The Journal of Laryngology and Otology August 1990, Vol. 104, pp. 608-610
Comparison of the Goode T-tube with the Armstrong tube in children with chronic otitis media with effusion EIZE W. J. WIELINGA,* M.D.,
GORDON D. L. SMYTH,* M.D.
DSC
Abstract Treatment of otitis media with effusion is focused on reaeration of the middle ear cavity. In achieving longterm aeration, the insertion of ventilation tubes that have a long duration of stay can be beneficial. The results are presented of a trial in which the Goode T-tube was compared with the Armstrong tube. Fifteen children were treated between 1981 and 1986 with a T-tube in one ear and a conventional tube in the other. The results are different with regard to duration of stay in the tympanic membrane. Re-insertions were necessary in 47 per cent in the Armstrong group and in 20 per cent in the T-tube group. Otorrhoea occurred in 20 per cent of the Armstrong and 13 per cent of the T-tube intubated ears. A persistent perforation was present in 6 per cent of the ears in both groups. It is concluded that the Goode T-tube is indicated primarily in cases when long-term ventilation is needed.
Introduction Eustachian tube malfunction is widely considered an important factor in the pathogenesis of chronic otitis media with effusion (OME). Hypoventilation of the middle ear with the accumulation of serous or mucoid fluid are the major clinico-pathological features in this disease entity (Lim and De Maria, 1988). The majority of ears will eventually recover spontaneously. Immediate restoration of hearing as well as prevention of atelectasis, retraction pockets and cholesteatoma that a number of ears will eventually develop, are the main rationale for surgical intervention. The two main procedures performed are adenoidectomy, with or without the insertion of ventilation tubes. Removal of the adenoid is based on the assumption that it plays an important role in both Eustachian tube malfunction and prolonged infection of the middle ear mucosa (Palva et al., 1983). Insertion of ventilation tubes, temporarily substituting the malfunctioning Eustachian tube has been widely used since its introduction by Armstrong in 1954. Evaluation of the effusion and re-establishment of middle ear aeration and thus restoration of hearing, are prompt, which are considerable short-term benefits. Also it has been shown previously that in 80 per cent of ears with pars tensa retraction pockets, progression to cholesteatoma was prevented by inserting short-term ventilation tubes (Smyth et al., 1982). Long-term benefits are thought to be achieved by reversal of the mucosal changes of the middle ear, normalizing secretory function or diminishing the number of secretory elements and restoring the ciliary clearance system (Tos and BakPedersen, 1975; Gundersen and Tonning, 1976). However, recurrence of effusion and failure to prevent ear-
drum atrophy, atelectasis and retraction pockets may occur necessitating re-intubation in at least 20 per cent of ears in different series (Curley, 1986; Smyth, 1986). Success rates improve with longer duration of stay, success being defined as the sufficiency of one intubation only to restore function and prevent irreversible middle ears pathology (Sade, 1979; Smyth etal, 1982). Although long-term ventilation tubes, which have an average duration of stay of more than 30 months (PerLee, 1981; Rothera and Grant, 1985) should theoretically have better results, reports on their performance were not always favourable, mainly because of the complications attributed to their use. Granulation tissue was reported to be formed more frequently in tubes designed for long duration (Sade, 1979), and also high rates of post-extrusion perforations were observed (Per-Lee, 1981; Hawthorne and Parker, 1988). According to several reports the Goode T-tube achieved better results than other long-term tubes with respect to longevity and low complication rate (Eliacher et al., 1983; Rothera and Grant, 1985; Nielsen and Hessel-Andersen, 1985). To ascertain the claims in these reports the second author (G.D.L.S.) initiated a long-term trial to compare the merits of the Goode T-tube with those of the bevelled Armstrong tube. A preliminary report on this prospective randomized study was published in 1986 (Smyth, 1986) and the final results so far are outlined here.
Patients and methods Fifteen patients (9 females, average age study. They were all unsuccessfully treated
From the Department of Otolaryngology, Royal Victoria Hospital, Belfast, Northern Ireland. *Department of ENT, St Radboud Hospital Nijmegen, The Netherlands. Accepted for publication: 31 May 1990. 608
males, average age 7 years; 6 6 years) were admitted to this suffering from bilateral OME, with the standard decongestive
609
COMPARISON OF THE GOODE T-TUBE WITH THE ARMSTRONG TUBE
medication for at least six months. Except for one patient that had undergone an adenoidectomy previously, none had received any prior surgical treatment. The diagnosis of OME was based on the results of otoscopy, pure tone audiometry and tympanometry. Silicone T-tubes (1.1mm internal diameter, 12 mm length) were used after being modified by shortening the shaft by 6 mm and the flanges by 1 mm. Teflon bevelled Armstrong tubes (1.15 mm internal diameter and 7.5 mm length) were used as they were supplied. A T-tube was introduced in one ear and an Armstrong tube in the contralateral. Selection of laterality was determined from a randomized numbers list to provide two matched groups for comparison. The mucoid secretion, its presence a prerequisite for inclusion in this study, was aspirated and the subsequent tubes were inserted in the way prescribed previously (Goode, 1973; Smyth et al., 1982). Follow-up examination was carried out at 3-6 monthly intervals and consisted of otoscopical assessment and establishment of air condition hearing thresholds. Results
The average length of stay for Armstrong tubes was 17.5 months (range 1-56) and for T-tubes 52.5 months (range 5-88). Length of stay is defined as the time between the date of insertion and the date at which the tube was last seen to be in place. The retention after various intervals is compared for the two groups in Table I. The x2 (chi-square) test shows a significant difference in retention after two and three years. The mean follow-up after insertion of the tubes was 6.8 years, and at the time of writing a T-tube was still in place in four ears while all other tubes were extruded. All ears had normal pre- and post-operative bone conduction thresholds. Pre-operative air conduction thresholds greater than 20 dB were present in 13 Armstrong-tubed ears (range 25—40 dB) and 11 T-tubed ears (range 25-40 dB). Post-operatively at the last test with the prosthesis still in situ, all ears intubated with Armstrong's and 14 T-tubed ears had thresholds for air conduction of 20 dB or better. The mean hearing loss was 11 dB in the Armstrong group and 14 dB in the T-tubed ears. Following extrusion, a recurrence of hearing loss due to OME necessitated re-insertion in seven ears (47 per cent) in the Armstrong group and in three ears (20 per cent) in the T-tube group. Success rates therefore were 53 per cent for the Armstrong tube and 80 per cent for the T-tube. TABLE I CASES WITH RETENTION DURING VARIOUS INTERVALS FOR THE TWO GROUPS COMPRISING OF 15 PATIENTS
Retention after: 1 year 2 years 3 years 4 years 5 years 6 years 7 years k 2 X = 10.85, p
Comparison of the Goode T-tube with the Armstrong tube in children with chronic otitis media with effusion EIZE W. J. WIELINGA,* M.D.,
GORDON D. L. SMYTH,* M.D.
DSC
Abstract Treatment of otitis media with effusion is focused on reaeration of the middle ear cavity. In achieving longterm aeration, the insertion of ventilation tubes that have a long duration of stay can be beneficial. The results are presented of a trial in which the Goode T-tube was compared with the Armstrong tube. Fifteen children were treated between 1981 and 1986 with a T-tube in one ear and a conventional tube in the other. The results are different with regard to duration of stay in the tympanic membrane. Re-insertions were necessary in 47 per cent in the Armstrong group and in 20 per cent in the T-tube group. Otorrhoea occurred in 20 per cent of the Armstrong and 13 per cent of the T-tube intubated ears. A persistent perforation was present in 6 per cent of the ears in both groups. It is concluded that the Goode T-tube is indicated primarily in cases when long-term ventilation is needed.
Introduction Eustachian tube malfunction is widely considered an important factor in the pathogenesis of chronic otitis media with effusion (OME). Hypoventilation of the middle ear with the accumulation of serous or mucoid fluid are the major clinico-pathological features in this disease entity (Lim and De Maria, 1988). The majority of ears will eventually recover spontaneously. Immediate restoration of hearing as well as prevention of atelectasis, retraction pockets and cholesteatoma that a number of ears will eventually develop, are the main rationale for surgical intervention. The two main procedures performed are adenoidectomy, with or without the insertion of ventilation tubes. Removal of the adenoid is based on the assumption that it plays an important role in both Eustachian tube malfunction and prolonged infection of the middle ear mucosa (Palva et al., 1983). Insertion of ventilation tubes, temporarily substituting the malfunctioning Eustachian tube has been widely used since its introduction by Armstrong in 1954. Evaluation of the effusion and re-establishment of middle ear aeration and thus restoration of hearing, are prompt, which are considerable short-term benefits. Also it has been shown previously that in 80 per cent of ears with pars tensa retraction pockets, progression to cholesteatoma was prevented by inserting short-term ventilation tubes (Smyth et al., 1982). Long-term benefits are thought to be achieved by reversal of the mucosal changes of the middle ear, normalizing secretory function or diminishing the number of secretory elements and restoring the ciliary clearance system (Tos and BakPedersen, 1975; Gundersen and Tonning, 1976). However, recurrence of effusion and failure to prevent ear-
drum atrophy, atelectasis and retraction pockets may occur necessitating re-intubation in at least 20 per cent of ears in different series (Curley, 1986; Smyth, 1986). Success rates improve with longer duration of stay, success being defined as the sufficiency of one intubation only to restore function and prevent irreversible middle ears pathology (Sade, 1979; Smyth etal, 1982). Although long-term ventilation tubes, which have an average duration of stay of more than 30 months (PerLee, 1981; Rothera and Grant, 1985) should theoretically have better results, reports on their performance were not always favourable, mainly because of the complications attributed to their use. Granulation tissue was reported to be formed more frequently in tubes designed for long duration (Sade, 1979), and also high rates of post-extrusion perforations were observed (Per-Lee, 1981; Hawthorne and Parker, 1988). According to several reports the Goode T-tube achieved better results than other long-term tubes with respect to longevity and low complication rate (Eliacher et al., 1983; Rothera and Grant, 1985; Nielsen and Hessel-Andersen, 1985). To ascertain the claims in these reports the second author (G.D.L.S.) initiated a long-term trial to compare the merits of the Goode T-tube with those of the bevelled Armstrong tube. A preliminary report on this prospective randomized study was published in 1986 (Smyth, 1986) and the final results so far are outlined here.
Patients and methods Fifteen patients (9 females, average age study. They were all unsuccessfully treated
From the Department of Otolaryngology, Royal Victoria Hospital, Belfast, Northern Ireland. *Department of ENT, St Radboud Hospital Nijmegen, The Netherlands. Accepted for publication: 31 May 1990. 608
males, average age 7 years; 6 6 years) were admitted to this suffering from bilateral OME, with the standard decongestive
609
COMPARISON OF THE GOODE T-TUBE WITH THE ARMSTRONG TUBE
medication for at least six months. Except for one patient that had undergone an adenoidectomy previously, none had received any prior surgical treatment. The diagnosis of OME was based on the results of otoscopy, pure tone audiometry and tympanometry. Silicone T-tubes (1.1mm internal diameter, 12 mm length) were used after being modified by shortening the shaft by 6 mm and the flanges by 1 mm. Teflon bevelled Armstrong tubes (1.15 mm internal diameter and 7.5 mm length) were used as they were supplied. A T-tube was introduced in one ear and an Armstrong tube in the contralateral. Selection of laterality was determined from a randomized numbers list to provide two matched groups for comparison. The mucoid secretion, its presence a prerequisite for inclusion in this study, was aspirated and the subsequent tubes were inserted in the way prescribed previously (Goode, 1973; Smyth et al., 1982). Follow-up examination was carried out at 3-6 monthly intervals and consisted of otoscopical assessment and establishment of air condition hearing thresholds. Results
The average length of stay for Armstrong tubes was 17.5 months (range 1-56) and for T-tubes 52.5 months (range 5-88). Length of stay is defined as the time between the date of insertion and the date at which the tube was last seen to be in place. The retention after various intervals is compared for the two groups in Table I. The x2 (chi-square) test shows a significant difference in retention after two and three years. The mean follow-up after insertion of the tubes was 6.8 years, and at the time of writing a T-tube was still in place in four ears while all other tubes were extruded. All ears had normal pre- and post-operative bone conduction thresholds. Pre-operative air conduction thresholds greater than 20 dB were present in 13 Armstrong-tubed ears (range 25—40 dB) and 11 T-tubed ears (range 25-40 dB). Post-operatively at the last test with the prosthesis still in situ, all ears intubated with Armstrong's and 14 T-tubed ears had thresholds for air conduction of 20 dB or better. The mean hearing loss was 11 dB in the Armstrong group and 14 dB in the T-tubed ears. Following extrusion, a recurrence of hearing loss due to OME necessitated re-insertion in seven ears (47 per cent) in the Armstrong group and in three ears (20 per cent) in the T-tube group. Success rates therefore were 53 per cent for the Armstrong tube and 80 per cent for the T-tube. TABLE I CASES WITH RETENTION DURING VARIOUS INTERVALS FOR THE TWO GROUPS COMPRISING OF 15 PATIENTS
Retention after: 1 year 2 years 3 years 4 years 5 years 6 years 7 years k 2 X = 10.85, p
