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Swimming and grommets.

Background. Traditionally, children with tympanostomy ventilating tubes or grommets, were advised that water should not enter their ears in order to prevent ear infections. This group of children has been considered somewhat handicapped regarding swimming. We conducted a prospective study to determine if there is a ralation between suppurative otitis media and surface swimming in chidren iwth grommets.

Methods. Forty-two children with tympanostomy ventilating tubes were included in this study. Of the 42 children, 22 were swimmers and 20 were nonswimmers, who served as the control groups. The age range was 3 to 12 years, and there was no difference in the age distribution between the groups. Surface swimming was allowed without earplugs or a bathing cap, although it was mandatory to use polymyxin B-neomycin-hydrocorisone eardrops at bedtime on the day of swimming. No diving was allowed.

Results. Three of 22 swimmers and 2 of 20 nonswimmers developed otorrhea. In 4 of the 5 children, the otorrhea was followed by an upper respitatory tract infection. In all cases, a bacterial culture revealed Pseudomonas. The ear drainage was easily controlled with local otic treatment in all the patients.

Conclusions. Taking into consideration the possible risks of infection and bearing in mind the value of joy of swimming to children and parents, families should be reassured that surface swimming does not increase the risk of infection in children with tympanostomy tubes.

Key word. Swimming; middle ear ventilation; otolaryngology.

Plastic ventilating tubes (grommets) have been used in the treatment of middle ear effusions for nearly 40 years.[1] Physician recommendations regarding swimming for children with tympanostomy tubes vary from a total prohition to no restrictions. Traditionally, children with tympanostomy tubes are advised not to get water in their ears so that ear infections will not occur. These children have been considered to be somewhat handicapped regarding swimming and bathing. Some physicians allow swimming and bathing if earplugs or bathing caps, or both, are used. Our study was conducted in order to determine if there is a relation between suppurative otitis media and surface swimming.

Methods

During a period of 3 years (1990 through 1992) 42 children with plastic ventilating tympanostomy tubes were enrolled in the study. All the patients underwent plastic ventilation tube insertion because of recurrent otitis media or serous otitis media complicated by impaired hearing. The age range was 3 to 12 years. The decision to swim was made by the patient or parents. Surface swimming was allowed without earplugs or bathing caps, although it was mandatory to use neomycin-polymxin-hydrocortisone eardrops a bedtime on the day that the child had been swimming. No diving was allowed.

Twenty-two of the children (12 boys and 10 girls) were swimmers, and 20 (11 boys, 9 girls) were nonswimmers. There was no significant difference between the age distribution of the groups. The 22 swimmers participated in swimming from 4 to 6 times per week. Swimming was done in chlorinated pool water and seawater, without any restrictions. The swimming season lasted for at least 6 months per year (April through September). The duration of swimming was 1/2 to 2 hours each day. The follow-up period lasted between 1:1/2 and 2:1/2 years. The group of non-swimmers served as the control group.

Results

Three of the 22 swimmers developed otorrhea during the follow-up period. Two of them, one boy and one girl, wer 3 years old, and the other child, a boy, was 4 years old. Two of the three patients subsequently developed an upper respiratory tract infection during this period. One patient's parents forgot to administer the otic drops. Bacterial culture revealed Pseudomonas infections in all three patients. In all the children, the ear drainage was easily controlled by administering polymxin B-neomycin-hydrocorisone eardrops for 7 days. Two of the 20 nonswimmers also developed ear drainage during the follow-up period, after an upper respiratory tract infection. Their ages were 3 and 4 years, and both were boys. Bacterial culture revealed Pseudomonas infections in both patients. The ear drainage was easily controlled by administering eardrops for 7 days in both patients.

Discussion

One of the frequent questions asked by parents of a child with tympanostomy tubes is whether the child is allowed to swim or to bathe, and whether there is a risk that the water will pass through the grommets and infect the middle ear.

Marks and Mills[2] found that water pressure of 12.5 to 22.5 cm would be needed to push watrer through a grommet. They concluded that in most patients, no water enters the middle ear during surface swimming, bathing or hair washing. The risk of water entering the middle ear increases if the child participates in underwater swimming or diving.

Chamman[3] and Jaffe and Chestnut[4] reported a lower incidence of otorrhea in children with tympanostomy tubes who swam without using earplugs than in nonswimmers. Earplugs or bathing cap seemed to provide no extra protection when patients used an otic suspension containing polymyxin B, neomycin, and hydrocortisone at bedtime on the day that they swam. Schwatz[] concluded that using otis antibiotic drops routinely after swimming was not necessary.

Approximately 2% of 3% of children with typanostomy tubes will develop acute otorrhea, but it is usually easily treated with topical otic antibiotic medications. Arcand et al[6] reported that otorrhea occurred more frequently in younger children, especially those 0 to 2 years of age. They also noticed that more than 50% of the ear infections were accompanied by an upper respiratory tract infection during tht period. In our study, among both swimmers and nonswimmers otorrhea occurred in the younger children (those 3 to 4 years of age). In four of five patients, it was accompanied by an upper respiratory tract infection.

Smelt and Monkhouse[6] irrigated the middle ear mucoa of guinea pigs with seawater, bath water, swimming pool water, and normal saline (control), and found that only bath water resulted in appreciable inflammation. The level of chlorination in swimming pools should preclude high bacterial counts,[8] but chlorine can act as a local irritant.

Gram-negative organisms such as Pseudomonas, Proteus, Klebsiella, and Escherichia coli may be found in bath water in a high concentration,[9,10] but it is unclear whether bath water increases the risk of ear infections in children with trommets.[11]

Many otolaryngologists recommend earplugs for ocean swimming because of their fear that sand grains might enter the middle ear space through the tympanostomy tube.[5] In our study, 2 of 3 children in the swimmer group developed otorrhea after swimming in a chlorinated pool and one patient after swimming in seawater.

During the follow-up period, 3 of 22 swimmers and 2 of 20 nonswimmers developed ear drainage. Their ages ranged from 3 to 4 years. In 4 of cases, the otorrhea was followed by an upper respiratory tract infection. In all 5 patients, bacteriawl cultures revealed Pseudomonas. The ear drainage was easily controlled with local otic (polymxin B-neomycin-hydrocortisone) treatment for 7 days in all the patients. No significant difference was observed between swimmers and nonswimmers.

Conclusions

In spite of the consensus in the medical literature, some pediatricians and ear specialists still recommend that water should not enter the child's ear if a ventilating tube has been inserted. The purpose of this study was to focus on this topic and to show that surface swimming is not detrimental to the health of the child. Taking into consideration the possible risks that and bearing in mind the value and joy of swimming to children and parents, the family should be reassured that surface swimming does not increase the risk of infection in patients with tympanostomy tubes.

References

[1.] Armstrong BW. A new treatment for chornic secretory otitis media. Arch Otol 1954; 59:653-4.

[2.] Marks NJ, Mills RP. Swimming and grommets. J R Soc Med 1983; 76:23-6.

[3.] Chapman DF. Swimming and grommets. Clin Otolaryngol 1980; 5:420.

[4.] Jaffe BF, Chestnut H. Are water and tympanostomy tubes compatible. J Laryngol Otol 1981; 91:563-4.

[5.] Schwartz RH. Recommendations for swimming for children with ear infection and/or associated complication. Pediatr Infect Dis J 1992; 11:58-9.

[6.] Arcand P. Gauthier P, Bilodeau G, et al. Post-myringotomy care: A prospective study. J Otolaryngol 1984; 13:305-8.

[7.] Smelt GJC, Monkhouse WS. The effect of bath water, sea water and swimming on the guinea pig middle ear. J L Laryngol Otol 1985; 99:1209-16.

[8.] Department of Health and Social Security Welsh Office and Ministry of Housing and Local Government. Reports of public health and medical subjects. No. 71, HMOS, London, 1969.

[9.] Aylife GAJ, Brightwell KM, Collins GJ, Lowbury GJL. Varieties of aseptic practice in hospital wards. Lancet 1969; 2:1117-9.

[10.] Aylife GAJ, Bab JR, Collins BJ Davies J, Deverill C, Varney J. Disinfection of baths and bathwater. Nurs Times 1975; 71: 22-3.

[11.] Pringle MB. Swimming and grommets. Children with grommets should be allowed to swim. BMJ 1992; 304:198.
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Title Annotation:swimming for children with plastic ventilating tubes in their ears
Author:Cohen, Herman A.; Kauschansky, Arieh; Ashkenasi, Arie; Bahir, Arieh; Frydman, Moshe; Horev, Zeev
Publication:Journal of Family Practice
Date:Jan 1, 1994
Words:1489
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