Grommets and swimmers ear

No abstract available.


Objectives
To present Cochrane and Literature review on the opinions of the role of water/swimmer precautions in children with ventilation tubes (grommets).

Search methods
The Cochrane ENT trials search register, central register of trials (central 2018), Pubmed, EMBASE, WEB of science, clinical trial.gov, and additional sources for published articles.The month of the search was September 2018.

Selection criteria
Randomised controlled trials recruiting children (0-17 years) with ventilation tubes and assessing the effect of water precautions (Avoidance or swimming/bathing restrictions) and mechanical (earplugs, moulds, swim seal, hats, bands) and review articles on the recent same topics.

Grommets (Ventilation tube)
These are tiny tubes made of different materials (plastic, metal, etc.) put in the eardrums as temporary on artificial eutascian tube.They are to improve middle ear ventilation, hearing improvement and drainage when eutascian tube is blocked in otitis media with effusion.

Grommets
Grommets are inserted under general anaesthesia as day procedures, while myringotomy and drainage aspiration of fluid are done.It can be done with adenoidectomy and/ or tonsillectomy, if indicated.Grommets are not a cure but a temporary drainage and ventilation of the middle ear to improve

Types of grommets
There are three types, short (6-8 months), medium (8months-2years) and long term (years until removed) grommets.Short term grommets can mostly fall out by themselves.

Discharging ear post grommets insertion
The function of grommets is to drain fluid from the middle ear and ventilate the middle ear.Post grommets discharges are normal and expected after grommets insertion not necessary due to middle ear infection.
The patients may have discharges with or without exposure to water (swimming).The absolute reduction in the episode of otorrhea appears to be very small unlikely to be clinically significant.The long term complications of grommets are Biofilm (discharges), perforation, cholesteatoma, tympanosclerosis and hearing loss.The rate of otorrhea ranges from 3.5% -41% in different studies (Table I) 4 .They all show significant number of otorrhea in children with grommets, irrespective of swimming.This is not surprising because the children for grommets are those with recurrent otitis media with effusion group already susceptible to chronic infection the function of grommets is to drain fluid (so otorrhea means the grommets are doing their job).

Does water pass through grommets?
Marks and Mills in (1983) theorized that before water passes through a grommet the tympanic membrane must be fixed and like in impedance studies 10-20cm H 2 O of pressure. 4,5It will take 2.8cm H 2 O pressure to push water through a 1.1mm grommet, hence needing between 12.8 to 22.8cm H 2 O pressure to push water through a grommet into the middle ear.Pashley and  Scholl (1984) indicated that the pressure of soapy water was little lower at 1.68cm H 2 O and for Corticosporin otic drop it is 0.9cm H 2 O. 6 Both authors concluded that in the case of normal surface swimming, bathing and hair washing, it is unlikely that water will enter the middle ear, but when the child dives (underwater) may be at risk.They also concluded that a functioning Eustachian tube like in normal ears is necessary to allow water into the middle ear due to pressure changes by the Eustachian tube through the nasopharynx.Roland (1978) proposed that it is safer for a child with a tendency to recurrent otitis media to swim with grommet in situ than without one. 7Grace et al (1987) concluded swimming may adversely affect middle ear pressure, which is not protected by grommets through the nasopharynx. 8

Does it matter if water enters middle ear?
Smelt and Monkhouse (1985), found very little effects when sea water and swimming pool water are compared to normal saline controls but bath water showed more pronounced reaction and inflammation. 9

Grommets and swimming
The earlier studies (Table II) show that whatever precautions are made very little benefit are derived because otorrhea is common after grommets. 4rplugs appear to confer no benefit, and as Groves (1983)  points out that, the occluded ears will muffle sounds and in order to be watertight, earplugs must fit well hence requiring close adult supervision.Both factors will decrease the fun and enjoyment of swimming. 10

Author's conclusion
In conclusion, evidence suggests that swimming without ear protection can be safely permitted for children with grommets. 11It is probably advisable to warn parents firstly that otorrhoea is a recognised complication of grommets irrespective of swimming but that treatment is usually simple and effective; secondly there may be a slightly increased risk of infection if children dive; and thirdly, it would seem prudent to advise against dunking the head under the water at bath time.Chapman (1980) wrote that the advice to forbid swimming in children with grommets 'causes distress, delays the acquisition of a life-saving skill and is based on no published evidence' 4,2 .
The baseline rate of ventilation tube otorrhoea and the morbidity associated with it is usually low and therefore careful prior consideration must be given to the efficacy, costs and burdens of any intervention aimed at reducing this rate.While there is some evidence to suggest that wearing ear plug reduces the rate of otorrhea in children with ventilation tubes, clinicians and parents should understand that the absolute reduction in the number of episodes of otorrhoea appears to be very small and is unlikely to be clinically significant.Based on the data The page number in the footer is not for bibliographic referencing www.tandfonline.com/oemd25 available, an average child would have to wear ear plugs for 2.8 years to prevent one episode of otorrhea. 1,9,11Some evidence suggests that advising children to avoid swimming or head immersion during bath does not affect rates of otorrhoea, although good quality data are lacking in this area.Currently, consensus guidelines therefore recommend against the routing use of water precautions on the basis that the limited clinical benefit is outweighed by the associated cost, inconvenience and anxiety.Future high-quality studies could be undertaken but may not be thought necessary.It is uncertain whether further trials in this area would change the findings of this review or have an impact on practice.Any future high-quality research should focus on determining whether particular groups of children benefit more from water precautions that others, as well as on developing clinical guidelines and their implementation. 1,2,10,11

Figure 2 :
Figure 2: Types of grommets short and long term

Table I :
4ummary of papers recording rates of otorrhoea in children with grommets4

Author and date Number of patients Number of ears Overall rate of otorrhea Persistent otorrhoea Swimming Type of grommet
e = percentage of EARS with otorrhoea.p = percentage of PATIENTS with otorrhoea.

Table II :
Summary of papers comparing otorrhoea rates in swimming and non-swimming patients 4