Insertion of grommets
Grommet insertion — also called myringotomy and ventilation tube insertion — is one of the most commonly performed surgical procedures in paediatric practice and is frequently performed in adults as well. A small tube is placed through a tiny incision in the eardrum to ventilate the middle ear, bypassing the dysfunctional Eustachian tube. The procedure addresses a range of middle ear conditions caused by inadequate Eustachian tube function and is associated with immediate restoration of hearing and substantial reduction in the frequency and severity of middle ear infections.
The Eustachian Tube and Its Role
The Eustachian tube is a narrow, oblique passage approximately 35mm long in adults (shorter and more horizontal in children) that connects the middle ear to the nasopharynx. It serves three functions: pressure equalisation (opening transiently to equilibrate middle ear pressure with atmospheric pressure), drainage of middle ear secretions into the nasopharynx, and protection of the middle ear from pharyngeal pathogens and pressure changes.
When the Eustachian tube is not functioning normally — whether from developmental immaturity, mucosal oedema from infection or allergy, mechanical obstruction by enlarged adenoids, or chronic dysfunction — the consequences are predictable: negative middle ear pressure, accumulation of secretions, hearing loss, and vulnerability to infection. Grommet insertion solves these problems mechanically by providing an alternative pathway for air to enter and fluid to drain from the middle ear, irrespective of Eustachian tube function.
Conditions Treated with Grommets
Types of Ventilation Tube
Several designs of grommet are available, differing in their expected duration of function:
Short-Term Grommets (Standard)
The most commonly used type, made from silastic (medical-grade silicone) or titanium. They have a cylindrical or bobbin-shaped design and are intended to remain in the eardrum for nine to twelve months before being extruded spontaneously as the eardrum heals. This duration is generally sufficient to span the period of Eustachian tube dysfunction in most children, who will have outgrown the condition by the time the grommet extrudes. Shah, Shepard, and Armstrong grommets are common designs in this category.
Long-Term Grommets (T-Tubes)
T-shaped tubes with flanges that anchor them securely in the eardrum, designed to remain in place for two to four years or longer. They are used in situations where long-term ventilation is needed: children with cleft palate or Down syndrome who consistently develop glue ear after standard grommets extrude, adults with chronic Eustachian tube dysfunction, or following certain types of ear surgery. Because they are designed not to extrude spontaneously, T-tubes may need to be removed under anaesthesia, and there is a higher rate of residual perforation after removal compared with standard grommets.
The Procedure in Detail
Grommet insertion is performed under general anaesthesia as day surgery. Children recover rapidly from the anaesthetic — most are awake and eating within an hour of the procedure and go home the same morning. Adults can occasionally tolerate grommet insertion under local anaesthesia in the clinic, depending on the size of the ear canal and the patient’s level of anxiety.
The steps of the procedure are:
- The external ear canal is examined under the operating microscope to confirm anatomy and assess the eardrum.
- A small radial incision (myringotomy) approximately 2mm in length is made in the anteroinferior quadrant of the eardrum — a position that avoids the hearing ossicles and facial nerve.
- Any fluid behind the eardrum is suctioned. In glue ear this may be thick and viscous. The quality and quantity of the fluid is noted.
- The grommet is grasped with fine forceps and placed into the myringotomy incision. It is positioned so that the outer flange sits against the eardrum surface and the lumen is open to the ear canal.
- The ear canal is cleaned and a small cotton pledget placed temporarily to absorb any residual secretion.
Each ear takes approximately five minutes. Where adenoidectomy is being performed at the same time, this adds approximately fifteen to twenty minutes to the procedure.
What to Expect After Surgery
Immediate Improvement in Hearing
Hearing returns to normal immediately after surgery in most patients, once the middle ear fluid has been cleared. Parents often report a dramatic change in their child’s responsiveness and engagement within hours of the procedure. The improvement in hearing is audible to the child: some children describe hearing sounds as louder or clearer than before.
Discharge After Grommet Insertion
A small amount of blood-tinged or mucoid discharge from the ear in the first day or two following surgery is normal and expected — this is residual fluid or secretion from the middle ear draining through the grommet. Persistent or purulent discharge beyond a few days should be assessed.
Water Precautions
While grommets are in place, water should be prevented from entering the ear canal. Bath and shower water is generally not pressurised enough to enter through the grommet lumen, but prolonged submersion of the ear canal increases the risk. For swimming, earplugs or a swim band are generally recommended. Diving and swimming in still, clean pool water at surface level is generally permitted with earplugs — deep diving, swimming in murky water, or activities that significantly pressurised the ear canal should be avoided. Specific advice will be provided at your post-operative visit.
Duration of Function and Extrusion
Standard grommets extrude spontaneously as the eardrum heals and migrates the tube outward — typically nine to twelve months after insertion. The extrusion is usually painless and unnoticed. The eardrum heals completely in the vast majority of cases, leaving no permanent defect. T-tubes require planned removal under anaesthesia at the appropriate time.
Recurrence of Glue Ear
Approximately 20–30% of children will require repeat grommet insertion after their first set extrude, because Eustachian tube function has not yet matured sufficiently. Repeat insertion is generally straightforward. If adenoidectomy was not performed at the first insertion, it is typically recommended at the time of any repeat procedure, as the evidence for adenoidectomy reducing recurrence is strong.
Risks and Complications
Grommet insertion is one of the safest surgical procedures performed in ENT. Serious complications are uncommon:
- Otorrhoea (ear discharge): The most common complication, occurring in approximately 15–25% of children with grommets at some point during their use. Usually managed with antibiotic ear drops. Persistent or recurrent discharge warrants assessment.
- Grommet blockage: The grommet lumen can become blocked with wax, dried mucus, or debris. This is usually managed with ear drops and may require clinic cleaning.
- Early extrusion: Occasionally a grommet extrudes earlier than expected — particularly in ears with very mobile, thin eardrums.
- Persistent perforation: A small residual hole remains in the eardrum after grommet extrusion in approximately 1–2% of standard grommets and 5–10% of long-term T-tubes. Most small perforations are asymptomatic and many close spontaneously over months. Larger persistent perforations may require surgical repair (myringoplasty).
- Eardrum scarring (tympanosclerosis): Calcium deposits in the eardrum are common after grommet insertion and are almost always cosmetic rather than functionally significant.
- Risks of general anaesthesia: The risks are low in healthy children in accredited facilities. The anaesthetist will discuss these at the pre-operative assessment.
Grommets patient handout (PDF) →
Grommet insertion post-operative information (PDF) →
Contact us to arrange a consultation → | Glue Ear → | Ear Infections in Children →
Dr Roth’s Clinical Perspective
Grommets are one of the most effective procedures we perform — the improvement in hearing is typically immediate and the impact on a child’s development and quality of life can be substantial. The most common question at consultation is how long the tubes will last, and the honest answer is that it varies. Standard grommets extrude in about twelve months on average — some earlier, some later. Whether they need replacement depends on whether the underlying Eustachian tube dysfunction has resolved by then. Many children only need one set; some need more. This is not a complication, it is the natural history of the condition.
Water precautions after grommet insertion are an area where the evidence and the standard advice have diverged over the years. The current evidence does not support routine ear plugging for bathing or swimming in most children — the risk of water entry causing otorrhoea is low in normal conditions. I discuss this at the post-operative appointment in the context of each child’s specific situation, including whether they have a history of recurrent ear infections and what their swimming habits are.
— Dr Jason Roth, MBBS, FRACS (ORL-HNS)
Specialist Otolaryngologist & Head and Neck Surgeon
Specialist registration — Otorhinolaryngology, Head & Neck Surgery
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