Grommet Insertion or Removal — Cost, Top Hospitals & Success Rates | MyMedicPlus

Grommet insertion — formally termed bilateral myringotomy and tube insertion (BMT) or ventilation tube (VT) insertion — is one of the most commonly performed surgical procedures in the world, and the most frequent elective operation performed under general anaesthesia in children. The procedure involves making a small incision in the tympanic membrane (myringotomy), aspirating any fluid (effusion) from the middle ear, and inserting a small plastic or titanium ventilation tube (grommet) through the incision. The tube acts as an artificial Eustachian tube, equalising middle ear pressure with the atmosphere, draining residual effusion, and ventilating the middle ear space — preventing the accumulation of fluid (effusion) that causes conductive hearing loss.

The primary indication is otitis media with effusion (OME), commonly known as ‘glue ear’ — a condition in which the middle ear fills with thick, viscous fluid without acute inflammatory signs. OME is almost universal in young children (at least one episode in 80% of children by age 10) and is the most common cause of hearing loss in children. The associated conductive hearing impairment (typically 20–30 dB) impairs speech development, language acquisition, school performance, and quality of life when persistent.

The procedure is typically performed under general anaesthesia in children aged 1–12 years. In adults with OME or eustachian tube dysfunction, myringotomy can sometimes be performed under topical anaesthesia in an outpatient setting, though grommet insertion in adults remains less common and is usually associated with pathological eustachian tube obstruction (e.g., nasopharyngeal tumours, post-radiotherapy fibrosis, chronic rhinosinusitis — all of which must be excluded before grommet insertion).

Grommet removal is generally unnecessary for short-stay grommets, which extrude spontaneously as the tympanic membrane regenerates over 6–18 months. Retained grommets (not extruded by 18–24 months) require surgical removal under general anaesthesia in children to prevent chronic perforation, cholesteatoma formation, or secondary infection. T-tubes (long-stay devices) are specifically intended for prolonged middle ear ventilation and may be retained for 2–4 years before planned removal.

Otitis Media with Effusion (OME / Glue Ear)

The primary indication. OME is defined as the presence of middle ear effusion without acute signs of inflammation (pain, fever, erythema) for at least 3 months with associated hearing loss. The effusion impairs tympanic membrane mobility (detected on tympanometry as a flat Type B tympanogram) and reduces sound conduction through the ossicular chain. In children aged 2–8 years, bilateral OME causes hearing loss of 20–40 dB in both ears — sufficient to impair perception of conversational speech and classroom instruction. The MRC Multicentre Otitis Media Study (MRC TARGET) and subsequent systematic reviews provide the key evidence base for treatment thresholds.

Recurrent Acute Otitis Media (rAOM)

Defined as 3 or more acute otitis media (AOM) episodes in 6 months, or 4 or more in 12 months, causing significant morbidity in terms of pain, antibiotic courses, parental work absence, and child quality of life. Grommet insertion reduces the frequency of AOM episodes by approximately 50–60% — the ventilation tube prevents the middle ear pressure differential and persistent effusion that predispose to secondary bacterial infection. A Cochrane review (Venekamp et al., 2018) confirmed that grommets reduce the number of AOM episodes per year by approximately 1.5 episodes compared with watchful waiting.

Eustachian Tube Dysfunction in Adults

Chronic negative middle ear pressure from eustachian tube dysfunction — caused by chronic rhinosinusitis, allergic rhinitis, nasopharyngeal obstruction, or post-radiation fibrosis — can cause OME, tympanic membrane retraction, and atelectasis. In adults, myringotomy alone (without grommet) allows middle ear ventilation; grommet insertion is indicated when dysfunction is expected to persist.

Barotrauma

Patients unable to equalise middle ear pressure during air travel or diving who develop middle ear barotrauma with haemotympanum or persistent effusion may benefit from myringotomy to drain the haemorrhagic effusion. Grommets are occasionally inserted for patients with chronic barotrauma who must continue to fly.

Cleft Palate-associated OME

Children with cleft palate have near-universal OME due to abnormal levator veli palatini muscle insertion impairing eustachian tube function. Grommet insertion is generally recommended in infancy at the time of lip repair and repeated throughout childhood as tubes extrude.

Patient selection balances the benefits of hearing improvement against the risks of surgery and the natural history of OME (which resolves spontaneously in the majority of children). Current NICE Guideline NG91 (2008, updated 2023) and AAO-HNS Clinical Practice Guideline (Rosenfeld et al., 2016) provide detailed evidence-based criteria:

Indications for Grommet Insertion in Children

• Bilateral OME with hearing loss: Persistent bilateral OME (documented for ≥3 months) with hearing loss ≥25–30 dBHL in the better ear on pure tone audiometry (PTA). The hearing threshold is the primary determinant of surgical benefit, not just the presence of effusion.
• Developmental, educational, or quality-of-life impact: Even with hearing loss below 25 dBHL, grommet insertion is recommended if OME is causing significant delays in speech and language development, educational difficulty, or behavioural problems attributed to hearing impairment.
• Structural tympanic membrane changes: Developing retraction pockets, particularly in the posterosuperior quadrant or pars flaccida, at risk of progressing to cholesteatoma — an aggressive keratinising epithelial disease.
• Recurrent AOM meeting frequency criteria: ≥3 episodes in 6 months or ≥4 in 12 months with otoscopic verification.

Watchful Waiting is Appropriate When

• OME has been present for fewer than 3 months — most episodes resolve spontaneously.
• Hearing loss is mild (<25 dBHL) with no developmental or educational concerns.
• Only one ear is affected (unilateral OME resolves spontaneously more often than bilateral).

Contraindications

• Active upper respiratory tract infection at time of surgery — defer by 2–4 weeks unless urgent.
• Chronic perforation of the tympanic membrane (grommet not required if the membrane is already perforated).
• Suspected nasopharyngeal tumour in adults — must be excluded before grommet insertion.

Short-stay (Standard) Grommets

Short-stay ventilation tubes are designed to extrude spontaneously within 6–18 months as the tympanic membrane regenerates and pushes the tube outwards. Common types include the Shah ventilation tube, Shepard grommet, and Armstrong grommet — all small (1.14–1.27 mm inner diameter), bobbin-shaped tubes. These are appropriate for the first grommet insertion in a child with typical OME, as the majority of OME resolves during the ventilation period and the tube extrudes without need for removal. Spontaneous extrusion rates are approximately 90% within 12 months.

Long-stay (T-tube) Grommets

T-tubes (e.g., Per-Lee T-tube, Reuter bobbin T-tube, Paparella T-tube) are wider-flange devices with a T-shaped cross-section that anchors them in the tympanic membrane, preventing spontaneous extrusion. They are specifically designed for ventilation over 2–4 years or longer. Indications include:

• Repeated grommet insertion (second or third set) in a child whose OME consistently recurs after tube extrusion.
• Cleft palate-associated OME requiring very long ventilation periods.
• Severe or refractory eustachian tube dysfunction in adults.

T-tubes carry a higher risk of persistent perforation after removal (approximately 25–35%) and are reserved for selected cases; they require elective removal under general anaesthesia when ventilation is no longer required.

Surgical Technique: Bilateral Myringotomy and Tube Insertion

1. Patient placed supine; general anaesthesia induced with laryngeal mask airway (LMA) or face mask — intubation is rarely required for this brief procedure.
2. Ear canal cleaned and wax removed under direct visualisation with an operating microscope or endoscope.
3. Radial incision (myringotomy) made in the anteroinferior quadrant of the tympanic membrane with a myringotomy knife — avoiding the posterosuperior quadrant (proximity to ossicles) and the annulus.
4. Middle ear effusion aspirated with a suction cannula; thick ‘glue’ may require thinning with saline irrigation.
5. Ventilation tube placed through the myringotomy using alligator or crocodile forceps; position confirmed under magnification.
6. Procedure repeated for the opposite ear. Total operative time 10–20 minutes.

Concurrent Adenoidectomy

The adenoid pad (nasopharyngeal tonsil) is a reservoir of bacteria that colonises the nasopharynx and contributes to eustachian tube dysfunction through both mechanical obstruction and chronic inflammation. Adenoidectomy at the time of grommet insertion reduces the rate of repeat grommet insertion in children aged ≥4 years. The MRC TARGET study and a 2014 Cochrane review (van den Aardweg et al.) support adenoidectomy concurrent with first grommet insertion in children >3–4 years with recurrent OME or rAOM, as it reduces the need for repeat tube sets by approximately 40–50%. Adenoidectomy is not recommended in children under 2–3 years due to limited adenoid mass and higher anaesthetic risk.

Grommet insertion offers well-documented short-term hearing improvements in children with bilateral OME, with more modest evidence for long-term developmental benefits:

• Immediate hearing improvement: Insertion of ventilation tubes restores normal middle ear pressure and eliminates the conductive hearing loss attributable to effusion within hours to days. Mean hearing improvement is 12–15 dBHL at the speech frequencies (0.5, 1, 2, 4 kHz), typically returning hearing to the normal range. This improvement is sustained for as long as the tube remains in situ and the middle ear remains effusion-free.
• Reduction in AOM episodes: In children with rAOM, grommets reduce episode frequency by approximately 1.5 episodes per year (Cochrane review, Venekamp 2018). Acute infections can still occur as otorrhoea through the patent tube (see Risks), but systemic illness and pain are typically less severe than in AOM behind an intact drum.
• Quality of life: Validated quality-of-life instruments (OM-6 questionnaire) consistently show significant improvement in parental-reported child quality of life following grommet insertion — reduced ear pain, improved sleep, better behaviour, and improved activity participation. The benefit is greatest in children with moderate-severe bilateral hearing loss and significant developmental concerns.
• Language and development: The MRC multicentre TARGET trial randomised 376 children aged 3.25–7 years with bilateral OME to early surgery versus watchful waiting. At 9 months, the surgery group had significantly better hearing and language scores. However, at 12 months, the developmental advantage was no longer statistically significant for most measures — reflecting the high natural resolution rate of OME and the equivalence of long-term outcomes. This finding is why NICE and AAO-HNS guidelines recommend watchful waiting for 3 months before proceeding to surgery.
• Prevention of structural complications: Adequate middle ear ventilation through grommets prevents progressive tympanic membrane retraction (which can lead to cholesteatoma formation) and ossicular erosion from chronic negative pressure.

Grommet insertion is a very safe procedure with a low rate of serious complications, but several clinically relevant adverse effects should be discussed with parents and patients:

Otorrhoea (Ear Discharge)

The most common complication, occurring in approximately 25–75% of children over the lifespan of the tube. Episodes of acute otorrhoea (purulent discharge through the tube) occur when bacteria enter the middle ear from the nasopharynx (Eustachian route), environmental water (bathing, swimming), or from the external ear. Most episodes are brief (3–7 days) and respond to topical antibiotic drops (e.g., ciprofloxacin 0.3% otic drops, ofloxacin 0.3% otic drops). Systemic antibiotics are not required unless there is cellulitis or systemic features. Chronic or recalcitrant otorrhoea (present >6 weeks) requires otoscopy to assess tube patency and consideration of microbiological culture to guide antibiotic selection.

Persistent Tympanic Membrane Perforation

After spontaneous tube extrusion or surgical removal, the tympanic membrane heals in approximately 97% of short-stay (bobbin) grommet cases. Persistent perforations occur in approximately 1–2% after short-stay tubes and 25–35% after T-tube removal. Persistent perforations cause conductive hearing loss and recurrent otorrhoea. They can be repaired electively with myringoplasty (fat plug or paper patch) or tympanoplasty (fascial graft) once the ear has been dry for 6 months and the child is old enough (usually >8–10 years).

Tympanosclerosis

White calcified plaques (calcium phosphate deposits) in the tympanic membrane and middle ear mucosa, seen in up to 30–40% of ears after grommet insertion. Usually asymptomatic and does not cause significant hearing loss unless extensive. Considered a long-term sequela of both OME and grommet-related middle ear inflammation rather than a direct tube complication.

Tube Blockage

Wax, dried secretions, or blood can occlude the grommet lumen, eliminating ventilation benefit. Usually detected on otoscopy; may require softening with topical preparations or revision surgery.

Tube Displacement

The grommet may migrate medially (into the middle ear) or laterally (into the ear canal). Medialised tubes are generally left in situ and monitored; some may be retrieved in theatre if causing symptoms. Lateralised tubes extrude into the canal and are removed at clinic.

Cholesteatoma

A rare but serious complication — keratinising squamous epithelium grows through the grommet tube into the middle ear. Risk is approximately 0.5–1% and is highest with T-tubes and prolonged ventilation. Cholesteatoma requires surgical removal (mastoidectomy).

Anaesthetic Risk

General anaesthesia in healthy children carries a very low mortality risk (approximately 1 in 100,000–300,000 for elective procedures). Modern paediatric anaesthesia techniques (LMA, face mask, rapid inhalational induction with sevoflurane) minimise time under anaesthesia and associated risk for this brief procedure.

Immediate Post-operative Period

Grommet insertion is universally performed as day surgery; the child is discharged home within 1–3 hours of waking from anaesthesia once they are eating and drinking and have appropriate post-operative analgesia. Paracetamol and ibuprofen are sufficient for post-operative pain, which is typically mild. Post-operative antibiotic ear drops (e.g., ciprofloxacin otic) are prescribed by some surgeons for 3–5 days to reduce the risk of early post-operative otorrhoea, though evidence from trials is mixed on benefit of routine prophylactic drops versus placebo.

Water Precautions

The question of whether children with grommets should use ear protection during bathing and swimming is one of the most debated topics in paediatric ENT. A systematic review and the NICE guideline (NG91) concluded that water precautions (cotton wool and Vaseline plugs, earplugs, headbands) during routine bathing and surface swimming are not necessary for most children and are not supported by clinical trial evidence for prevention of otorrhoea. However, diving, submerging the head in unclean water (lakes, rivers, chlorinated pools at depth), and hair washing that results in soap/shampoo water running into the ear canal may increase otorrhoea risk in some children. Individual variation is significant — children who develop recurrent otorrhoea associated with water exposure should use appropriate water protection.

Audiological Follow-up

A post-operative hearing test (pure tone audiogram or free-field audiometry) is performed at 4–8 weeks to confirm successful hearing improvement and document the outcome. Further audiological monitoring is arranged at 6–12 monthly intervals while the tube is in situ. If the tube has extruded and hearing has returned to baseline (no residual OME), the child is discharged from ENT follow-up. If OME recurs with recurrence of hearing loss, re-referral for further assessment is indicated.

Grommet Removal

Short-stay grommets (Shah, Shepard, Armstrong types) extrude spontaneously into the ear canal within 6–18 months in approximately 90% of cases; they are removed from the canal at clinic or fall out unnoticed. Retained short-stay grommets at 18–24 months require elective removal under general anaesthesia. T-tubes require planned surgical removal (typically at 2–4 years post-insertion, or when the middle ear disease has resolved) under brief general anaesthesia. Immediately after T-tube removal, paper patch myringoplasty or fat plug myringoplasty is performed to facilitate tympanic membrane closure and reduce the risk of persistent perforation.

Grommet insertion is among the most cost-efficient surgical procedures in paediatric medicine given its brevity, day-surgery basis, and short anaesthetic time:

• Public health systems (NHS, European social insurance): In the UK, grommet insertion is fully funded on the NHS. Waiting times for non-urgent paediatric surgery vary from 6–18 months. NICE guidance ensures procedures are performed when clinically indicated, with watchful waiting reducing unnecessary operations. There is no direct patient cost for NHS procedures.
• Private surgical fees: In the UK private sector, the all-in cost for bilateral grommet insertion (surgeon + anaesthetist + facility + day case) is typically GBP 1,500–2,500. In Australia, the out-of-pocket cost after Medicare rebate is approximately AUD 800–1,500. In India, the total cost is approximately USD 300–800. In the USA without insurance, outpatient bilateral BMT costs USD 2,000–5,000 including anaesthesia and facility fees.
• Concurrent adenoidectomy: Adds approximately 20–40% to the procedure cost but may reduce the need for repeat grommet insertion (saving the cost and risk of a future procedure).
• Hearing aids as an alternative: Bone-anchored hearing aids (BAHA) on a soft band or softband-worn hearing aids can improve hearing during the watchful waiting period in children with bilateral OME and significant hearing loss, avoiding surgery. Hearing aids cost USD 500–2,000 per device; this is less expensive than surgery for a single episode but requires ongoing maintenance and is less practical for young children who may resist wearing them.
• Indirect costs of untreated hearing loss: School support resources, speech therapy, parental productivity losses from missed school days, and GP visits for AOM represent significant indirect costs of untreated or late-treated OME that are not captured in direct procedure cost comparisons.

Watchful Waiting (Active Observation)

The most important alternative, supported by all major guidelines. OME resolves spontaneously in approximately 50% of cases within 3 months, and 90% within 12 months. Active observation with repeat audiometry at 3-month intervals is appropriate for children with mild bilateral OME (<25 dBHL hearing loss), unilateral OME, or OME of less than 3 months duration. The MRC Multicentre Otitis Media Study showed that at 12 months, long-term hearing and language outcomes were equivalent between early surgery and watchful waiting groups, justifying this conservative approach for most children.

Autoinflation

Autoinflation devices (e.g., Otovent balloon, EarPopper) allow children to self-administer nasal insufflation, equalising middle ear pressure via the Eustachian tube. A Cochrane review (Perera et al., 2013; updated 2015) found autoinflation improved tympanogram outcomes and hearing at 1 month, and NICE recommends it as a non-surgical option for children with OME. It is inexpensive (USD 10–20 per device) and carries no risks. Compliance can be challenging in young children (<3–4 years) who cannot coordinate the technique. It is most effective in mild-moderate OME with a partial eustachian tube dysfunction.

Hearing Aids

Bone-conduction hearing aids (softband-worn BAHA or conventional air-conduction hearing aids) are an effective non-surgical alternative for improving hearing in children with bilateral OME and significant hearing loss, particularly when surgery is contraindicated or the family prefers a non-surgical approach. The hearing aid addresses the symptom (hearing loss) without treating the underlying effusion, so OME-related complications (retraction, recurrent AOM) are not prevented. They are appropriate for children with medical contraindications to general anaesthesia (e.g., severe cardiac or respiratory disease).

Medical Treatments (Limited Evidence)

• Antihistamines and decongestants: No evidence of benefit in OME; not recommended by NICE, AAO-HNS, or SIGN guidelines.
• Antibiotics: Short-term resolution of OME has been shown with amoxicillin-clavulanate in some trials, but benefits are modest and short-lived, with antibiotic resistance implications; not recommended for OME without acute infection.
• Intranasal corticosteroids: Some evidence of short-term benefit in OME associated with allergic rhinitis; may reduce adenoid size and improve Eustachian tube function. A Cochrane review (Simpson et al., 2011) found no statistically significant benefit at 3 months for most outcomes. May be used as an adjunct in children with concurrent allergic rhinitis.
• Grommets plus adenoidectomy vs grommets alone: Concurrent adenoidectomy with first grommet insertion in children aged >3–4 years reduces the rate of repeat grommet insertion by 40–50% (MRC TARGET evidence). Adenoidectomy alone (without grommets) has a moderate effect on OME resolution and is an option for children with primarily obstructive adenoid hypertrophy.