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Re: Effect of ventilation tubes (grommets) on quality of life at age 1-2 years

Decision making to operate on young infants with otitis media with effusion (OME) is not easy. This multi-centre randomised control trial concludes that grommets do not have a substantial incremental effect on the quality of life of infants aged 1-2 years with uncomplicated persistent OME.[1] The children were detected by auditory screening at the age of 9-12 months. The two treatment arms were grommets and watchful waiting. The authors noted that certain subgroups of children could benefit from treatment with grommets but the study was unable to define the subgroups which might be a result of the lack of power of the study.

The study does not appear to support the view that a universal screen between 7-12 months of life is worthwhile in terms of surgical intervention. This may support the proposal to drop the health visitor distraction test in the UK following introduction of universal neonatal hearing screening (UNHS). The critical review on the role of neonatal hearing screening recommended systematic appraisal of the role of health visitors in detecting late onset permanent childhood hearing impairment (PCHI) and detecting the effects or signs of persistent OME.[2]

UNHS will soon commence in 20 sites in England which should lead to provision of this screen across the UK. This screen will detect some children with OME as well as children with PCHI. Decisions will have to be made about the follow up and management of such cases.

One danger of well focussed evidence based research is that the whole child perspective may be lost. It is interesting to note the overlap between risk factors for otitis media and children in need as defined by the UK Department of Health framework for assessment.[3][4] A mild fluctuating hearing impairment is likely to have more significant effect on the 3-400,000 children defined as being in need in England.[4]

Watchful waiting should not be confused with doing nothing. The process of watchful waiting for a child of any age should include accurate audiometric and otologic assessment, consideration of language and development followed by quality advice to the family about helping a child with hearing impairment. Such a process should help in all cases and perhaps help define subgoups for whom surgery or amplification (personal or environmental) may lead to improved quality of life. The watchful waiting period can be an opportunity for paediatric audiologists, health visitors and others to consider the wider needs of the child and family at a time when opportunities for universal oversight of children in the early years will diminish.

Dr D V Lang
Associate Specialist Child Health/Audiology
Royal Cornwall Hospitals Trust
Pendragon House, Treliske
Cornwall PL15 3LS, UK

References
(1) Rovers MM, Krabbe PFM, Straatman H, et al. Randomised controlled trial of the effect of ventilation tubes (grommets) on quality of life at age 1-2 years. Arch Dis Child 2001;84:5-49.

(2) Davis A, Bamford J, Wilson I, Ramkalawan T, Forshaw M, Wright S. A Critical review of neonatal screening in the detection of congenital hearing impairment. Health Technol Assessment 1997;1(10).

(3) Haggard M, Hughes E. Screening children’s hearing: a review of the literature and the implications of otitis media. Department of Health and the Medical Research Council. London: HMSO, 1991.