01Purpose and principlesWhat the treatment does and how it fits into care.
Grommet insertion and adenoidectomy address related but distinct aspects of childhood ear disease. The tube bypasses poor Eustachian tube ventilation by maintaining an opening in the drum, while removal of adenoid tissue can reduce a contributing nasopharyngeal problem. The decision should start with the child’s measured hearing, daily listening and the course of illness. It should not start with a presumption that every visible effusion needs an operation.
NICE NG233 provides the surgical decision framework for OME in children under 12. Recurrent acute infections, nasal obstruction and sleep-disordered breathing can provide other reasons for specialist discussion, but they require their own assessment rather than automatic transfer of one indication to another. The child and family should understand observation, autoinflation where feasible and hearing devices as well as surgery, including what each approach can and cannot achieve.
For surgery to be worthwhile, the intended benefit must match an actual problem. Better access to speech can improve participation quickly when hearing loss is a major barrier, but surgery cannot be assumed to resolve every speech, attention or developmental concern. Postoperative audiology closes this loop by checking the result objectively. Continuing hearing loss needs investigation rather than reassurance based only on a tube being visible in the drum.
Key points
- A grommet is a small ventilation tube inserted through the eardrum after a myringotomy.
- For under-12 OME, consider grommets for hearing loss and its impact, using shared decision-making.
- Grommets usually provide temporary ventilation; they do not guarantee permanent resolution of Eustachian tube dysfunction.
- When grommets are planned for OME, NICE advises considering adjuvant adenoidectomy unless there is a palatal abnormality.
- Assess the palate because adenoid removal can expose or worsen velopharyngeal insufficiency.
- Use ear-dry precautions for the first two weeks after grommet surgery under NICE guidance.
- Arrange a postoperative hearing test at six weeks and investigate continuing hearing loss.
- Uncomplicated otorrhoea after grommets is usually treated with a suitable non-ototoxic topical antibiotic course.
02Indications, selection and cautionsWho may benefit, who needs urgent treatment and important alternatives.
Review formal hearing results, laterality, symptom duration, fluctuation and day-to-day impact. Check whether the child has had appropriate reassessment or needs earlier intervention because current hearing difficulty substantially limits daily living.
Examine the ears and consider craniofacial conditions, previous surgery and developmental ability. Children with learning disability or communication difficulty may need a more individual follow-up plan because recurrence is less easily reported.
Before adenoidectomy ask about palatal disorders, previous cleft repair, nasal regurgitation and speech quality, and arrange the appropriate examination. Abnormal anatomy changes the risk-benefit decision and may require specialist cleft-team advice.
Check intercurrent illness, bleeding history, medicines, previous anaesthetic problems and relevant airway symptoms. Confirm that the family can follow fasting, analgesia, transport and postoperative contact instructions.
03Assessment before treatmentTests and checks that guide safe selection.
Read from the initial assessment onwards. Tests may run in parallel in urgent care; first-line, preferred, confirmatory, definitive and gold-standard labels appear only when the chapter explicitly states them.
- 01
Preoperative audiology and tympanometryFirst step - Why
- Confirm a hearing problem compatible with the proposed ear procedure.
- Interpretation and limitations
- Interpret ear-specific hearing results and membrane findings together. A tympanogram showing abnormal mechanics does not alone demonstrate the size of the functional benefit expected from surgery.
- 02
Targeted nasopharyngeal and palatal assessment - Why
- Assess adenoid-related disease and avoid overlooking a palatal risk.
- Interpretation and limitations
- ENT selects examination or endoscopy according to the child’s symptoms and tolerance. Palatal abnormality is particularly important when considering adenoidectomy alongside grommets.
- 03
Anaesthetic assessment and selective preoperative tests - Why
- Identify patient-specific risks before an elective operation.
- Interpretation and limitations
- Tests should follow the child’s history, comorbidities and anaesthetic plan rather than being ordered routinely for every well child. A personal or family bleeding history needs specific evaluation.
- 04
Hearing test six weeks after surgery - Why
- Confirm whether the intervention has corrected the hearing deficit.
- Interpretation and limitations
- NICE recommends testing at six weeks. Persistent loss requires investigation; normal hearing allows an appropriate discharge or individual follow-up plan rather than indefinite routine appointments for every child.
04Treatment approachPreparation, options, escalation and aftercare.
01Choosing treatmentReach a shared procedural decisionFirst stepOME-related hearing loss persists or has a significant effect on daily life.+
- 1Explain observation and hearing-support options alongside grommets, using the child’s hearing and daily difficulties to make the comparison concrete.
- 2Discuss tube-related infection, blockage, extrusion, persistent perforation and drum changes, without presenting hearing improvement as a guaranteed permanent cure.
- 3When planning grommets, consider adjuvant adenoidectomy unless palatal assessment identifies an abnormality; discuss its separate bleeding and velopharyngeal risks.
- 4Agree the procedure and follow-up plan with the family, involving the child in a developmentally appropriate way.
02Procedure and recoverySupport healing and effective follow-upThe child undergoes grommet insertion with or without adenoidectomy.+
- 1The surgical team makes a small drum opening, removes fluid as appropriate and inserts a ventilation tube, using the anaesthetic plan agreed for the child.
- 2Consider a single intraoperative ciprofloxacin ear-drop dose to reduce postoperative otorrhoea and tube blockage, using the surgical protocol and product-specific prescription.
- 3Advise keeping ears dry for two weeks after grommets, including care with bathing and hair washing and avoiding swimming during this initial period.
- 4Give clear recovery and emergency instructions, and book the six-week hearing test before assuming the treatment episode is complete.
03Discharge after grommetsTreat otorrhoea and investigate persistenceFluid or pus drains through a grommet after the immediate postoperative period.+
- 1Examine the child and ear to distinguish an isolated discharge episode from severe infection, a blocked tube or another complication.
- 2Treat uncomplicated otorrhoea with a non-ototoxic topical antibiotic such as a suitable ciprofloxacin preparation for five to seven days, checking the exact licence and dose.
- 3Keep the ear dry during the episode; for recurrent discharge discuss water protection such as earplugs or headbands when swimming.
- 4If otorrhoea remains despite topical treatment, reassess and discuss ENT review; NICE advises considering tube removal when persistent discharge does not respond.
05Regimens, contraindications and interactionsTreatment details and the circumstances that modify them.
Cetraxal Plus for acute otitis media with tympanostomy tubes
For this 3 mg/mL ciprofloxacin plus 0.25 mg/mL fluocinolone single-dose product, instil one 0.25 mL container into the affected ear every twelve hours for seven days. The same dose is licensed for adults and children aged six months or older; reassess persisting symptoms.Check quinolone, corticosteroid and excipient allergy; do not use for fungal or relevant viral otic infection. Warm in the hands and, for a tube-containing ear, pump the tragus four times and maintain the affected ear upwards for around one minute. Stop for hypersensitivity, investigate recurrent or persistent discharge, and use an individual pregnancy benefit-risk assessment or breastfeeding caution where applicable.
06Complications, monitoring and follow-upAdverse effects, response and longer-term review.
- After adenoidectomy check pain control, drinking, breathing and any evidence of bleeding before discharge and during home recovery.
- Confirm whether hearing and everyday listening have improved at the six-week assessment.
- If hearing is normal, discuss discharge with return access, a one-year test when recurrence could be missed, or individual follow-up for additional needs.
- Review ongoing otorrhoea for response to the selected treatment and confirm that repeated courses are not masking another problem.
- Explain that a tube can extrude naturally and that recurrent hearing difficulty afterwards should trigger reassessment.
07Special situationsVariants, exceptions and circumstances that change the usual approach.
Grommets and adenoids have separate risks
A family consenting to a short ear procedure may not understand why an additional operation is proposed. Explain the expected reduction in recurrent effusion and the distinct risk of postoperative bleeding or altered nasal speech.
Check the current age framework
NG233 does not restrict consideration of adjuvant adenoidectomy to an inherited over-four age rule. The recommendation is to consider it with planned grommets unless a palatal abnormality is identified, within individual specialist assessment.
A tube makes a topical route possible
In an uncomplicated infected ear with a patent tube, a suitable drop can reach the middle ear directly. Oral antibiotics are reserved for their own clinical indication rather than being automatic for every discharge episode.
A prophylactic dose is a different prescription
NICE’s single intraoperative ciprofloxacin consideration should not be confused with a full infection course or assumed to share a combination product’s licence. The operating team specifies the preparation and dose in its protocol.
Referred ear pain after adenoidectomy
A sore throat can produce ear pain through shared sensory pathways. Assess the whole postoperative picture, distinguishing expected discomfort from bleeding, dehydration, infection or another complication.
Plan for an imperfect hearing result
A six-week test that remains abnormal should prompt investigation for continued middle-ear dysfunction or coexisting permanent loss. Do not wait until the tube extrudes before addressing the child’s ongoing communication needs.
08Common pitfallsFrequent interpretation and management errors.
- 01
Do not operate for the appearance of fluid alone without considering hearing and its functional impact.
- 02
Do not overlook cleft or other palatal abnormality before adding adenoidectomy.
- 03
Avoid treating postoperative nose or throat bleeding as an ordinary minor symptom that can wait for a routine clinic.
- 04
Do not use aminoglycoside-containing preparations routinely through a grommet or substitute drop concentrations without checking the product.
- 05
A normal early hearing result does not prevent recurrence, so families still need a clear route back to assessment.