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Grommets for glue ear in children

Grommets for glue ear in children

Statutory Guidance

Guidance under review

This guidance is clinically safe but is being updated to reflect the latest evidence identified during a recent review of all published EBI guidance.

Content will be updated and finalised by the end of September 2024.

Summary

This is a surgical procedure to insert tiny tubes (grommets) into the eardrum as a treatment for fluid build up (glue ear) when it is affecting hearing in children.

Glue ear is a very common childhood problem (4 out of 5 children will have had an episode by age 10), and in most cases it clears up without treatment within a few weeks. Common symptoms can include earache and a reduction in hearing.

Often, when the hearing loss is affecting both ears it can cause language, educational and behavioural problems.

Please note this guidance only relates to children with Glue Ear (Otitis Media with Effusion) and SHOULD NOT be applied to other clinical conditions where grommet insertion should continue to be normally funded, these include:

  •  Recurrent acute otitis media
  • Atrophic tympanic membranes
  • Access to middle ear for transtympanic instillation of medication Investigation of unilateral glue ear in adults

Recommendation

The NHS should only commission this surgery for the treatment of glue ear in children when the criteria set out by the NICE guidelines are met:

  • All children must have had specialist audiology and ENT assessment
  • Persistent bilateral otitis media with effusion over a period of 3 months
  • Hearing level in the better ear of 25-30dbHL or worse averaged at 0.5, 1, 2, & 4kHz
  • Exceptionally, healthcare professionals should consider surgical intervention in children with persistent bilateral OME with a hearing loss less than 25-30dbHL where the impact of the hearing loss on a child’s developmental, social or educational status is judged to be significant
  • Healthcare professionals should also consider surgical intervention in children who cannot undergo standard assessment of hearing thresholds where there is clinical and tympanographic evidence of persistent glue ear and where the impact of the hearing loss on a child’s developmental, social or educational status is judged to be significant
  • The guidance is different for children with Down’s Syndrome and Cleft Palate, these children may be offered grommets after a specialist MDT assessment in line with NICE guidance
  • It is also good practice to ensure glue ear has not resolved once a date of surgery has been agreed, with tympanometry as a minimum.

The risks to surgery are generally low, but the most common is persistent ear discharge (10-20%) and this can require treatment with antibiotic eardrops and water precautions. In rare cases (1-2%) a persistent hole in the eardrum may remain, and if this causes problems with recurrent infection, surgical repair may be required (however this is not normally done until around 8-10 years of age).

Rationale for recommendation

In most cases glue ear will improve by itself without surgery. During a period of monitoring of the condition a balloon device (e.g. Otovent) can be used by the child if tolerated, this is designed to improve the function of the ventilation tube that connects the ear to the nose. In children with persistent glue ear, a hearing aid is another suitable alternative to surgery. Evidence suggests that grommets only offer a short-term hearing improvement in children with no other serious medical problems or disabilities.

The NHS should only commission this surgery when the NICE criteria are met, as performing the surgery outside of these criteria is unlikely to derive any clinical benefit.

Patient information

Information for Patients

Surgically inserting grommets (small temporary tubes) helps to let air into the middle part of the ear, allowing fluid (glue ear) to resolve but, should only be carried out when specific criteria are met. This is because the medical evidence tells us that the intervention in children under 12 can sometimes do more harm than good and the symptoms usually clear up of their own accord.

About the condition

Glue ear is a very common childhood problem that affects about four in five children by the age of ten. In most cases, it clears up without treatment in a few weeks. Common symptoms can include earache and a reduction in hearing. If the hearing loss is affecting both ears it can cause language, educational and behavioural problems. The procedure should only be considered if your child has at least three months of persistent hearing loss in both ears.

It’s important you and your doctor make a shared decision about what’s best for your child if they have glue ear. When making that decision you should both consider the benefits, the risks, the alternatives and what will happen if you do nothing.

What are the BENEFITS of the intervention?

The insertion of grommets can be beneficial in certain circumstances. If the hearing loss is affecting both ears and it is persistent, treatment may help prevent challenges your child might face as a result of hearing loss.

What are the RISKS?

The insertion of grommets can be uncomfortable for children. As with most procedures there is the risk of infection and bleeding. There is also a small risk the ear drum could be perforated during the procedure.

What are the ALTERNATIVES?

A simple solution which can sometimes alleviate the problem is to encourage your child to swallow while keeping their nostrils tightly closed. Your doctor may also prescribe a small balloon which is specifically designed to help glue ear by blowing it up the nose. Only a balloon designed for this purpose should be used. Temporary hearing aids could also be worn whilst waiting for symptoms to improve.

What if you do NOTHING?

Doing nothing is usually the best course of action. Most children get better within a few weeks without any treatment.

Coding

Code script

WHEN LEFT(der.Spell_Dominant_Procedure,4) in ('D151') 
AND (der.Spell_Primary_Diagnosis like 'H65[2349]%’ 
OR der.Spell_Primary_Diagnosis like 'H66[012349]%') 
AND ( isnull(APCS.Age_At_Start_of_Spell_SUS,APCS.Der_Age_at_CDS_Activity_Date) between 0 AND 18 
OR isnull(APCS.Age_At_Start_of_Spell_SUS,APCS.Der_Age_at_CDS_Activity_Date) between 7001 AND 7007 )
AND APCS.Admission_Method not like ('2%') 
THEN 'G_gromm'

Code Definitions

Procedure codes (OPCS)

D151 Myringotomy with insertion of ventilation tube through tympanic membrane

Diagnosis codes (ICD)

H652 Chronic serous otitis media
H653 Chronic mucoid otitis media
H654 Other chronic nonsuppurative otitis media
H659 Nonsuppurative otitis media, unspecified
H660 Acute suppurative otitis media
H661 Chronic tubotympanic suppurative otitis media
H662 Chronic atticoantral suppurative otitis media
H663 Other chronic suppurative otitis media
H664 Suppurative otitis media, unspecified
H669 Otitis media, unspecified

Exclusions
apcs.der_diagnosis_all not like '%C[0-9][0-9]%' and 
apcs.der_diagnosis_all not like '%D0%' and 
apcs.der_diagnosis_all not like '%D3[789]%' and
apcs.der_diagnosis_all not like '%D4[012345678]%’

This code captures code in the ranges C00-C99, D00-D09 and D37-D48.
Age range: the codes use the following age ranges 0-18 for children and 19-120
for adults.
— Private Appointment Exclusion
AND apcs.Administrative_Category<>’02’

References

  1. NICE guidance (2008): Otitis media with effusion in under 12s: surgery [CG60]
  2. Browning, G; Rovers, M; Williamson, I; Lous, J; Burton, MJ. Grommets (ventilation tubes) for hearing loss associated with otitis media with effusion in children. Cochrane Database of Systematic Reviews 2010, Issue 10. Art. No.: CD001801. doi: 10.1002/14651858.CD001801.pub3

How up to date is this information?

Last revised December 2023


Changes

December 2023 - Coding updated. August 2022 - Coding updated