Are grommets (ear tubes) always inserted bilaterally?

Grommets (Ear Tubes) Are Not Always Inserted Bilaterally

Grommets are not always inserted bilaterally, though bilateral insertion is recommended in most clinical scenarios involving children with otitis media. 1

Clinical Scenarios for Grommet Insertion

Bilateral Insertion (Most Common)

The American Academy of Otolaryngology-Head and Neck Surgery guidelines specifically recommend bilateral tympanostomy tube insertion in:

• Children with bilateral otitis media with effusion (OME) for 3 months or longer AND documented hearing difficulties 1
• Children with recurrent acute otitis media (AOM) who have unilateral OR bilateral middle ear effusion at the time of assessment 1

Unilateral Insertion (Less Common)

Unilateral grommet insertion may be appropriate in:

• Cases where only one ear has persistent middle ear effusion
• Situations where the contralateral ear has a contraindication to tube placement
• Research settings where comparative studies are being conducted 2

Evidence Supporting Bilateral vs. Unilateral Insertion

The 2013 and 2022 clinical practice guidelines from the American Academy of Otolaryngology-Head and Neck Surgery emphasize bilateral insertion in most clinical scenarios 1. This recommendation is based on:

1. The natural history of otitis media as typically affecting both ears
2. The goal of optimizing hearing and reducing recurrent infections in children
3. The need for a single anesthetic procedure rather than potentially requiring a second procedure later

Historical research has sometimes used unilateral grommet insertion as a research methodology to compare outcomes between treated and untreated ears in the same patient 2. In these studies, researchers inserted grommets in only one ear (typically the right ear) while using the other ear as a control. However, these study designs do not reflect current clinical practice recommendations.

Factors Influencing the Decision

The decision for unilateral versus bilateral insertion should consider:

• Presence of effusion in one versus both ears
• Hearing status in each ear
• History of recurrent infections in one versus both ears
• Anatomical considerations that might contraindicate placement in one ear

Potential Pitfalls

1. Undertreating bilateral disease: Inserting grommets in only one ear when both ears have chronic effusion may leave persistent hearing loss and infection risk in the untreated ear.

2. Unnecessary anesthesia exposure: If unilateral tubes are placed initially but the contralateral ear later requires treatment, this would necessitate a second anesthetic procedure.

3. Asymmetric outcomes: Research has shown that ears treated with grommets have better short-term hearing outcomes than those treated with paracentesis alone, with only 1% of ears with grommets having hearing losses exceeding 30 dB HL compared to 20% in untreated ears 2.

In conclusion, while grommets can technically be inserted unilaterally, current clinical practice guidelines recommend bilateral insertion in most clinical scenarios involving children with bilateral disease or recurrent acute otitis media with effusion in either ear at the time of assessment.