CRYING BABIES & BEYOND the ins and outs & ups and downs


CHAPTER 13

GROMMETS

Inserting grommets is the most common surgery performed for children in Western countries.

There are a small number of doctors who believe that this is unnecessary surgery. They say [simplistically] that children will eventually outgrow their ear problems, so invasive treatment is inappropriate.

Others believe that it is the most definitive management strategy available for the treatment of severe middle ear problems and middle ear effusions [glue ear] that do not respond adequately to medical treatment, and that prevention of many possible sequelae is very important. I am one of the latter.

The GP will refer the child to the ENT specialist when he/she, and the child’s parents, feel that the child is not making adequate progress. Parents should request referral to an ENT specialist who does a lot of work with young children. The anaesthetic risk is greater in infants under twelve months, so the surgery for these infants should be done at a tertiary medical centre so it will be equipped to deal with this age group. The surgeon will choose an anaesthetist who is trained to work with infants.

The ENT specialist will assess the child’s history, the previous management and the current findings and offer advice that may include suggesting inserting grommets. The final decision to insert grommets is made by the parents on the advice provided by the ENT surgeon.

There are guidelines given for when grommets should be inserted. These include the length of time to wait to see if effusions will clear spontaneously and the number of bouts of ear infection a child should have before the child is referred to the ENT specialist. However, I believe that making a decision to refer the child depends on many factors other than those suggested, as children are individuals and their problems are individual. Parent’s experience, expectations, knowledge and concerns are also different and it is very important for the doctor to acknowledge these differences and work with the parents.

I believe it is important for parents to understand all the features of grommets, the good and the less good, so they know what to expect and can ask questions appropriately.


SUMMARY

Inserting grommets is the most common surgery performed for children in Western society.

Although grommets do not provide the perfect answer for all children with middle ear problems they are the best treatment currently available for children whose ME problems do not respond adequately to medical treatment.

Surgery to insert grommets does not often have problems when done by an experienced ENT surgeon. However a general anaesthetic is required and the risks of surgery are mainly the risks of the general anaesthetic. The risks of the anaesthetic are higher in infants less than twelve months of age, but this age group have the highest risk of sequelae from continuing middle ear problems, because it covers the sensitive time for language and other development.

It is important to give the anaesthetist information about any family history of anaesthetic problems and about the child’s medical problems [e.g., that the child has reflux]. It is also important to fast the child strictly as directed.

Different types of grommets are inserted depending on the child’s age, and the severity and type of problems.

Precautions are required to prevent water entering the ME and these are discussed.

Grommets most commonly do not cause any problems, only benefits, to the child’s well being and development. However some children do have some problems and these, and their management are described.

Some doctors disapprove of the use of grommets, believing that the children will outgrow ME problems eventually. It is hard to predict when a child will outgrow his ME problems. There are potential risks of permanent hearing loss and ear damage for some children if ME problems are not managed adequately. There are also possible sequelae from developmental problems.

Treating children with ME problems energetically is hoped to prevent [or limit] these later developmental problems….


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