Glue Ear and the use of Grommets in Children

For burst eardrum problems please click hear

The ear drum is a very thin porous membrane, thin enough for liquids in the middle ear to leak through into the ear canal if the pressure is great enough.

The medical term for glue ear is otitis media with effusion - a condition in which a sticky glue-like fluid builds up in the middle ear chamber and leaks into the ear canal. It is a very common condition that affects mainly young children aged between two and five years. In most children, glue ear clears up on its own. However, up to 5% of children get persistent glue ear, which if left untreated, can cause long term hearing loss. Physicians call glue ear 'otitis media with effusion', 'secretory otitis media' or 'chronic secretory otitis media'. 

Glue Ear is not a disorder in itself; it is just a visible symptom of a discharge from the middle ear. When the white sticky liquid mixes with the normal ear wax in the ear canal, it changes to a thick gluey orange color.

Note: Glue ear is sometimes confused by anxious parents with the normal discharge of wax from a child's ear canal. During an infant or child's growth, there may be periods when ear wax is produced more copiously than normal, causing wax to leak from the ear.

How to tell the difference:

• If the child has not had a fever then it is probably excessive wax discharge
• If the child has not complained of an earache then it is probably an excessive wax discharge
• If the discharge does not have a really smelly odor then it is probably an excessive wax discharge (there is a slight odor to normal wax)

Symptoms of Glue Ear

The usual symptoms of glue ear are:

• A thick whitish liquid discharge from the ear that changes to orange when it mixes with ear wax
• Ear aches
• Headaches
• Fever
• Listlessness
• The child may be clumsy. With very small infants (1-3 years old), it might also take them longer to start to walk, speak or understand language.
• Older children may be able to tell you if they cannot hear very well. Or you may notice that they say 'pardon' or 'what' a lot or that they turn the television up loud. Glue ear also makes older children clumsy and dizzy.

Direct Causes of Glue Ear

Usually the Eustachion tube is the culprit causing glue ear. The middle ear needs to be full of air to let the eardrum and three small small bones (ossicles) vibrate freely to transmit sound from the ear drum to the inner ear. The Eustachian tube regulates air pressure in the middle ear and drains the natural secretion from the middle ear to the back of the throat  The Eustachian tube is closed for 95% of the time and only opens when swallowing or yawning. Its main purpose is to keep the air pressure in the middle ear the same as the outside air pressure.

Common colds often cause otitis media, simply because the swollen mucous membranes such as swollen adenoids block the outlet from the Eustachian tube, or because micro organisms migrate from the back of the throat through the Eustachion tube to cause infection in the middle ear.

The lining of the middle ear is similar to that in the lungs in that air is absorbed through outer lining of the middle ear and into the bloodstream. This means that unless the Eustachian tube opens properly to balance the air pressure, you eventually lose air from the middle ear space .

Children have a narrow Eustachian tube, often hindering it from opening properly. This can lead to a vacuum in the middle ear. Once this vacuum forms, the lining of the middle ear becomes inflamed and swollen. As part of the inflammation reaction, a thin sticky fluid seeps out from this lining into the middle ear space. If the Eustachian tube is blocked, this secretion has nowhere to go. The fluid then becomes thicker preventing the eardrum and small bones (ossicles) from vibrating. Unless the ossicles can vibrate, no vibrations get from the ear drum to the inner ear receptor (cochlea).

As the secretion fills up the inner ear cavity, it begins to put pressure on the eardrum and the eardrum will bulge out under the pressure. The ear drum is porous enough that some of the liquid will seep through to the ear canal until the pressure is relieved within the middle ear cavity. This stage is usually accompanied by ear aches, headaches, and fever.

Burst Eardrum

If the material in the middle ear cavity remains there and becomes infected the consequential bacterial waste may build up too fast for either the Eustachion tube to drain it or for the ear drum to pass it through. The resultant pressure may burst the eardrum leaving a tear in the ear drum. This is actually a positive event. The burst eardrum will immediately relieve the pressure in the middle ear and the accompanying earache will diminish. Your child will stop screaming :). More information on Burst Eardrum in children.

Treatment for Otitis Media and Glue Ear

The treatment your doctor (family or pediatrician) offers for glue ear will depend on how long your child has had glue ear and the number of prior incidents of glue ear

There are three methods of treatment for glue ear:

1. Many children recover from glue ear if the Eustachian tube re-opens on its own.  Doctors usually adopt a wait-and-see approach to begin with. Your child will normally be observed for about three weeks to see if they need further treatment. If the eardrum has burst, it should heal over time (3-6 weeks)
    
2. As a parent, self medication can be performed on your child by obtaining an OTC (Over The Counter) pediatric oral decongestant to thin the fluid in the ear and reduce the Eustachion tube swelling, causing the fluid to drain into the throat. If that does not work you might want to try a small dose of an antihistamine such as Benadryl™. Have your pharmacist recommend a child's dosage.  If that treatment still doesn't work after one week, see your family doctor or physician. They might prescribe stronger antihistamines or nasal steroids in the form of drops or sprays - both of which will help reduce the swelling of the Eustachian tube.
    
3. The second treatment is if there is a suspected infection.  If the eardrum has burst, this is usually the case. Antibiotics are sometimes prescribed, often initially by injection, then a regimen orally three times a day for at least 7 days.
   
   ****However, before you ask a pediatrician or family doctor for antibiotics, you may want to read the latest from the American Academy of Pediatrics
   
   Another factor in considering antibiotics is that in the past, penicillin, erythrosine, or erythromycin were prescribed. However, in the last few decades, many in the general population have become immune to the effects of these antibiotics, and stronger ones are often prescribed. (The cause of immunity is often blamed on antibiotics fed to the food supply (chickens and beef) before they are brought to market. )

If your child continues to have problems, your doctor may decide to refer them to an ear, nose and throat (ENT) specialist.

Surgical Treatments for Continual Glue Ear with no Burst Ear Drum

Surgical treatment using grommets (Myringotomy)

If your child has had glue ear and a low grade fever with earaches over a few months and the eardrum has not burst and antibiotics have not worked, the other option is to have a small ventilation drain known as a grommet inserted into the ear drum. The grommet is made of either stainless steel or plastic. This procedure involves making a small hole in the eardrum and inserting the grommet through the hole to keep it open. Initially fluid is sucked out of the middle ear through this hole by your ENT, then once the grommet is inserted it allows air into the middle ear space and lets fluid in the middle ear drain away.

Plastic grommet to drain middle ear fluids

 

This procedure is known as a myringotomy. It is carried out under a short general anesthetic and takes about 15 minutes. Your child will usually be allowed to go home the same day.

What happens to the grommet in the eardrum?

The grommet slowly moves outwards as the eardrum grows, usually 9 - 12 months. It is then naturally pushed out of the eardrum into the outer part of the ear. It moves outwards with earwax until it falls out of the ear canal, often unnoticed. They can also easily be removed at a follow-up ENT appointment.

Over half of children who have grommets do not need further surgical treatment as they get older. However, 30% of children will need grommets inserted a number of times until their glue ear condition improves. Although the eardrum is tough, repeated grommet insertions may eventually scar it, which can sometimes cause a hearing loss as the scar tissue makes the ear drum less resilient i.e. less able to vibrate.


Looking after a child with grommets

The hole in the eardrum for grommet insertion is small, however, it is worth taking a few simple precautions to stop water getting into your child's ear:

• Your child should swim on the surface of the water only and not dive.
• Use earplugs or cotton wool with Vaseline to stop soap water getting into the ears when showering or washing their hair.

Flying is actually easier for a child with a grommet. The grommet allows air in and out of the ear as air pressure changes. However, children who have a history of frequent ear infections or have had grommets in the past (but no longer have them) are occasionally at risk of perforation of the eardrum when flying. If you are worried about this, ask your doctor.

About 5% of children with grommets get an ear discharge at some time, often after a cold. This is usually not serious or painful, but it is important to keep your child's ears clean and to consult your doctor as soon as possible. Your doctor will usually prescribe antibiotics or eardrops.

If your child gets a lot of discharge, gently clean their ears using a twist of clean cotton wool or a very soft cloth. Never use a cotton-tipped ear cleaning stick as you may go too far into the ear and cause damage. If infections are treated quickly, the ears will get back to normal with the grommets in place in most children.


Other surgical treatment for glue ear

Other surgical treatment for glue ear involves an 'adenoidectomy' or surgical removal of the adenoids. The adenoids are located above the tonsils, at the back of the throat and are thought to assist the body in its defense against incoming bacteria and viruses by helping the body to form antibodies. With ear infections, the adenoids often swell, usually due to an infection in the immediate area, in this case, the middle ear. However, the reverse is also true. If there is an infection in the throat and the tonsils and adenoids swell, they can sometimes cause a middle or inner ear infection.

Adenoids get larger between birth and four years of age and then become progressively smaller. By adulthood they have disappeared altogether.

An adenoidectomy is commonly carried out in children over the age of three and is thought to help stop a child from getting glue ear again. Removing their adenoids does not harm a child. Adenoids are removed through the mouth under general anesthetic and the child is usually allowed to go home the same day.

How you can help your child with glue ear

If your child has glue ear condition, you can do a number of things to help:

• Make sure your child has been properly assessed by your doctor who may refer you to an ENT specialist.
• If you suspect that an allergy is causing glue ear, ask the ENT specialist about this.
• Avoid smoking near your child.

While waiting to see if glue ear clears up on its own or waiting for grommet surgery, children sometimes have reduced hearing for quite some time and will need help with communication. During this time, they may need to use a hearing aid and have support at home and school. Here are some ways in which you can make communication easier with your child:

• Reduce background noise when talking to your child, for example turn down the television.
• Attract their attention before you start speaking to them.
• Put your head at their level. Do not shout.
• Speak clearly. Do not exaggerate mouth movements.
• Let family and teachers know about the problem.
• Remember that glue ear usually stops being a problem well before puberty.

Predisposition factors for Otitis Media and Glue Ear

There are factors that can increase the risk of a child being susceptible to otitis media and glue ear:

Stress

Many children suffer from stress today. Modern children spend many hours in day care institutions with a high noise level and limited space. Another stress inducing factor can be the changed social pattern, where many children live with a single divorced parent. Stressed parents may also transmit some of the stress to their children. Stress causes the immune system to deteriorate, and opportunistic infections take advantage of children with low immune resistance.

Allergy and otitis media

The role of allergy as one of the major cause of otitis media has been firmly established in the medical literature. Most of the children are allergic to food or inhalants or both. The mucous membranes are particularly affected by milk allergy. Allergic reactions cause blockage of the Eustachian tube by two mechanisms:

• Inflammatory swelling of the tube, and inflammatory swelling of the nose, causing the Toynbee phenomenon (swallowing when both mouth and nose are closed, forcing air and secretions into the middle ear). One illustrative study of 153 children with ear aches demonstrated that 93,3% of the children were allergic to foods, inhalants or both (Mc. Mahan 1981).

Bottle feeding

Recurrent ear infection is strongly associated with early bottle feeding, while breastfeeding of minimum 6 month has a protective effect. Whether this is because of cow's milk intolerance or the protective effect of mother's milk against infection has not yet been proven. It is probably a combination of both. Another fact is, that it is not a good idea to bottle feed a child lying on her back, as it may lead to regurgitation of the bottles contents into the middle ear.