“Mummy – my ear’s wet again!”

Martin Burton, Ear, Nose and Throat doctor, writes for parents and carers about the latest evidence on treatments for ear discharge in children with grommets.

Children have grommets (ventilation tubes) put in their ears for two main reasons. Either because they have persistent “glue ear” or frequent ear infections.   There is a general feeling amongst specialists that grommets don’t usually cause much trouble.   If you ask them to estimate how many children will have an episode of discharge – liquid (sometimes smelly but not always) leaking out of the ear – they are likely to reply “not many”.   Is this true? Or do the specialists based in hospitals just not hear about children being taken to their GPs with leaking ears, and so are unaware of it. Whilst GPs, on the other hand, are only too well aware that this happens quite often.

Grommets and ear discharge

One of the things that a recent Cochrane review showed, is that between one quarter and three quarters of children with grommets will get some ear discharge, when you look for it carefully enough. And this is when you ignore whatever might happen in the first two weeks after the operation. This is thought to be due to a middle ear infection.

When children don’t have grommets, a middle ear infection very often involves a lot of pain and children can wake in the night screaming with it. When the ear drum bursts – as it often does – the pain goes because the pressure producing pain is released. The ear then discharges.

When children have grommets there is no chance for pressure to build up. So some children get no pain at all or it is less than when you don’t have a grommet. But there is still some discharge.

What are the choices when your child’s ear leaks?

Some people have suggested that you just need to “watch and wait” and it will all go away on its own.   But not everyone agrees and all sorts of things have been tried over the years: antibiotic tablets or liquid that children must swallow and ear drops containing antibiotics and – sometimes – also steroids.

There is always a general feeling that nobody wants to give their children antibiotics if they can avoid it. It is not uncommon when you take antibiotics by mouth, to get complications such as rashes and diarrhoea. If we, as a community, take too many antibiotics, it will make bacteria resistant and that isn’t good for anyone.

Ear drops for ear Infection

Antibiotics drops are better than swallowed antibiotics

So what is the best treatment?

The review looked at this. It showed that antibiotic drops (with or without steroids mixed in) were better than swallowed antibiotics. Almost all children (95%) ended up with dry ears at the end of two weeks with drops, compared to 56% with oral antibiotics. These numbers are from just one scientific study but we can be reasonably certain about the results and relatively confident that drops really are better.

What about complications?

Are drops less likely to cause these? The review didn’t find any difference between the chance of getting complications whichever type of treatment you used. But this could be for two reasons. Either there really isn’t a difference – and the drops are as likely to cause rashes and diarrhoea as the tablet.   Or the study just wasn’t big enough to find a difference. This is quite a common thing to see in scientific studies like this. No difference is found between two groups of patients when in truth (if only we could get at “the truth”) there is a difference but it is a small one. The smaller the number of things you are looking for in any study – in this case “complications” – the more people you need in your study to detect a difference.

What did the report say about other treatments?

Ear drops containing antibiotics and steroids worked better than simply watching and waiting. Or using drops that just had steroids in them.

So, on balance, it looks like antibiotic-steroid drops are the best thing to use. But…

…a word of caution

There is one important and very practical thing to bear in mind. The type of antibiotics included in some ear drops are the sort that can damage the inner ear and affect hearing and balance. This type of antibiotic is referred to as an “ototoxic” one as it is “toxic” to the ear (“oto-“ being the Greek word for ear).

For this reason, the leaflet in the box with the ear drops often advises that drops with antibiotics that might be ototoxic aren’t used when a person has a hole in the ear drum). And isn’t a grommet just that – a type of hole in the ear drum? Specialists have considered this carefully. It is known that a middle ear infection can itself cause hearing and balance problems because the infection is “toxic” to the ear.

Weighing things up

boy talking to woman

“Mummy! My ear’s wet again!”

So how do we weigh things up: both a middle ear infection and ototoxic ear drop treatments for that infection can be harmful? Specialists believe that, on balance, the risks of damage to the ear are greater from a middle ear infection with fluid leaking out of the ear than from the drops. So the drops are the “lesser of two evils” provided they are used for a short period and under direct medical supervision. The opposite is also true. It is risky and not at all sensible to use drops containing antibiotics that might be ototoxic, if there is no infection there in the first place, or for long periods. The longer you use the drops for, the greater the chance of harm.

“Mummy…!”

So when young Archie says, “Mummy – my ear’s wet again!”, how might you respond? Perhaps pause for a while to see if the problem sorts itself out. But if not, talk with your GP and decide together whether or not your child should have a short course of antibiotic-steroid ear drops.

Martin Burton reports personal fees from OXENT Ltd,  outside the submitted work.

Link:

Venekamp RPJaved Fvan Dongen TMAWaddell ASchilder AGMInterventions for children with ear discharge occurring at least two weeks following grommet (ventilation tube) insertion. Cochrane Database of Systematic Reviews 2016, Issue 11. Art. No.: CD011684. DOI: 10.1002/14651858.CD011684.pub2.

A plain language summary of this review may be found here.

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Martin Burton

About Martin Burton

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Martin Burton is Director of the UK Cochrane Centre, the unit responsible for supporting Cochrane activities in the UK & Ireland. He is Professor of Otolaryngology, University of Oxford, Honorary Consultant Otolaryngologist, Oxford University Hospitals NHSFoundation Trust and Fellow in Clinical Medicine at Balliol College. He is joint co-ordinating editor of the Cochrane ENT Disorders Group.

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