OME, and should more promptly evaluate hearing, speech, language, and the need for intervention, including grommets.

Grommets in Children: Clinical Practice Guidelines

Risk factors for developmental difficulties (delay or disorder) include: permanent hearing loss independent of OME, suspected or confirmed speech and language delay, Autism Spectrum Disorder and other pervasive developmental disorders, syndromes such as Down Syndrome or craniofacial disorders and any cognitive, speech, or language delay, blindness or uncorrectable visual impairment, cleft palate with or without associated syndrome and or documented developmental delay.

  • OME OF SHORT DURATION: Clinicians should not perform tympanostomy tube insertion in children with a single episode of OME of less than three months duration.

  • HEARING TESTING: Clinicians should obtain an age appropriate hearing test if OME persists for three months or longer and prior to surgery when a child is considered a candidate for tympanostomy tube insertion.

  • CHRONIC BILATERAL OTITIS MEDIA WITH HEARING DIFFICULTY: Clinicians should offer tympanostomy for bilateral otitis media with effusion for three months or longer who have documented hearing difficulties.

  • CHRONIC OTITIS MEDIA WITH SYMPTOMS: Clinicians may perform tympanostomy tube insertion in children with unilateral or bilateral OME for three months or longer (chronic OME) and symptoms that are likely attributed to OME that include, but are not limited to, balance problems, poor school performance, behavioral problems, ear discomfort, or significant reduction in quality of life.

  • SURVEILLANCE OF CHRONIC OME: Clinicians should reevaluate, at three to six month intervals, children with chronic OME who do not receive grommets, until the effusion is no longer present, significant hearing loss is detected, or structural abnormalities of the tympanic membrane or middle ear care are suspected.

  • RECURRENT ACUTE OTITIS MEDIA WITHOUT MIDDLE EAR EFFUSION: Clinicians should not perform tympanostomy tube insertion in children with recurrent acute otitis media who do not have middle ear effusion in either ear at the time of assessment for tube candidacy. This recommendation is based on a meta-analysis of randomized control studies, a systemic review of randomized controlled studies regarding natural history of recurrent acute otitis media. The level of confidence in this recommendation is high.

  • RECURRENT ACUTE OTITIS MEDIA WITH MIDDLE EAR EFFUSION: Clinicians should offer bilateral grommet insertion in children with recurrent acute otitis media who have unilateral or bilateral middle ear effusion at the time of assessment for tube candidacy.

  • AT RISK CHILDREN: Clinicians should determine if a child with recurrent acute otitis media or otitis media with effusion of any duration is at increased risk for speech, language, or learning problems form otitis media because of baseline sensory, physical, cognitive, or behavioral factors.

  • TYMPANOSTOMY TUBES AND AT RISK CHILDREN: Clinicians may perform tympanostomy tube insertion in at risk children with unilateral or bilateral otitis media with effusion that is unlikely to resolve quickly as reflected by a type B (flat) tympanogram or persistence of effusion for three months or longer.

  • PERIOPERATIVE EDUCATION: In the perioperative period, clinicians should educate parents and caregivers of children with grommets regarding the expected duration of tube function, recommended follow up schedule, and early detection of complications.

  • ACUTE TYMPANOSTOMY TUBE OTORRHEA (RUNNY EAR): Clinicians should prescribe topical antibiotic drops only without oral antibiotics for children with uncomplicated acute tympanostomy tube otorrhea. This is a strong recommendation based on randomized control trials with a preponderance of benefit over harm.

  • WATER: Clinicians should not encourage routine, prophylactic water precautions (the use of ear plugs or headbands; avoidance of swimming or water sports) for children with grommets. This in Australia is some what controversial but detailed analysis of all randomized control trials seem to suggest that in the first instance stringent water prophylaxis is not necessary, if however, the child has an episode of otorrhea or runny ears, or if there is early extrusion of a set of tympanostomy tubes then stringent water exclusion is recommended.

    In children with grommets, if no water prophylaxis is undertaken they should be encouraged to surface swim only. The pressure gradient that is generated by diving to the bottom of a swimming pool has be shown to be associated with ingress of water into the middle ear cleft which can be harmful.

This clinical practice guideline is provided for the information and education purposes only; it is not intended to act as a sole source of guidance in managing children with acute otitis media, otitis media with effusion, or chronic otitis media. It is intended to provide up to date background knowledge for primary care physicians, with regards to acceptable current clinical guidelines for the insertion and management of tympanostomy tubes.