Grommets in adults

What a grommet is

A grommet, also called a ventilation tube or tympanostomy tube, is a tiny tube placed in a small opening in the eardrum. It lets air into the middle ear from the ear canal, bypassing the Eustachian tube, the narrow channel from the back of the nose that normally does this job. While the tube is open, fluid drains, pressure stays equal on both sides of the drum, and the hearing loss caused by the fluid usually resolves.

The operation is the same as for glue ear in children; in adults, the reasons and the questions to answer first differ.

Why adults get fluid behind the eardrum

Fluid collects when the Eustachian tube does not open often enough: the lining absorbs the trapped air and fluid seeps in. Hearing becomes muffled and the ear feels blocked. In adults the usual causes are:

• a cold or flu, after which fluid often lingers for weeks;
• allergic rhinitis, chronic sinusitis or nasal polyps;
• a pressure injury from flying or diving (barotrauma);
• smoking, previous radiotherapy to the head and neck, or a repaired cleft palate.

Most fluid that follows a cold clears by itself within weeks to a few months, and waiting, with a hearing test to follow it, is a reasonable first step.

Fluid in one ear: the back of the nose is checked

The Eustachian tube opens into the nasopharynx, the space behind the nose. A growth there, most importantly a nasopharyngeal carcinoma, can block the tube, and fluid in one ear may be its first sign: in a Hong Kong series of people newly diagnosed with this cancer, about four in ten had fluid behind the eardrum. The cancer is uncommon in Europe and much more common in people from southern China and South-East Asia, but an adult with fluid in one ear and no clear explanation should have the nasopharynx examined.

This is usually done in clinic with a thin endoscope after a numbing spray, with an MRI scan or biopsy if anything looks abnormal. Most examinations are normal; in a UK series of 98 adults with fluid, none had a carcinoma. A blocked nose or nosebleeds on one side, a lump in the neck, double vision or facial numbness make the check more urgent.

When a grommet is considered

• Fluid that has persisted for some months, with hearing loss or a blocked feeling that troubles the person, after any nasal problem has been treated.
• Repeated pressure pain or barotrauma in someone who has to fly often.
• An early retraction pocket, where ventilating the ear may stop it deepening.

A hearing test and tympanometry beforehand show how much of the loss is due to the fluid (see interpreting hearing tests).

The procedure

In adults grommets are usually inserted under local anaesthesia, in a clinic room or as a day case; general anaesthesia is kept for a narrow canal or when another procedure is done at the same time.

1. The eardrum is numbed with an anaesthetic placed in the canal, or a small injection into the canal skin.
2. Under the microscope, the surgeon makes a cut of a couple of millimetres in the eardrum (the myringotomy), usually in the lower front part, away from the hearing bones.
3. The fluid is sucked out; the suction is loud but brief.
4. The tube is placed in the opening, with one flange inside the drum and one outside.

It takes a few minutes per ear. A little blood-stained discharge for a day or two is common.

Tube types. Short-term grommets are pushed out by the eardrum itself, usually within months. Long-term tubes, often T-shaped, stay for years; they are used when fluid keeps returning, at the price of a higher chance that a hole remains when they come out.

What results to expect

When the fluid was causing the hearing loss, hearing usually improves at once, often before the person leaves the room, and the blocked feeling goes. If part of the loss is in the inner ear (sensorineural), only the conductive part caused by the fluid improves.

A grommet ventilates the ear; it does not repair the Eustachian tube, so fluid may return once the tube is out. In a UK series of 53 adults, more than half of whom had had grommets before, the tube had come out in 31 by 15 to 27 months, and fluid had already returned in 19 of those 31.

Complications

Most complication figures come from children. Adult series are smaller: in one UK series followed for three to five years, a complication of some kind was recorded in 37%, more often after previous grommets.

• Discharge (otorrhoea), the most frequent problem. A review of 134 studies, mostly in children, found discharge soon after surgery in 16% and later in 26%; it was recurrent in 7.4% and chronic in 3.8%. In a prospective study, 27% of adults had at least one episode while the tube was in, against 14% of children. Antibiotic ear drops work better than antibiotics by mouth.
• Persistent perforation. A hole remained in about 2% of ears after short-term tubes and 17% after long-term tubes. It can be left alone or repaired; see eardrum perforation.
• Tympanosclerosis and thinning. White chalky patches in the drum appeared in about a third of ears, and thin areas in a quarter; they rarely affect hearing.
• Blocked tube, granulation tissue or early extrusion, in roughly 7%, 5% and 4% of ears.
• Rare: a tube that slips into the middle ear (0.5%), or a cholesteatoma (0.7%).

Water: what the evidence says

The trials are in children. In a Cochrane review of two randomised trials, earplugs reduced discharge from 1.2 to 0.84 episodes a year (about 2.8 years of plugs to prevent one episode), and advice to avoid swimming made no measurable difference. Guidelines therefore advise against routine water precautions. There appear to be no trials in adults.

In practice most surgeons advise keeping water out for the first week or two and then allow showering and surface swimming without plugs. Many suggest a plug, or cotton wool with petroleum jelly, for swimming underwater, soapy bath water or lakes and rivers, and while the ear is discharging. Scuba diving is not possible with an open tube. Practice varies; follow the advice given for your own ear.

How long grommets stay

Short-term tubes usually come out on their own: in a series of adults, those that did so came out within 20 months, after 8.6 months on average. The tube falls into the ear canal, often unnoticed, and the eardrum heals behind it. Long-term tubes can stay for years and are often removed deliberately. A check afterwards shows whether fluid, a hole or a retraction remains.

Alternatives

• Watchful waiting with a repeat hearing test, and treating the nose (allergy, sinusitis, polyps).
• Autoinflation: blowing gently against a closed nose, or inflating a small balloon through one nostril. Low-risk; the evidence comes mainly from children.
• Balloon dilation of the Eustachian tube for chronic Eustachian tube dysfunction confirmed on testing; it aims at the cause rather than bypassing it.
• A hearing aid, for persistent fluid when tubes are not wanted.
• A myringotomy alone: the opening closes within days to weeks, so fluid often returns.

Flying with grommets

Flying is fine as soon as it is comfortable. While the tube is open, the middle ear equalises through it, which is why grommets are sometimes used for repeated pressure pain on flying. A blocked tube no longer protects. See flying after ear surgery.

When to seek advice

Call within a day or two for discharge that increases or continues despite drops, worsening pain, or fever. Seek care the same day for facial weakness, severe or spinning vertigo, a sudden drop in hearing, swelling behind the ear, or a severe headache; see when to contact your surgeon.

Sources

• Kay DJ, Nelson M, Rosenfeld RM. Meta-analysis of tympanostomy tube sequelae. Otolaryngol Head Neck Surg. 2001;124(4):374-80. PubMed
• Heaton JM, Mills RP. Otorrhoea via ventilation tubes in adults and children. Clin Otolaryngol Allied Sci. 1993;18(6):496-9. PubMed
• Mohammed H, Qureshi MH, Yates P. Outcomes of examination under anaesthesia of post-nasal space and grommet insertion in adults presenting with otitis media with effusion. J Laryngol Otol. 2021;135(7):620-4. PubMed
• Yung MW, Arasaratnam R. Adult-onset otitis media with effusion: results following ventilation tube insertion. J Laryngol Otol. 2001;115(11):874-8. PubMed
• Chao WY, Wang CF, Chang SJ. Ventilation tube in adults with middle-ear effusion. J Otolaryngol. 1999;28(5):278-81. PubMed
• Sham JS, Wei WI, Lau SK, et al. Serous otitis media. An opportunity for early recognition of nasopharyngeal carcinoma. Arch Otolaryngol Head Neck Surg. 1992;118(8):794-7. PubMed
• Moualed D, Masterson L, Kumar S, Donnelly N. Water precautions for prevention of infection in children with ventilation tubes (grommets). Cochrane Database Syst Rev. 2016;2016(1):CD010375. PubMed
• Steele DW, Adam GP, Di M, et al. Prevention and treatment of tympanostomy tube otorrhea: a meta-analysis. Pediatrics. 2017;139(6):e20170667. PubMed

This page provides general educational information. It cannot replace an individual assessment, which depends on a full history, examination, audiometry and, where relevant, imaging. If you have sudden hearing loss, severe pain, facial weakness, severe dizziness or discharge with fever, seek medical care promptly.