bDepartment of Ear, Nose and Throat Surgery, Epsom General Hospital, Epsom, Surrey, UK
Abstract
Myringotomy and grommet insertion is one of the most common operations performed in Europe today, with an estimated 70,000 being carried out annually in Britain alone [Lancet 1 (1984) 835]. Otorrhoea is a common postoperative complication. There is controversy about the degree to which surgical asepsis should be maintained during the operation. This prospective study of 35 patients (70 ears) undergoing grommet insertion was carried out to evaluate the efficacy of two differing degrees of surgical asepsis. Using each patient as their own control a grommet was inserted into one ear with the surgeon wearing sterile gloves and masks, and the other wearing only clean non-sterile gloves. Discharge in the first 14 days occurred in five ears, three cases belonging to the former group and two to the latter. The results indicate that there is no significant difference in the incidence of postoperative otorrhoea using either of the above methods, and demonstrate that this operation may be performed in a safe but more cost efficient manner.
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doi:10.1016/S0531-5131(03)01116-6
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Contents
1. Introduction
Ear discharge is the most common complication following grommet insertion [1]. It may be due to intrinsic pathology of the middle ear, the operative technique or a combination of the two [2]. Methods of aseptic precautions for this procedure vary a lot from surgeon to surgeon. Some perform this operation wearing sterile gloves, masks, and even gowns. Others wear only clean non-sterile gloves or even no gloves at all. The consensus among many otolaryngologists is that the former method does not confer any advantage. It is also much more expensive. However no objective study has been published to consider the efficacy of either method. The aim of this study was to do this and determine whether this very common operation could be carried out in a more cost efficient way.
2. Materials and methods
Clinical data was collated prospectively for 2 months on 40 patients undergoing bilateral grommets insertion on the weekly day case theatre list at Whipps Cross Hospital, London. The indications for grommet insertion ranged from recurrent acute otitis media with otalgia, to glue ear causing deafness, and Eustachian tube dysfunction in adults. Patients undergoing any concomitant surgery such as adeno-tonsillectomy, antral washouts or submucous diathermy were excluded from the study. Shephard grommets were inserted in all cases, with the exception of one patient who had Shah grommets inserted. No prophylaxis in the form of oral or topical antibiotics were used either pre- or postoperatively.
All the grommets were inserted under a short general anaesthetic. Normal aseptic precautions were observed. Sterile gloves and masks were worn for the first ear to be operated on in each patient, the surgeon removing them and donning clean non-sterile gloves for the other ear. The grommets were inserted using a no touch technique. The type of effusion found at myringotomy was recorded.
The patients were all seen 2 weeks postoperatively in the outpatient's clinic. Those with discharge had swabs taken and sent off for culture. Five patients were excluded from the study as a result of not returning for follow-up within the stipulated period. This left 35 patients (70 ears, i.e. 35 ears in each group) in the study.
2.1. Statistical analysis
The two groups of ears and their discharge rates were compared using McNemars tables for paired alternatives and a Chi-squared test.
3. Results
During the period of study 40 patients underwent bilateral grommet insertion with no concomitant surgery. Thirty-five patients were eventually seen 2 weeks postoperatively. Twenty-one were male and fourteen were female and their ages ranged from 1 to 57 years with a mean age of 10 years. Sixteen of them were having grommets for the first time, 12 for the second and seven had already had two or three previous sets of grommets.
A total of five patients (14.29%) subsequently developed otorrhoea of one ear (5 ears or 7.14%), with no one having bilateral ear discharge. Of the discharging ears, three (4.29%) belonged to the sterile gloves/mask group and two (2.9%) belonged to the clean gloves only group. This difference was not statistically significant (Chi-squared=0.2, 0.8<p<0.9). The other patient variables showed no statistically significant difference in their discharge rates.
Bacteriology of the discharging ears yielded growth of Pseudomonas in two of the ears whilst the other three had mixed growths. The five patients with discharging ears were all successfully treated with a combination of oral and topical antibiotics. These were started empirically, and amended later if necessary. Opinion on the management of postgrommet otorrhoea is divided, but a survey carried out in the United Kingdom in 1990 by Robb and Johnston [3] showed that a similar proportion of General Practitioners and Consultant Otolaryngologists prescribed a combination of oral and topical antibiotics simultaneously.
4. Discussion
Various studies have been carried out to see how to reduce the risk of surgical contamination during grommet insertion, and thus reduce postgrommet otorrhoea by
- (a) Using different types of grommets [4].
- (b) Preparation of the ear canal or use of prophylactic topical antibiotics [5, 6, 7].
- (c) Use of a no touch technique [8].
None of these studies have shown any significant outcome in reduction of postoperative ear discharge.
Our limited study shows no significant difference in the incidence of postgrommet otorrhoea between the sterile gloves/mask group and the clean gloves only group. We suspect the same would have held true if no gloves had been worn at all.
In this study the patient discharge rate was 14.29% which is in keeping with other reports on postgrommet otorrhoea [2, 5, 9]. Four of the five ears which developed discharge had thick mucoid effusions at myringotomy, the remaining one having had a thin serous effusion (Fig. 1). While this may suggest that ears with mucoid effusions are more prone to early postgrommet otorrhoea a statistically significant difference was not proved (p>0.1). This might be due to the relatively small numbers in our study. Studies by Baldwin and Aland [5], and Scott and Strunk [6], reported significant associations between mucoid effusions and early postgrommet discharge.
It is interesting to note that in our study none of the ears with no effusion at myringotomy subsequently developed any discharge (Fig. 1).
5. Conclusions
It would seem from all the above that early postoperative discharge is probably related more to pre-existing middle ear pathology rather than the surgical technique. The cost of a pair of clean non-sterile latex gloves is approximately one thirtieth that of the price of a pair of sterile gloves. Considering the vast numbers of grommet insertions performed in Europe every year substantial savings could be made. The results of this prospective, albeit small study, indicate that this very common operation may be carried out in a less clinically fastidious but safe and more cost-effective manner.