Describe grommet insertion with its indications and complications.

Indications and Technique

• A grommet (ventilation tube, tympanostomy tube) is a small tube inserted through the tympanic membrane to ventilate the middle ear, taking over the function of a failing Eustachian tube.
• Its purpose is aeration, not drainage — a distinction that explains much about its use.
• Primary indication — otitis media with effusion persisting beyond 3 months bilaterally with a hearing loss of 25 to 30 dB or worse, or with speech, language, educational or behavioural consequences

Aftercare and Complications

• Water precautions have become less strict: current evidence suggests that routine swimming in clean water without diving is safe, and that earplugs make little difference to infection rates. Avoidance is advised for soapy bathwater, diving and deep swimming.
• Follow-up — review with otoscopy and audiometry to confirm the tube is patent and hearing restored, and again after extrusion to check for recurrence of the effusion
• Complications:
• Otorrhoea is much the commonest, occurring in a substantial minority. It is treated with topical antibiotic drops (ciprofloxacin.
• Blockage of the tube by blood or secretion.
• Early extrusion or, conversely, retention requiring removal
• Persistent perforation after extrusion, in a small percentage — higher with T-tubes — which may need myringoplasty
• Tympanosclerosis at the site.
• Medial displacement into the middle ear.
• Granuloma at the tube, and localised atrophy or atelectasis of the drum
• The honest summary of the evidence is that grommets give a clear and immediate hearing benefit that diminishes over 6 to 12 months as untreated effusions resolve spontaneously — so the benefit is greatest in children with the most persistent disease and the greatest hearing loss.
• Adenoidectomy should be considered alongside, particularly at a second set of tubes or where there is nasal obstruction.
• The purpose is aeration rather than drainage, which explains why drops suffice for otorrhoea through a patent tube
• Swimming in clean water is safe, and earplugs make little difference to infection rates
• Avoid soapy bathwater and diving; surfactant lowers surface tension and lets water pass through the tube
• Treat otorrhoea with drops, not oral antibiotics, using a non-ototoxic agent such as ciprofloxacin
• T-tubes stay longer but perforate more often, which is the trade-off when choosing a long-term tube
• Extrusion is spontaneous as epithelium migrates outward, so a grommet is always a temporary measure