Grommets and Glue Ear: A Five-Year Follow up of a Controlled Trial

Adenoidectomy for otitis media with effusion (OME) in children

BACKGROUND

Otitis media with effusion (OME) is an accumulation of fluid in the middle ear cavity, common amongst young children. The fluid may cause hearing loss. When persistent, it may lead to developmental delay, social difficulty and poor quality of life. Management of OME includes watchful waiting, autoinflation, medical and surgical treatment. Adenoidectomy has often been used as a potential treatment for this condition.

OBJECTIVES

To assess the benefits and harms of adenoidectomy, either alone or in combination with ventilation tubes (grommets), for OME in children.

SEARCH METHODS

The Cochrane ENT Information Specialist searched the Cochrane ENT Register; Central Register of Controlled Trials (CENTRAL); Ovid MEDLINE; Ovid Embase; Web of Science; ClinicalTrials.gov; ICTRP and additional sources for published and unpublished trials. The date of the search was 20 January 2023.

SELECTION CRITERIA

Randomised controlled trials and quasi-randomised trials in children aged 6 months to 12 years with unilateral or bilateral OME. We included studies that compared adenoidectomy (alone, or in combination with ventilation tubes) with either no treatment or non-surgical treatment.

DATA COLLECTION AND ANALYSIS

We used standard Cochrane methods. Primary outcomes (determined following a multi-stakeholder prioritisation exercise): 1) hearing, 2) otitis media-specific quality of life, 3) haemorrhage.

SECONDARY OUTCOMES

1) persistence of OME, 2) adverse effects, 3) receptive language skills, 4) speech development, 5) cognitive development, 6) psychosocial skills, 7) listening skills, 8) generic health-related quality of life, 9) parental stress, 10) vestibular function, 11) episodes of acute otitis media. We used GRADE to assess the certainty of evidence for each outcome. Although we included all measures of hearing assessment, the proportion of children who returned to normal hearing was our preferred method to assess hearing, due to challenges in interpreting the results of mean hearing thresholds.

MAIN RESULTS

We included 10 studies (1785 children). Many of the studies used concomitant interventions for all participants, including insertion of ventilation tubes or myringotomy. All included studies had at least some concerns regarding the risk of bias. We report results for our main outcome measures at the longest available follow-up. We did not identify any data on disease-specific quality of life for any of the comparisons. Further details of additional outcomes and time points are reported in the review. 1) Adenoidectomy (with or without myringotomy) versus no treatment/watchful waiting (three studies) After 12 months there was little difference in the proportion of children whose hearing had returned to normal, but the evidence was very uncertain (adenoidectomy 68%, no treatment 70%; risk ratio (RR) 0.97, 95% confidence interval (CI) 0.65 to 1.46; number needed to treat to benefit (NNTB) 50; 1 study, 42 participants). There is a risk of haemorrhage from adenoidectomy, but the absolute risk appears small (1/251 receiving adenoidectomy compared to 0/229, Peto odds ratio (OR) 6.77, 95% CI 0.13 to 342.54; 1 study, 480 participants; moderate certainty evidence). The risk of persistent OME may be slightly lower after two years in those receiving adenoidectomy (65% versus 73%), but again the difference was small (RR 0.90, 95% CI 0.81 to 1.00; NNTB 13; 3 studies, 354 participants; very low-certainty evidence). 2) Adenoidectomy (with or without myringotomy) versus non-surgical treatment No studies were identified for this comparison. 3) Adenoidectomy and bilateral ventilation tubes versus bilateral ventilation tubes (four studies) There was a slight increase in the proportion of ears with a return to normal hearing after six to nine months (57% adenoidectomy versus 42% without, RR 1.36, 95% CI 0.98 to 1.89; NNTB 7; 1 study, 127 participants (213 ears); very low-certainty evidence). Adenoidectomy may give an increased risk of haemorrhage, but the absolute risk appears small, and the evidence was uncertain (2/416 with adenoidectomy compared to 0/375 in the control group, Peto OR 6.68, 95% CI 0.42 to 107.18; 2 studies, 791 participants). The risk of persistent OME was similar for both groups (82% adenoidectomy and ventilation tubes compared to 85% ventilation tubes alone, RR 0.96, 95% CI 0.86 to 1.07; very low-certainty evidence). 4) Adenoidectomy and unilateral ventilation tube versus unilateral ventilation tube (two studies) Slightly more children returned to normal hearing after adenoidectomy, but the confidence intervals were wide (57% versus 46%, RR 1.24, 95% CI 0.79 to 1.96; NNTB 9; 1 study, 72 participants; very low-certainty evidence). Fewer children may have persistent OME after 12 months, but again the confidence intervals were wide (27.2% compared to 40.5%, RR 0.67, 95% CI 0.35 to 1.29; NNTB 8; 1 study, 74 participants). We did not identify any data on haemorrhage. 5) Adenoidectomy and ventilation tubes versus no treatment/watchful waiting (two studies) We did not identify data on the proportion of children who returned to normal hearing. However, after two years, the mean difference in hearing threshold for those allocated to adenoidectomy was -3.40 dB (95% CI -5.54 to -1.26; 1 study, 211 participants; very low-certainty evidence). There may be a small reduction in the proportion of children with persistent OME after two years, but the evidence was very uncertain (82% compared to 90%, RR 0.91, 95% CI 0.82 to 1.01; NNTB 13; 1 study, 232 participants). We noted that many children in the watchful waiting group had also received surgery by this time point. 6) Adenoidectomy and ventilation tubes versus non-surgical treatment No studies were identified for this comparison.

AUTHORS' CONCLUSIONS

When assessed with the GRADE approach, the evidence for adenoidectomy in children with OME is very uncertain. Adenoidectomy may reduce the persistence of OME, although evidence about the effect of this on hearing is unclear. For patients and carers, a return to normal hearing is likely to be important, but few studies measured this outcome. We did not identify any evidence on disease-specific quality of life. There were few data on adverse effects, in particular postoperative bleeding. The risk of haemorrhage appears to be small, but should be considered when choosing a treatment strategy for children with OME. Future studies should aim to determine which children are most likely to benefit from treatment, rather than offering interventions to all children.

Multifrequency multicomponent tympanometry in children with a history of ventilation tube insertion

OBJECTIVES

To use multifrequency multicomponent tympanometry (MF-MCT) for evaluating the middle ear mechano-acoustics of children with a history of ventilation tube (VT) insertion and to determine the effects of tube insertion sequelae on middle ear function.

METHODS

A prospective case-control study in a tertiary referral center involving 26 children (51 ears) aged 3-15 years. The children had undergone VT insertion surgery at least one-year previously and had no other known ear diseases. In addition, 13 age-matched healthy controls (26 ears) with no prior history of ear disease were included. The patients and control subjects underwent an otoscopic examination, standard 226 Hz tympanometry, and MF-MCT.

RESULTS

In 13.7% of cases, the VT was still in place in the operated ears. Post-operative myringosclerosis and/or eardrum retraction were noticed in 30% of ears with intact tympanic membranes in the patient group. While patients exhibited a great variability of tympanometric types (with standard 226 Hz tympanometry and tympanometric patterns with 1000 Hz MF-MCT), all cases in the control group had type A tympanograms and 3B1G patterns.

CONCLUSION

The effects of VT treatment on the mechano-acoustics of the middle ear have been revealed in this study. It has also been determined that VT application may increase the mass effect on the middle ear functions, which can be detected in the tympanometric shape and pattern.

Association of tympanostomy tubes with future assistive hearing devices-a population based study

Background

Ear (tympanostomy) tube (TT) placement is a common ambulatory surgery in children. Despite the commonality of this treatment, the long-term effects are unknown. The objective of this study was to determine the rate of permanent hearing loss, as measured by use of a rehabilitative hearing device.

Methods

A retrospective comprehensive population-based cohort study was performed, evaluating all hospitals in the Canadian province of Ontario. Three cohorts of children were constructed: TT – at least one ear tube procedure (n = 193,880), No-TT –recurrent visits to a physician for middle ear disease, did not undergo ear tubes (n = 203,283), and Control – an age/sex matched group who had not undergone ear tubes and who didn’t have repeat physician visits for middle ear disease (n = 961,168). The main outcome measures were risk and odds ratio (OR) of rehabilitative hearing devices.

Results

The TT cohort had a higher risk of obtaining a hearing aid (OR 4.53 vs. No-TT, p < 0.001; OR 10.81 vs. Control, p < 0.001), an FM system (OR 3.84 vs. No-TT, p < 0.001; OR 15.13 vs. Control, p < 0.001), and an implanted bone conduction device (OR 5.08 vs. No-TT, p < 0.001; OR 15.67 vs. Control, p < 0.001).

Conclusions

An association between ear tube placement and long-term need for a rehabilitative hearing device was found. This association warrants future prospective research in this area.

Long-term follow-up of otitis media with effusion in children: comparisons between a ventilation tube group and a non-ventilation tube group

OBJECTIVE

The objective of this study was to investigate the long-term outcomes in children with otitis media with effusion who received either medical treatment or ventilation tubes.

METHODS

We retrospectively analyzed the medical records of 89 bilateral cases of otitis media with effusion in children who were recommended to receive ventilation tube insertion and were followed up for more than 5 years. Tympanic membrane was inspected by otoscopic examination. Hearing was evaluated with pure tone audiometry. The mean duration of follow-up was 8.4 years (range, 5.2-15.7 years). Twenty-three children were treated without surgery, while 22 were treated once by ventilation tube insertion and 44 were treated more than once by ventilation tube insertion.

RESULTS

At the fifth year of follow-up, both groups of children who underwent ventilation tube insertion had more frequent tympanic membrane abnormalities than the medication group (8.7% in those treated without surgery, 72.7% in those treated once by ventilation tube insertion, and 88.6% in those treated more than once by ventilation tube insertion). Common tympanic membrane abnormalities were retraction (27.0%) and tympanosclerotic plaque (23.6%), regardless of the treatment modality. At the fifth year follow-up, the average air-conduction threshold was 10.0 dB (± 6.5 dB) in patients treated without surgery, 15.9 dB (± 11.2dB) in patients treated once by ventilation tube insertion, and 17.8 dB (± 7.6 dB) in those treated more than once by ventilation tube insertion. The audiological difference was significant when we compared the hearing level of children treated by medication without surgery to the two ventilation tube groups.

CONCLUSION

Though ventilation tube insertion can resolve hearing loss quickly, there were more tympanic membrane abnormalities and a decline in hearing levels in our ventilation tube insertion group vs. the observation group measured 5 years later. Physicians should therefore be cautious when applying a ventilation tube in patients with otitis media with effusion and should explain the risks to patients who are a candidate for repeated ventilation tube insertion.

Surgical treatments for otitis media with effusion: a systematic review

BACKGROUND AND OBJECTIVE

The near universality of otitis media with effusion (OME) in children makes a comparative review of treatment modalities important. This study's objective was to compare the effectiveness of surgical strategies currently used for managing OME.

METHODS

We identified 3 recent systematic reviews and searched 4 major electronic databases. Eligible studies included randomized controlled trials, nonrandomized trials, and cohort studies that compared myringotomy, adenoidectomy, tympanostomy tubes (tubes), and watchful waiting. Using established criteria, pairs of reviewers independently selected, extracted data, rated risk of bias, and graded strength of evidence of relevant studies. We incorporated meta-analyses from the earlier reviews and synthesized additional evidence qualitatively.

RESULTS

We identified 41 unique studies through the earlier reviews and our independent searches. In comparison with watchful waiting or myringotomy (or both), tubes decreased time with OME and improved hearing; no specific tube type was superior. Adenoidectomy alone, as an adjunct to myringotomy, or combined with tubes, reduced OME and improved hearing in comparison with either myringotomy or watchful waiting. Tubes and watchful waiting did not differ in language, cognitive, or academic outcomes. Otorrhea and tympanosclerosis were more common in ears with tubes. Adenoidectomy increased the risk of postsurgical hemorrhage.

CONCLUSIONS

Tubes and adenoidectomy reduce time with OME and improve hearing in the short-term. Both treatments have associated harms. Large, well-controlled studies could help resolve the risk-benefit ratio by measuring acute otitis media recurrence, functional outcomes, quality of life, and long-term outcomes. Research is needed to support treatment decisions in subpopulations, particularly in patients with comorbidities.

Otological findings ten years after myringotomy with tympanostomy tube insertion

INTRODUCTION

To study the long-term complications of tympanostomy tube insertion in young children 10 years after surgery.

MATERIALS AND METHODS

In September 2011, the medical records of all patients who had undergone myringotomy with tympanostomy tube insertion between February 2000 and March 2001 at the two general hospitals of Isfahan University of Medical Sciences were studied. Of the 98 patients who fulfilled the inclusion criteria, 82 patients agreed to participate and were enrolled in the study. The complications of the operation were evaluated in these patients.

RESULTS

Of the 164 ears that were operated on, myringosclerosis was found in 17.1%, atrophy of the tympanic membrane in 1.2%, permanent perforation of the tympanic membrane in 0.6% and tympanic membrane atelectasis in 0.6%. None of the patients developed cholesteatoma as a complication of tympanostomy tube insertion.

CONCLUSION

Considering the low risk of serious complications after 10 years, tympanostomy tube insertion is a safe and effective treatment option in the treatment of otitis media with effusion.

Grommets (ventilation tubes) for hearing loss associated with otitis media with effusion in children

BACKGROUND

Otitis media with effusion (OME; 'glue ear') is common in childhood and surgical treatment with grommets (ventilation tubes) is widespread but controversial.

OBJECTIVES

To assess the effectiveness of grommet insertion compared with myringotomy or non-surgical treatment in children with OME.

SEARCH STRATEGY

We searched the Cochrane ENT Disorders Group Trials Register, other electronic databases and additional sources for published and unpublished trials (most recent search: 22 March 2010).

SELECTION CRITERIA

Randomised controlled trials evaluating the effect of grommets. Outcomes studied included hearing level, duration of middle ear effusion, language and speech development, cognitive development, behaviour and adverse effects.

DATA COLLECTION AND ANALYSIS

Data from studies were extracted by two authors and checked by the other authors.

MAIN RESULTS

We included 10 trials (1728 participants). Some trials randomised children (grommets versus no grommets), others ears (grommet one ear only). The severity of OME in children varied between trials. Only one 'by child' study (MRC: TARGET) had particularly stringent audiometric entry criteria. No trial was identified that used long-term grommets.Grommets were mainly beneficial in the first six months by which time natural resolution lead to improved hearing in the non-surgically treated children also. Only one high quality trial that randomised children (N = 211) reported results at three months; the mean hearing level was 12 dB better (95% CI 10 to 14 dB) in those treated with grommets as compared to the controls. Meta-analyses of three high quality trials (N = 523) showed a benefit of 4 dB (95% CI 2 to 6 dB) at six to nine months. At 12 and 18 months follow up no differences in mean hearing levels were found.Data from three trials that randomised ears (N = 230 ears) showed similar effects to the trials that randomised children. At four to six months mean hearing level was 10 dB better in the grommet ear (95% CI 5 to 16 dB), and at 7 to 12 months and 18 to 24 months was 6 dB (95% CI 2 to 10 dB) and 5 dB (95% CI 3 to 8 dB) dB better.No effect was found on language or speech development or for behaviour, cognitive or quality of life outcomes.Tympanosclerosis was seen in about a third of ears that received grommets. Otorrhoea was common in infants, but in older children (three to seven years) occurred in < 2% of grommet ears over two years of follow up.

AUTHORS' CONCLUSIONS

In children with OME the effect of grommets on hearing, as measured by standard tests, appears small and diminishes after six to nine months by which time natural resolution also leads to improved hearing in the non-surgically treated children. No effect was found on other child outcomes but data on these were sparse. No study has been performed in children with established speech, language, learning or developmental problems so no conclusions can be made regarding treatment of such children.

Randomized controlled studies and the treatment of middle-ear effusions and tonsillar pharyngitis: How random are the studies and what are their limitations?

Objective

To determine the applicability and external validity of randomized control studies (RCTs) in the light of patient susceptibilities and vulnerabilities to the sequelae of otitis media with effusion (OME) and tonsillar pharyngitis (T&A) and the composition of their cohorts.

Study Design

RCTs for OME and T&A were analyzed to determine which intrinsic and extrinsic susceptibilities to the otolaryngic disease and its sequelae were included or excluded and the composition of the cohort.

Methods

A Medline and a Science Direct search were performed for all RCTs concerning OME and T&A through 2007. The articles selected to be included in this study are the OME RCTs that reported language and/or hearing outcomes and the T&A RCT studies in which the outcome measure was infection, alleviation of airway obstruction, and/or quality of life. These were analyzed for their inclusion or exclusion of intrinsic and extrinsic susceptibilities to the otolaryngic disease and their sequelae and the composition of the cohort. The pertinent otolaryngologic literature was assessed to determine applicable risk factors.

Results

The analysis of the inclusion or exclusion of risk factors showed that for OME 0 percent were included and 16 percent were excluded, and there were no data for 84 percent. The T&A findings were similar in that 1 percent of risk factors were included, 8 percent excluded, and there were no data for 92 percent. Both the OME and the T&A cohorts data were similar in that approximately half of the suitable candidates completed the study; 25 percent of the OME and 13 percent of the T&A enrolled subjects were either withdrawn or placed into a different experimental group. On the average, with data available, it took 4.6 years to recruit the OME sample and 5.5 years to recruit the T&A sample.

Conclusion

The results of RCTs for these conditions are only applicable to narrowly defined and highly circumscribed populations. They cannot be generalized to the entire patient population because of their limited external validity. Future RCT protocols should be designed to control for the intrinsic and extrinsic susceptibilities that result in a propensity to acquire the disease and/or an exacerbation of the disease's sequelae. These studies would determine the most effective strategies for preventing disorders and/or their deleterious sequelae.

Grommets (ventilation tubes) for hearing loss associated with otitis media with effusion in children

BACKGROUND

Otitis media with effusion (OME), or 'glue ear', is very common in children, especially between the ages of one and three years with a prevalence of 10% to 30% and a cumulative incidence of 80% at the age of four years. OME is defined as middle ear effusion without signs or symptoms of an acute infection. OME may occur as a primary disorder or as a sequel to acute otitis media. The functional effect of OME is a conductive hearing level of about 25 to 30 dB associated with fluid in the middle ear. Both the high incidence and the high rate of spontaneous resolution suggest that the presence of OME is a natural phenomenon, its presence at some stage in childhood being a normal finding. Notwithstanding this, some children with OME may go on to develop chronic otitis media with structural changes (tympanic membrane retraction pockets, erosion of portions of the ossicular chain and cholesteatoma), language delays and behavioural problems. It remains uncertain whether or not any of these findings are direct consequences of OME. The most common medical treatment options include the use of decongestants, mucolytics, steroids, antihistamines and antibiotics. The effectiveness of these therapies has not been established. Surgical treatment options include grommet (ventilation or tympanostomy tube) insertion, adenoidectomy or both. Opinions regarding the risks and benefits of grommet insertion vary greatly. The management of OME therefore remains controversial.

OBJECTIVES

To assess the effectiveness of grommet insertion compared with myringotomy or non-surgical treatment in children with OME. The outcomes studied were (i) hearing level, (ii) duration of middle ear effusion, (iii) well-being (quality of life) and (iv) prevention of developmental sequelae possibly attributable to the hearing loss (for example, impairment in impressive and expressive language development (measured using standardised tests), verbal intelligence, and behaviour).

SEARCH STRATEGY

We searched the Cochrane Central Register of Controlled Trials (CENTRAL) (The Cochrane Library Issue 1, 2003), MEDLINE (1966 to 2003), EMBASE (1973 to 2003) and reference lists of all identified studies. The date of the last systematic search was March 2003, and personal non-systematic searches have been performed up to August 2004.

SELECTION CRITERIA

Randomised controlled trials (RCTs) evaluating the effect of grommets on hearing, duration of effusion, development of language, cognition, behaviour or quality of life. Only studies using common types of grommets (mean function time of 6 to 12 months) were included.

DATA COLLECTION AND ANALYSIS

Data from studies were extracted by two reviewers and checked by the other reviewers.

MAIN RESULTS

Children treated with grommets spent 32% less time (95% confidence interval (CI) 17% to 48%) with effusion during the first year of follow-up. Treatment with grommets improved hearing levels, especially during the first six months. In the randomised controlled trials that studied the effect of grommet insertion alone, the mean hearing levels improved by around 9 dB (95% CI 4 dB to 14 dB) after the first six months, and 6 dB (95% CI 3 dB to 9 dB) after 12 months. In the randomised controlled trials that studied the combined effect of grommets and adenoidectomy, the additional effect of the grommets on hearing levels was improvement by 3 to 4 dB (95% CI 2 dB to 5 dB) at six months and about 1 to 2 dB (95% CI 0 dB to 3 dB) at 12 months. Ears treated with grommets had an additional risk for tympanosclerosis of 0.33 (95% CI 0.21 to 0.45) one to five years later. In otherwise healthy children with long-standing OME and hearing loss, early insertion of grommets had no effect on language development or cognition. One randomised controlled trial in children with OME more than nine months, hearing loss and disruptions to speech, language, learning or behaviour showed a very marginal effect of grommets on comprehensive language.

AUTHORS' CONCLUSIONS

The benefits of grommets in children appear small. The effect of grommets on hearing diminished during the first year. Potentially adverse effects on the tympanic membrane are common after grommet insertion. Therefore an initial period of watchful waiting seems to be an appropriate management strategy for most children with OME. As no evidence is yet available for the subgroups of children with speech or language delays, behavioural and learning problems or children with defined clinical syndromes (generally excluded from the primary studies included in this review), the clinician will need to make decisions regarding treatment for such children based on other evidence and indications of disability related to hearing impairment. This review does not resolve the discrepancy between parental and clinical observation of a beneficial treatment effect and the results in the reviewed RCT showing only a short-term effect on hearing and virtually no effect on development. Is the perceived, often dramatic, effect of grommets only a short-term one? Are some children more sensitive to OME-related hearing loss than others? If so, how do we identify them?Further research should focus upon indications. Studies should use sufficiently large sample sizes to show significant interactions. There is a need to determine the most suitable variables and appropriate "softer" outcomes to be the subject of these interaction tests. Interesting options include measures of speech-in-noise and binaural hearing. The generally modest results in the trials which are included in this review should make it easier to justify randomisation of more severely affected and higher-risk children in appropriately constructed trials. Randomised controlled trials are necessary in these children before more detailed conclusions about the effectiveness of grommets can be drawn.

Tympanic membrane abnormalities and hearing levels at the ages of 5 and 6 years in relation to persistent otitis media and tympanostomy tube insertion in the first 3 years of life: a prospective study incorporating a randomized clinical trial

OBJECTIVE

One current practice guideline recommends myringotomy with tympanostomy tube insertion (M&T) for young children in whom middle-ear effusion (MEE) has persisted for 3 months, and another recommends the procedure after MEE has persisted for 4 to 6 months provided that a bilateral hearing loss of > or=20 dB is present. Sequelae of M&T are not uncommon, but the extent to which these sequelae are attributable to M&T itself or to the middle-ear disease that prompted the procedure or to both has not been clear. Our objective in the present study was to examine the prevalence of various tympanic membrane (TM) abnormalities in otherwise healthy children at the age of 5 years and hearing levels at the age of 6 years in relation to persistent MEE and M&T in the children's first 3 years of life.

METHODS

In a prospective study of child development in relation to early-life otitis media, we randomly assigned 429 children who met specified criteria regarding the persistence of MEE in their first 3 years of life to undergo M&T either promptly (the "early-treatment" group) or after a defined extended period if MEE remained present (the "late-treatment" group). We also followed a representative sample of 241 children who ranged from having no MEE to having MEE whose cumulative duration fell just short of meeting randomization criteria for the clinical trial (the "nontrial" group). Most of the children in each group underwent both otomicroscopic examination at the age of 5 years and audiometric testing at the age of 6 years, at times when they were free of MEE. Among these children, M&T had been performed in 82.3% of those in the early-treatment group, 38.1% of those in the late-treatment group, and 3.0% of those in the nontrial group.

RESULTS

At the age of 5 years, we found 1 or more types of TM abnormality in 1 or both ears in 70.7%, 42.5%, and 9.5% of the children in the early-treatment, late-treatment, and nontrial groups, respectively. Within the 3 groups, however, among children who received tubes, the proportions who had an abnormality of some type were similar, namely, 82.6%, 80.4%, and 83.3%, respectively. The corresponding proportions among children who had not received tubes were 15.4%, 19.3%, and 7.2%, respectively. Segmental atrophy and tympanosclerosis were the most common abnormalities found. At the age of 6 years, mean pure-tone average audiometric thresholds in the early-treatment, late-treatment, and nontrial groups, respectively, were 6.18 dB, 5.49 dB, and 4.63 dB in left ears and 6.17 dB, 6.02 dB, and 4.32 dB in right ears. The thresholds in the early- and late-treatment groups did not differ significantly, but the thresholds in the early- and late-treatment groups were each significantly higher than in the nontrial group. Within the early- and late-treatment groups, we found no significant relation between hearing levels and the presence or type of TM abnormalities.

CONCLUSION

In otherwise healthy children who have persistent MEE during their first 3 years of life, ready resort to M&T results in far more TM abnormalities at age 5 than does selective management in which most children do not receive the procedure. With these differing approaches, however, hearing levels at age 6 do not differ. Regardless of whether children with persistent early-life MEE receive M&T, they have more TM abnormalities at age 5 and negligibly poorer hearing at age 6 than do children who had less or no otitis media. Longer term otologic and audiologic outcomes of persistent early-life MEE and of M&T remain to be determined. In view of 1) the present findings and the remaining uncertainties concerning sequelae, 2) the fact that M&T involves certain immediate risks--albeit minimal--and substantial cost, and 3) previously reported findings in the study's randomized clinical trial that show no developmental advantage at ages 3 and 4 years accruing from children's having received prompt M&T, a prolonged period of watchful waiting seems desirable in otherwise healthy children who are younger than 3 years and have persistent, asymptomatic MEE that is not complicated by sensorineural or severe conductive hearing loss, balance dysfunction, or severe TM retraction.

Follow-up of 366 Ears after Tympanostomy Tube Insertion: Why is it Draining?

OBJECTIVE: Tympanostomy tube insertion is one of the most frequently performed procedures in otolaryngology. Complications, such as otorrhea, tympanosclerosis, and cholesteatoma, have been reported in the literature after its application.

STUDY DESIGN: This study reports the complications encountered with 239 children (439 ears) with a follow-up of 7 to 73 months (median, 29 months) after tympanostomy tube insertion. Hearing results and middle ear pressures were compared and complications were noted in 366 ears that were available for the study.

RESULTS: Otorrhea developed in 3 (0.8%) cases. Tympanosclerosis was seen in 74 (20.2%) cases. Tympanic membrane perforation, retraction pocket, granulation tissue, and atelectasis were seen in 4.6%, 5.2%, 1.1%, and 6%, respectively. No patients developed cholesteatoma after tube insertion. Hearing results were improved postoperatively in 93.4% of patients (median, 14.2 dB) and worse in 6.6% of patients (median, 8.3 dB). The average extrusion time was 7.3 months for grommet and 16.3 months for T-tubes.

CONCLUSION: Multifactor etiologies show some unsolved or misunderstood underlying pathology, or unmentioned environmental factor such as atopy due to rich flora and humidity might exist to consider in the pathophysiology of the otorrhea.

Quantitation and prevalence of tympanosclerosis in a pediatric otolaryngology clinic

OBJECTIVE

To determine the incidence and prevalence of tympanosclerosis (TS) in patients seen in a pediatric otolaryngology clinic.

DESIGN

Prospective observational study.

SETTING

Tertiary care, ambulatory care clinic.

PATIENTS AND OTHER PARTICIPANTS

We conducted a prospective observational study to determine the incidence of TS in 218 patients seen consecutively in a pediatric otolaryngology clinic for otologic and nonotologic reasons. The patient age range was 3 weeks to 30 years; 63% were male and 37% female. Of the 218 patients, 37% (81) had undergone bilateral myringotomy and tube placement (BM&T), and 35% (21) of the 81 showed signs of TS; 63% (137) of the 218 patients had no history of otologic surgery, but 12% (15) of the 137 showed signs of TS.

METHOD

The area of the tympanic membrane affected by TS was determined by otoscopy performed by one viewer, who drew the otoscopic findings on a standardized tympanic membrane template. The area of TS was quantified in terms of percentages by digital image analysis of the scaled drawings.

RESULTS

There was a range of 0.5-59.9% involvement of the tympanic membrane with TS, with the median percentage of involvement being 4.95%. There was an increased percentage of TS with repeat BM&T.

CONCLUSION

This observational study shows that patients who have had BM&T have a higher incidence of TS than those who have not had the surgery. However our findings also show that 38% of the patients in this study who had TS had never undergone BM&T.

Middle ear effusions and structure of the tympanic membrane

OBJECTIVE

To study the effect of various middle ear effusions on the structure of the lamina propria of the tympanic membrane.

METHODS

Sterile and infective middle ear effusions were induced by obstruction of the eustachian tube in specific pathogen-free (SPF) rats and in rats with upper airway infections (URI), respectively. The condition of the tympanic membrane was monitored at regular intervals. After varying survival times, the animals were killed and the tympanic membranes processed for light and electron microscopy.

RESULTS

Sterile effusions always resulted in tympanosclerotic lesions. These lesions did not develop in the presence of primary-infected effusions. These effusions had a severe destructive effect on the lamina propria, followed by fibrosis. Generally, secondary infection did not markedly affect preexisting tympanosclerotic lesions. Moreover, calcification disappeared when re-aeration of the middle ear occurred, but the abnormal collagen depositions persisted.

CONCLUSIONS

Both sterile and infective effusions result in comprehensive irreversible changes in the lamina propria of the pars tensa. The development of tympanosclerosis is confined to sterile effusions. Mechanical injury and compromised vascularization of the lamina propria are likely to be important etiological factors in the development of tympanosclerosis.

Relationships between otitis media sequelae and age

OBJECTIVES

To explore relationships between age and sequelae in two groups of children treated with tympanostomy tubes for chronic otitis media with effusion (OME).

STUDY DESIGN

Cross-sectional study of sequelae among children, adolescents, and adults at 4 years and 9 to 23 years after tympanostomy tube treatment.

METHODS

Group I was examined with otomicroscopy, tympanometry, and audiometry two to four times a year as part of a prospective study, and they were evaluated 4 years after initial tube treatment for this study. Group II received tubes while participating in a chronic OME study, but participants were not followed prospectively after treatment. Nine to 23 years after tube treatment, they were examined with otomicroscopy, tympanometry, and hearing screening.

RESULTS

Among the 5- to 28- year-old subjects, cholesteatoma (< or = 1%) and perforation (< or = 2%) were rare. In Group I, tympanosclerosis increased with age (P < .01), and OME (flat tympanograms) decreased with age in Group II (P < .01). The older cohort was more likely to have severe retractions (18% vs. 4%, P = .02), hearing loss (21% vs. 10%, P < .01), and severe atrophy (24% vs. 0%, P < .01) than the younger cohort, but they were less likely to have flat tympanograms (2% vs. 12%, P < .01).

CONCLUSIONS

Although OME became less prevalent with age, important sequelae (severe atrophy, severe tympanic membrane retraction, hearing loss, cholesteatoma, and chronic perforation) may develop in children with chronic OME as they become adolescents and young adults. Long-term prospective studies are important in defining the progression of sequelae in these children.

Grommet insertion in children: a survey of parental perceptions

Grommet insertion is a widely accepted method of treatment of glue ear in children. There have been questions raised over the last few years about the indications for grommets and whether assessing the hearing alone is an efficient outcome measure. Parental pressure accounts for one of the factors that is taken into consideration when the decision to insert grommets for glue ear is made. In this paper, a prospective questionnaire is used to investigate the parental perceptions of the effectiveness of grommet insertion in children, focusing on alternative outcome measures such as general health, language, and social skills. The results of this survey suggest that grommet insertion causes improvement in many factors other than hearing and this seems to account for the parental pressure for siblings to have grommet insertion.

Current considerations in the etiology and diagnosis of tympanosclerosis

Current concepts of formation of tympanosclerosis in the middle ear are reviewed, as are various clinical considerations. Ultrastructural changes are discussed. A differential diagnosis includes disorders affecting middle ear sound conduction, with the most prevalent involving otosclerosis and cholesteatoma.

Use of the trimmed Shah permavent tube in the management of glue ear

Twenty-five children (mean age six years) with de novo bilateral ear effusions received a 'trimmed' high grade silicone (HGS) Shah permavent ventilation tube in one ear and a conventional polyethylene Shah grommet in the other. The extrusion rate and the degree of tympanosclerosis formation was examined. At 29 months the conventional grommet had extruded in 90 per cent of children and a recurrent middle ear effusion was found in over 50 per cent of these ears. The average length of stay for the conventional grommet was 12.5 months. Five permavent tubes had extruded, one was extruding but the remainder were all in place and patent. Comparing ears on each side the amount of tympanosclerosis was worse in the ear with the conventional grommet in 47 per cent of children and worse on the permanent side in 11 per cent of the children. The 'trimmed permavent' appears to act as a medium to long-term grommet which self extrudes without serious complications. Its use at the primary operation in young children may save repeated insertions of conventional grommets.

Short-term efficacy of tympanostomy tubes for secretory otitis media in children with Down syndrome

Twenty-four children with Down syndrome, aged six to 14 years, were tested with audiometry six to nine weeks after insertion of tympanostomy tubes for bilateral secretory otitis media (SOM). There was no improvement in hearing in 40 per cent of ears, compared with only 9 per cent of ears in 21 age-matched controls with bilateral SOM. Tympanostomy tubes for SOM in children with Down syndrome have a high short-term failure rate, which should be explained to the parents before insertion, and the children should have audiometry tests shortly after the operation. Persistent hearing-loss may require the fitting of hearing aids. Management should involve ensuring that the children are in a situation in which they can hear as well as possible, and making allowances for the hearing impairment.

Otitis Media: Trends in management

Otitis media remains one of the least understood conditions seen by a family physician. More attention to follow up instead of widespread use of antibiotics and decongestant mixtures could improve family practice care of children with middle ear disorders. Greater selection in resorting to surgical management would be helpful. Unnecessary interference is unlikely to be of long-term benefit to either children or their families.

An animal investigation into the effects of tympanostomy on middle ear mucociliary function and cilia

The effect of tympanostomy on guinea-pig middle ear mucosa with particular reference to mucociliary function and cilia was investigated. 13 guinea-pigs were used; 5 acted as the control group with no surgical intervention whilst the other 8 had perforations made in one tympanic membrane. 6 weeks later an attempt was made to measure mucociliary function in all the ears, but this was unsuccessful. However, it would appear that fashioning a perforation in the tympanic membrane causes no histological changes in this animal model.

Can meta-analysis help uncertainty in surgery for otitis media in children

While otitis media is perhaps the most common disease of childhood that receives medical attention, there is little agreement concerning the efficacy of the medical and surgical therapies employed to try to alleviate its symptoms or hasten its natural resolution. Because various surgeries including adenoidectomy, myringotomy, and insertion of tympanostomy tubes are frequently involved in the treatment of otitis media with effusion (OME), it is likely the most expensive condition being managed in national terms. In an attempt to elucidate the most appropriate management of this condition, a meta-analysis was attempted to the 12 randomized control trials of surgical treatments for OME in children, published between 1966 and 1990. Heterogeneity both in the populations and comparisons studied and in the outcomes presented made meta-analysis an inappropriate method for clarifying this area of clinical uncertainty. Important elements in the design of randomized control trials that should be included in future studies of treatment for OME are therefore discussed.

The use of ventilation tubes in secretory otitis media: a review of consultant otolaryngologists

A questionnaire concerning various aspects of secretory otitis media was completed by a random sample of Consultant Otolaryngologists in the United Kingdom. The replies to questions associated with the use of ventilation tubes are presented. The results suggest a wide disparity associated with their use and these findings are discussed with reference to current research.

Late results of treatment with ventilation tubes for secretory otitis media in ENT practice

Ventilation tubes were inserted in 262 children aged 0-9 years for secretory otitis media in the period 1975-78. Treatment according to earlier described procedures during the intubation period, including a final check 3 months and 1 year after extrusion, were done. If recurrences were observed, retubulation was performed. 191 patients (73% (355 ears] have been re-evaluated in February, 1986, to February, 1987, mean observation period 7 1/2 years. Clinical information was obtained. Otomicroscopy, including pneumatic otoscopy, impedance and pure-tone audiometry, has been carried out. Flaccida retractions of varying degree were present in 21% of the ears. Atrophic scars were present in 28%; no case of complete atelectasis was found. Perforations were seen in 2%. Myringosclerosis was seen in 48%. No cholesteatoma or meningitis was found or reported in the entire material. 99% had a pure-tone average (500, 1,000, and 2,000 Hz) of 20 dB-HL or less (5 dB, 60%). Treatment with a ventilation tube seems to give the least complications when installed early in life. The importance of careful follow-up is emphasized. We recommend otomicroscopy at each control check, especially 3 months and 1 year after extrusion.

Otitis media with effusion: is medical management an option?

Persistent middle ear effusion is a common cause of hearing impairment and remains underdiagnosed, particularly among younger children. Detection can be improved by adequate follow-up of otitis media. Decisions on management need to take into account the child's age, duration and severity of illness, degree of hearing impairment, and any evidence of learning difficulties. There is no definitive cure but both medical and surgical treatments may improve outcome. With increasing evidence that antihistamine-decongestant mixtures are ineffective, there may in the future be a role for antibiotics and steroids.

Screening for otitis media with effusion in preschool children

1439 Dutch children were included in a randomised trial to evaluate the efficacy of preschool screening for otitis media with effusion (OME) by 3-monthly tympanometry. Children with bilateral OME on two consecutive occasions were referred for further investigation and then, if parents gave their consent, allocated at random to treatment or non-treatment groups. The effect of childhood screening for OME and subsequent treatment was evaluated by assessment of language performance; no benefit was found, mainly because of the large degree of spontaneous recovery.

A 15 year follow-up of a controlled trial of the use of grommets in glue ear

The long-term natural history of secretory otitis media and the changes induced in the middle ear following grommet insertion are of importance. We report the results 15 years following the unilateral insertion of a Shepard grommet and adenoidectomy for bilateral secretory otitis media. The results suggest that grommets do not protect against attic disease of late onset and induce atrophic scars which do not resolve. Grommets confer no long-term advantages to the hearing when used in the management of childhood secretory otitis media.

Tympanosclerosis, grommets and shear stresses

This paper deals with grommet induced tympanosclerosis. In the first part, patients from a controlled trial of the treatment of bilateral glue ear using unilateral grommet insertion are reviewed 15 years later. Tympanosclerosis due to grommet insertion is summated using computer graphics. Two areas of maximal tympanosclerosis are found, anteriorly and posteriorly midway between the annulus and the umbo. These maximal areas join inferiorly in the classical horse shoe shape. In an attempt to identify reasons for this distribution, the structure of the lamina propria is reviewed, and the changes that occur in tympanosclerosis considered. With this in mind, the tympanic membrane is modelled using finite element methodology to determine the areas of maximal shear stresses. These are found to be in the same position as tympanosclerosis. Such stresses would be increased by the weight of a grommet in situ. These stresses will damage the fibrils interconnecting between the fibrous layers of the lamina propria and this may lead to tympanosclerosis. This raises the question of whether a lighter grommet would decrease the incidence of grommet-induced tympanosclerosis.

Carbocysteine

Carbocysteine is prescribed for conditions characterized by the accumulation of excessive mucus. Although often described as a mucolytic, its function is probably that of mucoregulation, which results in physical changes in accumulated secretions that are favorable in terms of clearance. The chemistry, pharmacology, pharmacokinetics, clinical applications, and toxicology of carbocysteine are reviewed.

Secretory otitis media in the adult

Middle ear effusion secondary to Eustachian tube obstruction may complicate nasal and nasopharyngeal conditions. It may be the presenting feature of a nasopharyngeal tumour. A series of 94 adult cases of middle ear effusion was reviewed. Examination under anaesthetic of the postnasal space was performed in each case, but did not result in the diagnosis of a tumour in any patient in whom it was not strongly suspected clinically on the basis of non-otologic features. Patients having grommet insertion had better hearing for 9 months postoperatively than those having myringotomy alone. Treatment of coexisting nasal, nasopharyngeal or sinus conditions at the time of grommet insertion did not result in any long-term improvement in hearing levels in comparison with those patients in whom no such aetiological factor was identified.

Finnish approach to the treatment of acute otitis media. Report of the Finnish Consensus Conference

The theme of the first consensus conference to be held in Finland was the treatment of acute otitis media. The statements and recommendations accepted by the conference, which was organized according to the National Institutes of Health model, are presented in this report. On the basis of scientific knowledge, clinical experience, and conditions in Finland, the conference delegates concluded that penicillin V, in large doses, is still the drug of first choice in this disease. The importance of surgical drainage of the middle ear was stressed, as was the necessity of careful follow-up of the patient until the condition is completely healed. Decongestants were considered rather useless. In the prevention of recurrent attacks, adenoidectomy but not tonsillectomy was regarded as being of help, tympanostomy of probable benefit, antimicrobial (sulfonamide) prophylaxis worth considering in selected cases, but the effect of pneumococcal vaccination poor. The conference delegates agreed that uncomplicated acute otitis media should, as before, usually be treated by physicians taking care of children at the primary health care level.

Previous ear, nose and throat surgery in children presenting with allergic perennial rhinitis

Children with allergic perennial rhinitis had a four-fold greater likelihood of having had an ear, nose and throat (ENT) operation than children with orthopaedic problems. Whilst the patients who had ENT operations had significantly lower serum IgA and IgE levels than the non-operated patients, there was no difference in clinical features of atopy or allergy skin-test responses between the two groups of rhinitic patients. Forty per cent of the perennial rhinitics had an improvement in symptoms following ENT operations, whereas 90% improved on medical therapy. Thus, patients with perennial rhinitis should have allergy investigations and the benefit of medical treatment prior to consideration for surgery.

Structural changes in the tympanic membrane after repeated tympanostomy tube insertion

In an animal model (rat) a polyethylene tympanostomy tube was repeatedly inserted (four periods lasting 2 weeks) into the upper rear quadrant of the right tympanic membrane (TM). The intervals between the different tubulation periods (TPs) lasted 3 weeks. The corresponding quadrant of the left TM was subjected to repeated myringotomies (four times). The structural changes in the TMs were evaluated otomicroscopically and by histological techniques 3 weeks and 3 months after the final TP. Repeated tympanostomy tube insertion caused a dramatically thickened pars tensa. The thickened areas were characterized by a scar tissue exhibiting sclerotic plaques and a dense connective tissue with bone-like formations. Occasionally, islands of keratinizing stratified squamous epithelium were noted within the thickened pars tensa as well as interrupting the epithelial lining facing the tympanic cavity. Similar structural changes occurred after myringotomy without tube insertion, but they were not so pronounced as after repeated tympanostomy tube insertion. The changes were not restricted to the manipulated quadrants, but also affected the untouched anterior quadrants. Throughout the observation period the anterior quadrants improved, while the rear quadrants remained severely affected.

Untreated persistent middle ear effusion

Seventy-nine children have been followed with persistent middle ear effusion (MEE). They were scheduled for myringotomy and insertion of ventilating tubes (VT). Several factors delayed elective surgery for two-and-a-half years in a closed population. After that period, the children were again examined otomicroscopically and hearing tests were performed. MEE persisted in 69 per cent of the ears, but was absent in 31 per cent. Atelectasis appeared in 26 per cent of the ears; in only a very few cases did severe atelectasis develop. Complications following delay of myringotomy and introduction of VT are minor.

The effectiveness of adenoidectomy in the treatment of glue ear: a randomized controlled trial

One hundred children with glue ear, in whom surgical treatment was indicated, were randomly allocated to 1 of 4 treatment groups. Children in 2 of the groups underwent adenoidectomy plus various combinations of ear operations while in the other 2 groups surgery was confined to the ears. The effect of adenoidectomy was assessed 6 weeks, 6 months and 1 year after surgery by means of audiometry, impedance tympanometry and parental opinion. Improvements in hearing were greater in those children who underwent an adenoidectomy than in those who did not (4.0 dB at 6 weeks; 2.4 dB at 6 months; 0.7 dB at 1 year). However, these differences are of little clinical significance and were only statistically significant (P less than 0.05) 6 weeks after surgery. Middle ear function, measured by tympanometry, revealed a similar pattern of response to treatment. Despite this, 6 months after surgery a higher proportion of parents were satisfied with their child's condition if an adenoidectomy had been performed. Possible explanations of this discrepancy between clinical and parental assessments of outcome are discussed.

Tympanostomy tube complications and efficacy in children of a rural community

In the pediatric group practice and the otolaryngologic practice of our rural community, 41 patients were seen in 1984 with 49 episodes of suppurative discharge after tympanostomy tube insertion. Streptococcus pneumoniae was the most common organism after upper respiratory tract infection. Staphylococcus or enteric organisms were most frequently encountered after bathing or swimming. Most patients regained hearing within normal limits. The benefits of tympanostomy tubes in terms of good hearing and reduced incidence of suppurative otitis media outweigh the risk of transitory suppuration for most patients.

The extrusion rate of grommets

A prospective study was performed to determine the factors influencing the extrusion rate of tympanostomy tubes. Nine hundred thirty-nine tubes were inserted in 589 patients and the extrusion of these tubes was reviewed up to a period of 27 months. The eight tubes used in the survey were the Shepard, Exmoor, Bobbin, Armstrong, Paparella, Shah, Arrow, and collar button. These tubes were inserted in strict rotation, the operator using the designated tube. The position, type of incision, presence of fluid, quality of tympanic membrane, and degree of difficulty of insertion were all recorded at operation. The sex, age, side of operation, and any simultaneous operative procedures were also recorded. The patients were reviewed the day after operation and then every 3 months thereafter until the tube was extruded. A definite pattern was identified for the extrusion of each type of tube. At one end of the spectrum, Exmoor and Shepard tubes were, for the most part, extruded between 6 and 9 months after insertion, while at the other end, most of the collar button tubes were still functioning at 18 months. The design of the tube was the only factor found to be a significant determinant of the extrusion of the tube, although the experience of the surgeon affected the extrusion rate of the Arrow tube. The different dimensions of the Exmoor and collar button tubes are examined and compared.

Fashion, science and technical change: the history of the treatment of glue ear

One reason for the current epidemic in the rate of surgery for glue ear in children is that a shift in treatment has taken place from non-surgical to surgical methods. An historical review of the treatment of this condition reveals the existence of previous 'surgical epidemics' and the importance of two particular factors-technical developments, such as the design of tympanostomy tubes and the introduction of antibacterial drugs; and the lure of panaceas such as ionizing radiation. In addition, it reveals how medical practice is, like most human behaviour, subject to fashion. Despite this, there is a constant desire by practitioners to be adjudged 'scientific' in their work, and definitions of science are equally susceptible to change over time.

Prospective study of tympanosclerosis developing after grommet insertion

Grommets have been used as a treatment for middle-ear effusions since their introduction by Armstrong in 1954. However, it is now accepted that the presence of a grommet in a tympanic membrane is associated with the development of tympanosclerosis in that membrane. Furthermore, it has been shown that this is a progressive phenomenon and that the incidence increases with time to as much as 65 per cent at 3 to 4 years after grommet insertion (Mawson and Fagan, 1972; Tos and Poulsen, 1976). Initially it was suggested that the development of tympanosclerosis might be due to the middle ear disease rather than to the grommet (McKinnon, 1971). However, most recent studies have found that, in bilateral cases of effusion, tympanosclerosis develops more frequently in ears with a grommet than in those without (Brown, Richards and Ambegaokar, 1978; Lildholt, 1979). This prospective study was designed to show the development of tympanosclerosis in the tympanic membrane of children treated for bilateral middle-ear effusions and to elicit any factors from the clinical history and operative technique which might be associated with the pathogenesis of the complication.

Management of middle-ear effusions in children

A double-blind placebo controlled trial of Mucodyne (carbocisteine, Berk Pharmaceuticals), Actifed (triprolidine HC1 and pseudoephedrine HC1, Wellcome) and combined Mucodyne and Actifed in the treatment of middle-ear effusions is reported. The trial was undertaken to assess whether either preparation, alone or in combination, would reduce the number of children requiring surgical treatment for this condition. No statistical difference between the various groups in avoiding surgical treatment was detected. In those patients undergoing surgery, pre-operative treatment with Mucodyne was associated with a significantly greater number of ears restored to a normal appearance and middle ear function as measured by tympanometry. All patients relapsing after surgery belonged to the groups receiving placebo, Actifed or the combination of Mucodyne and Actifed prior to the operation.

Tympanosclerosis of the ear drum in children

Tympanosclerosis of the ear drum in children is associated with secretory otitis media. The tympanosclerotic changes affect the pars tensa and seem to be a dynamic process of new formation together with regress and restoration to normal tissue. Our study includes 90 cleft palate children followed for 7.8 years with a total of 2068 examinations. During the observation period 59% of the ear drums were affected by tympanosclerosis, while only 42% had tympanosclerosis at the last examination. The tympanosclerotic lesion of the ear drum disappeared completely in 30%, seemed stable in 40% and tended to grow steadily in 30% of the ear drums affected. The pathogenesis of tympanosclerosis is not clear, although the inflammation known to exist in secretory otitis media probably plays an important part.

A prospective trial of unilateral grommets for bilateral secretory otitis media in children

Fifty-four children with established chronic secretory otitis media, who had failed to respond to medical measures were treated with adenoidectomy and insertion of 1 grommet on a side chosen at random. Both sides improved and remained significantly improved at 12 months (P less than 0.001). At 3 months, the side with the grommet improved significantly more than the other side (P less than 0.05) but at 12 months there was no significant difference between the 2 sides (P greater than 0.1).

Deafness after otitis media in general practice

Forty-one children between the ages of four and 10 years who presented with acute otitis media were offered routine audiometry six weeks after the attack. Fifteen of the 39 children who attended audiometry failed the test at six weeks, and eight children had a persistent hearing loss of 30 decibels (dB) or greater at three months and so were referred to an ENT specialist. In all these eight children an abnormal tympanic membrane had been detected before audiograms were seen. The mother's opinion of the child's hearing and the assessment by the doctor using tuning fork and whisper test were much less accurate. A total of 17 children had abnormal auroscopic appearances and 11 of these failed their first audiogram, eight failed the second and they were therefore referred.It is suggested that general practitioners should examine the ears of children six weeks after an attack of otitis media. Those children with abnormal tympanic membranes should undergo audiometry at three months, and those whose audiograms fail should then be referred.