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Otorhinolaryngology Otorhinolaryngology |
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Otology Case
You are a GP and a mother comes in with her eight year-old daughter.
The mother tells you that the girl’s teacher has been worried about the girl’s hearing in class.
MCQ 1
MCQ 2
Your history and examination reveal that this eight year old girl has had symptoms for six months, where she often goes off task at school and appears to not hear instructions.
Her mum has noticed that at home she doesn't turn her head when her name is called.
The family identifies as being Maori.
On examination you find that she appears healthy with no gestalt impressions of a syndromic condition. Her ear drums are difficult to examine because of the presence of wax and the examination is otherwise unremarkable.
MCQ 3
You are now the ENT surgeon who is seeing this little girl.
You find that she has bilaterally dull ear drums with visible air-fluid levels. The tympanogram supports the finding that there is an effusion.
Jot down what you think the next step should be.
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The next step would be to discuss the benefits and risks of ventilation tube (grommet) insertion with the whanau.
Grommets are placed under a general anaesthetic, where an incision is made into the tympanic membrane. The grommet allows for a controlled perforation in the tympanic membrane that aerates the middle ear and stops negative pressure and effusion forming.
Grommets last, on average, 3 – 9 months and then fall out by themselves. They can be effective after a single insertion or may need to be put in repeatedly until the underlying Eustachian tube dysfunction settles. A second operation is usually performed with a simultaneous adenoidectomy as the adenoid can contribute to the obstruction of the Eustachian Tube orifice.
The whanau elects for grommet insertion and this is performed without complication.
You see them in a follow up appointment at 3 months after surgery.
The grommets are still in-situ and the symptoms have improved. Repeat tympanograms support well-functioning grommets.
How would you best manage this patient going forward?
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The most important aspect here is educating the child’s relatives about the prognosis. The main points to cover are:
- The grommets will likely fallout by themselves but they should have a check with their GP in around 6 months to ensure this has happened
- After the grommets have fallen out, the problem may return and if it does, they should see their GP to be referred back
- Eustachian tube dysfunction can persist into teenage years, particularly in high risk patients
- They should see their GP if she gets ear discharge as she can develop acute otitis media with grommets in-situ
(N.B. grommets are also used to treat recurrent acute otitis media).
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