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S Afr Fam Pract
ISSN 2078-6190 EISSN 2078-6204

REVIEW

Introduction

Children younger than 7 years are at increased risk of otitis
media because of their immature immune systems and poorly
functioning eustachian tubes that normally ventilate the middle
ear space and equalize pressure with the external environment.
More than 80% of children have at least one episode of acute
otitis media (AOM) before the age of 3 years and 40% experience
six or more recurrences by the time they are 7 years old.1 By the
age of 3 years, approximately 7% of children undergo surgery for
tympanostomy tube insertion for a range of otitis media issues,
most commonly for chronic otitis media with effusion (OME),
recurrent acute AOM, and acute otitis media that persists despite
antibiotic therapy.2 However, tympanostomy tube insertion
is associated with risks and remains a controversial practice
especially in children with OME of less than three months’
duration and in children with recurrent AOM. Adverse effects
associated with tympanostomy tube insertion include those
associated with anaesthesia and its complications (laryngospasm,
bronchospasm), as well as tube related sequelae such as
recurrent (7%) or persistent (16–26%) otorrhoea, blockage of the
tube lumen (7%), granulation tissue (4%), premature extrusion
of the tube (4%), tympanostomy tube displacement into the
middle ear (0.5%) and persistent perforation of the tympanic
membrane (1%–6%).3 This article offers guidance for family
practitioners wishing to optimize health outcomes in children
potentially requiring tympanostomy tube placement.

Otitis media with effusion (OME) of short duration

Otitis media with effusion (OME) is defined as middle-ear effusion
(MEE) without acute signs of infection4 (Figure 1). It is common;
90% of children have OME before school age, experiencing, on
average, 4 episodes of OME per year.5 The prevalence of OME
in children with Down Syndrome or cleft palate is much higher.
It is frequently asymptomatic and therefore often remains
undetected. It is strongly recommended that pneumatic
otoscopy be used to assess OME in children with otalgia, hearing

loss or both.5 OME mostly occurs after acute otitis media (AOM)
with a prevalence of 70% at 2 weeks, 40% at 1 month, 20% at
2 months and 10% at 3 months post infection.6 OME may also
occur with eustachian tube obstruction in the absence of AOM.4
A recent meta-analysis suggests that allergic rhinitis and allergy
may be risk factors for OME.7 There is strong evidence against
the insertion of tympanostomy tubes in children experiencing
a single episode of OME of less than 3 months’ duration because
of the likelihood of spontaneous resolution in this instance as
well as the risks associated with unnecessary surgery.3,6 Rather,
watchful waiting for 3 months following the onset of effusion/
diagnosis is strongly recommended.5 Early surgical referral is,
however, indicated for children who are at risk for developmental
delays where hearing is critical for their speech, language and
learning development, irrespective of the duration of OME.8
Hearing loss related to OME averages 18–35 dB.9 Risk factors
for developmental difficulties include permanent hearing loss
independent of OME, suspected or confirmed speech and
language delay, autism and other pervasive developmental
disorders, syndromes or cranio-facial disorders that include
cognitive, speech or language delays, blindness, cleft palate or
any other cause of developmental delay.3,4

Chronic otitis media with effusion (OME)

Once OME has persisted in both ears for 3 months or longer,
spontaneous resolution is unlikely: only 20% of these resolve
within 3 months, 25% after 6 months and 30% after a year of
observation.6 Chronic middle ear fluid results in decreased
mobility of the tympanic membrane and may be associated
with hearing loss, balance (vestibular) problems, poor school
performance, behavioural problems, ear discomfort, recurrent
AOM, or reduced quality of life.3 Other rarer complications of
OME include structural damage to the tympanic membrane that
requires surgical intervention.5

Age-appropriate hearing testing is therefore recommended,
if OME persists for 3 months or longer. Children with bilateral
chronic OME associated with documented hearing difficulties

South African Family Practice 2017; 59(3):13-16

Open Access article distributed under the terms of the
Creative Commons License [CC BY-NC-ND 4.0]
http://creativecommons.org/licenses/by-nc-nd/4.0

Grommets - an update on common indications for tympanostomy
tube placement
K Outhoff

Senior Lecturer, Department of Pharmacology, University of Pretoria
Corresponding author, email: kim.outhoff@up.ac.za

S Afr Fam Pract 2017;59(3):13-1614

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may be offered bilateral tympanostomy tube insertion. In chronic
OME sufferers, the benefits of tympanostomy tube include a
30% reduction of middle ear effusion (MEE) with an associated
5 to 12 dB improvement in hearing in the first 6 to 9 months
after tube insertion.10 Although quality of life improvements
for both the child and the caregiver are considerable,2 there is
little evidence that optimised auditory access has a significant
impact on speech, language or cognitive outcomes in children
not at risk for developmental delays.3 There is some consensus
that a hearing loss exceeding 39 dB probably warrants surgery,
but shared decision-making with caregivers is strongly advised
in all cases.4

Alternatives to tympanostomy tube insertion are limited to
surveillance. The latest guidelines emphasise that clinicians
should recommend against using intranasal or systemic steroids,
systemic antibiotics, antihistamines or decongestants for
treating OME.2-5

Chronic OME with other symptoms

Children who have either unilateral or bilateral chronic OME
with symptoms that are likely attributable to OME may also
be offered tympanostomy tube insertion. Symptoms include
vestibular problems (clumsiness, balance problems, delayed
motor development), poor school performance, behavioural
problems, ear discomfort or poor quality of life. Although OME

has a direct and reversible effect on the vestibular system,11 it
must be noted that the causes of all of the above symptoms
may be multifactorial, and once again, shared decision-making
with caretakers is critical and should be based on realistic
expectations about how the reduction in MEE may improve the
child’s health. Quality of life indicators such as physical symptoms,
caregiver concerns, emotional distress, hearing loss and speech
impairment may improve significantly after tympanostomy tube
insertion.3,12

Surveillance of chronic OME

Children with chronic OME who do not have tympanostomy
tubes should be re-evaluated at 3 to 6 month intervals with
pneumatic otoscopy, developmental surveillance and hearing
testing until the effusion resolves, significant hearing loss
(> 39 dB) is detected or structural abnormalities of the tympanic
membrane (local inflammatory response, focal retraction
pockets, generalised adhesive atelectasis,) or middle ear
(cholesteatoma, ossicular erosion) are suspected. Although
uncommon, suspected tympanic membrane abnormalities
should prompt specialist referral.3-5

Recurrent acute otitis media (AOM)

Tympanostomy tube insertion is not indicated in children with
recurrent AOM who do not have MEE in either ear because of the

Figure 1: Comparison of otitis media with effusion (top) and acute otitis media (bottom). The left images show the appearance of the eardrum on
otoscopy, and the right images depict the middle ear space. For otitis media with effusion, the middle ear space is filled with mucus or liquid (top
right). For acute otitis media, the middle ear space is filled with pus, and the pressure causes the eardrum to bulge outward (bottom right). (With
permission from Rosenfeld 20165)

S Afr Fam Pract 2017;59(3):13-1616

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favourable natural history of this condition and good evidence
that these children do not have a reduced incidence of AOM
after tympanostomy tube insertion.2

This contrasts with children who have recurrent AOM associated
with unilateral or bilateral MEE who may be offered bilateral
tympanostomy tube insertion. Persistent MEE may be an
indicator of underlying eustachian tube dysfunction that
may possibly predispose to future AOM recurrence. The other
potential benefits of tympanostomy tube insertion are that
future episodes may be treated with topical antibiotics rather
than systemic, and may be associated with less pain and hearing
loss. Once again, the possible benefits of surgery need to be
weighed against the risks, and caregivers should be involved
in the decision-making process. Surveillance may be offered if
there is uncertainty.3

Persistent or severe acute otitis media (AOM)

Although no trials have been conducted in this difficult-to-enrol
patient group, increasing problems with bacterial resistance
have paved the way for tympanostomy tube placement in
children with persistent or severe AOM. This allows drainage of
secretions, facilitates culture of infective organisms and provides
a direct route for delivering antibiotic eardrops to the middle ear.
In addition, when children with tympanostomy tubes continue
to experience AOM episodes, they may be managed with
topical antibiotic eardrops rather than with systemic therapy.3
Noteworthy is that chronic suppurative otitis media is a major
cause of hearing impairment in many developing countries.1

Post-operative care

Tympanostomy tubes usually remain in place for 12 to 14
months. During this period, children should be followed up
routinely by an ENT surgeon as well as by their primary care
provider who should refer patients if the tympanostomy tubes
cannot be visualised or are occluded, if there are concerns about
changes in hearing or if other complications such as granuloma,
persistent or recurrent otorrhoea, perforation of the tube site,
persistent tube for longer than 2-3 years, retraction pocket or
cholesteatoma are identified. The ultimate goal is for the tubes
to remain in place until children have outgrown their middle ear
disease.3

Approximately 15–26% of children with tympanostomy tubes
will have additional episodes of AOM, and otorrhoea is typically
their only symptom.3 Uncomplicated (temperature < 38.5oC, no
concurrent illness requiring systemic antibiotics, no cellulitis
extending beyond the external ear canal) acute (less than
4 weeks duration) tympanostomy tube otorrhoea (TTO) usually
caused by typical nasopharyngeal pathogens (S pneumonia,
H influenza, M catarrhalis) and/or external auditory canal
pathogens (P aeruginosa, S aureus) responds to topical antibiotic
ear drops such as ciprofloxacin, ofloxacin or ciprofloxacin-
dexamethasone and benefits from water precautions until
the discharge resolves.3 The advantages of topical rather than
systemic antibiotics are multiple and include higher tissue levels,
reduced adverse effects and less likelihood of the development

of antimicrobial resistance.13 Only eardrops specifically approved
for use with tympanostomy tubes should be used because non-
approved drugs, including over-the-counter preparations, are
ototoxic and may induce pain or infection, or even damage
hearing.

Routine prophylactic water precautions, such as avoidance
of water sports or the use of earplugs, are not recommended,
unless children are immuno-compromised, swim in heavily
contaminated water, participate in deep diving or experience ear
discomfort during swimming.3

Conclusions

There is relatively strong evidence for tympanostomy tube
insertion in children with chronic bilateral OME with associated
significant hearing difficulties as well as in children with recurrent
AOM with MEE. Tube insertion is optional but recommended in
children at risk for speech, language or learning problems who
have recurrent AOM or OME, and in children who have chronic
OME with symptoms. These recommendations should be
implemented within a collaborative team approach to ensure
developmental outcomes are not compromised.14 When making
clinical decisions, the risks of tube insertion must be balanced
against the risks of prolonged or recurrent otitis media, which
include suppurative complications, damage to the tympanic
membrane, adverse effects of antibiotics, and potential
developmental sequelae of hearing loss.

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