Eustachian tube dysfunction in children with cleft palate: A tympanometric time‐to‐event analysis

Comparative Efficacy of Different Therapeutic Interventions in Eustachian Tube Dysfunctions: A Cross-Sectional Analysis

Eustachian tube dysfunction (ETD) affects a significant portion of the population, manifesting symptoms that impact the quality of life. Despite the prevalence of ETD, there remains a notable gap in comprehensive studies exploring the condition's dynamics within specific demographic contexts, particularly within Saudi Arabia. This study aimed to assess the prevalence and severity of ETD across different demographic groups, to evaluate the efficacy of various treatment modalities, and to identify key predictors of treatment response in a Saudi Arabian cohort. A cross-sectional study was conducted from June 2022 to May 2023 in tertiary care hospitals in the Aseer region, Saudi Arabia. Participants included adults diagnosed with ETD, assessed through clinical symptoms, otoscopic examinations, audiometric evaluations, tympanometry, and the ETDQ-7 questionnaire. The study incorporated advanced diagnostics such as nasopharyngoscopy and pressure equalization tube function tests and involved 154 participants, revealing significant variations in ETD severity, with the 46-60 age group exhibiting the highest mean ETDQ-7 score of 4.85, and urban residents displaying lower severity scores compared to rural counterparts. Pharmacological interventions were most effective, achieving the highest symptom relief and audiological improvement rates of 87.78%. Multivariate regression highlighted age, geographic location, and treatment modality as key predictors of treatment efficacy, with notable interaction effects between climate conditions and treatment types influencing outcomes. The findings underscore the heterogeneity in ETD presentation and the differential efficacy of treatment modalities.

Tympanostomy Tube Otorrhea: Microbiological Differences Between Children with and Without Cleft Palate

OBJECTIVE

To characterize and compare microbiological profiles in tympanostomy tube otorrhea for children with and without cleft palate.

DESIGN

Retrospective cohort study.

SETTING

Pediatric otolaryngology and multidisciplinary cleft/craniofacial clinic at a single tertiary care center.

PATIENTS

Children with and without cleft palate <18 years of age who underwent tympanostomy tube placement between 2017-2021.

MAIN OUTCOME MEASURES

Otopathogen profiles and antibiotic resistance patterns in ear culture specimens obtained in children presenting for treatment of recalcitrant post-tympanostomy tube otorrhea.

RESULTS

Of the 886 children with tympanostomy tubes placed between 2017-2021, 345 (38.9%) had clinically significant otorrhea defined as requiring at least one otolaryngology visit for treatment. Children with cleft palate had higher rates of otorrhea (50.0% versus 35.7%; P < .01). In the 128 cultures obtained, Staphylococcus aureus was the most common organism in both groups present in 39.8% of cultures; 49% were methicillin-resistant (MRSA). Pseudomonas aeruginosa was also frequently isolated (20.0% versus 23.4%, P = .69) in children with and without cleft palate. Collectively, fluoroquinolone resistance was observed in 68.6% and 27.6% of the S. aureus and P. aeruginosa isolates, respectively, however, no differences in fluoroquinolone resistance were observed between cleft and non-cleft cohorts. Corynebacterium species were isolated more frequently in children with cleft palate (26.7% versus 6.1%, P < .01), a finding of unclear significance.

CONCLUSIONS

Recalcitrant post-tympanostomy tube otorrhea is more common in children with cleft palate. MRSA was the most common isolate, which was commonly resistant to first-line fluoroquinolone therapy.

Determination of Tympanostomy Tube Types for Otitis Media with Effusion in Patients with Cleft Palate: Comparison between Paparella Type 1 and Type 2 Tubes

This study examined the effects of different types of tympanostomy tubes in pediatric patients undergoing cleft palate (CP) surgery in order to provide guidance for the proper insertion of tympanostomy tubes in the management of otitis media with effusion (OME). A total of 101 ears with middle ear effusion in 51 patients with CP were included in this study. Patients underwent palatoplasty and tympanostomy tube surgery at the same time. The type of tube inserted (Paparella type 1 or 2), the severity of CP, and types of palatoplasty surgeries were investigated. All patients were followed up for at least 6 months, and recurrence rates, complications, and reinsertion surgery were evaluated. The rate of OME recurrence after spontaneous tube extrusion was significantly higher in the type 1 group than in the type 2 group (44.3% vs. 19.4%, respectively, p = 0.016). Persistent eardrum perforation was more common in the type 2 group than in the type 1 group (41.9% vs. 12.9%, respectively, p = 0.001). The tube reinsertion rate was higher in the type 1 group than in the type 2 group (22.9% vs. 3.2%, respectively, p = 0.015). The tube reinsertion rate decreased to 8.6% in cases of palatoplasty with Sommerlad's technique, even with type 1 tube insertion, which was not significantly different from the reinsertion rate in the type 2 group (3.7%, p = 0.439). The Paparella type 1 tube would be a better choice in cases of palatoplasty performed using Sommerlad's technique, particularly considering the higher rate of persistent eardrum perforation after extrusion associated with the Paparella type 2 tube. Alternatively, a larger size type 2 tube may be considered in other surgeries to decrease the frequency of recurrence and tube reinsertion.

Three-Dimensional Assessment of Eustachian Tube in Patients With Cleft Palate Versus Controls: A CBCT Study

To compare the morphological characteristics of the Eustachian tube (ET) between patients with cleft palate and healthy controls with the use of cone-beam computed tomography (CBCT).

Retrospective assessment of treated nonsyndromic patients with cleft palate and a control group.

CBCT images of 51 patients with cleft palate who had previously undergone surgery to close the cleft palate and a control group of 51 patients were included in this study. Syndromic patients were excluded.

The cleft group were divided into 3 groups according to the palatoplasty technique, which was done in the infancy period to close the cleft palate (Nadjmi modification of Furlow, Sommerlad, and V-Y pushback). Finally, ET length (ETL), ET angle, and auditory tube angle (ATA) were measured in all patients.

The ETL, ETA, and ATA in the cleft and the normal control groups were 29.73 ± 3.14 and 32.18 ± 3.34 mm, 33.18 ± 2.57 and 35.40 ± 3.93, and 141.64 ± 4.13 and 138.87 ± 4.96, respectively. All 3 features were statistically significant among the groups (All Ps < .05). ETL and ETA were significantly higher in Nadjmi modification of Furlow and Sommerlad palatoplasty techniques compared to the V-Y pushback technique, while there was no significant difference in the ATA between the palatoplasty groups.

Cleft palate can significantly affect the morphological characteristics of the ET. Type of the infancy palatoplasty can influence some of its dimensions.

Otomicroscopic and functional outcomes after cleft palate repair via Sommerlad intravelar veloplasty vs. modified Veau-Wardill-Kilner push-back

OBJECTIVE

We aim to compare the modified Veau-Wardill-Kilner push-back technique (VWK) and the Sommerlad intravelar veloplasty (Sommerlad IVVP) in terms of middle ear outcomes and oronasal fistulae frequency in three years old children.

METHODS

For this retrospective cohort study, data were collected and anonymized from consecutive patients with cleft palate (with or without cleft lip) who underwent surgery in our hospital between January 2008 and December 2018. Patients with syndromic diagnoses and patients who underwent surgical treatment elsewhere were excluded. We collected data from 101 children (202 ears) regarding middle ear complications at the age of three, including acute otitis media, middle ear effusion, tympanic membrane retraction, tympanic membrane perforation, tympanic membrane atelectasis and chronic otitis media with cholesteatoma. In addition, the presence of oronasal fistulae and the number of ventilation tubes received by the age of three were recorded.

RESULTS

The odds of children having a normal middle ear evaluation were 3.07 (95% Confidence interval (95%CI): [1.52, 6.12]; p < 0.05) times higher when children received Sommerlad IVVP compared to modified VWK. With 40.7% compared to 26.7%, a significantly higher incidence of middle ear effusion was present in the modified VWK group compared to Sommerlad IVVP (X²(1) = 4.38, p < 0.05). Furthermore, this group needed significantly more ventilation tube reinsertions (X²(2) = 12.22, p < 0.05) and was found to have a significantly higher incidence of oronasal fistula (53.5% vs. 17.2%, X²(1) = 14.75, p < 0.05). The latter was significantly associated with a higher need for ventilation tube reinsertion (X²(1) = 7.34, p < 0.05).

CONCLUSION

This study shows superior middle ear outcomes and fewer oronasal fistulae after Sommerlad IVVP compared to modified Veau-Wardill-Kilner push-back at the age of three.

Middle ear disease requiring myringotomy in the first two years after tracheotomy in the pediatric population

OBJECTIVES

Risk factors for middle ear disease necessitating myringotomy with tympanostomy tube placement after a tracheostomy have not been thoroughly explored. This study investigates the incidence and risk factors for ear tube placement in pediatric patients with a tracheostomy.

METHODS

Pediatric patients under age 18 who underwent tracheotomy between 2002 and 2010 at two institutions were identified. Patients were excluded if they had undergone myringotomy prior to, or at the same time as, the tracheotomy, or did not have at least two years of follow-up clinic visits. The presence of other comorbidities was recorded. Descriptive statistics and logistic regression models were used to assess the impact of clinical characteristics on outcomes.

RESULTS

A total of 214 patients met inclusion criteria. Median patient age at time of tracheotomy was 6 months (IQR 2-17), median patient age at time of myringotomy with tubes was 12 months (IQR8-17), and median time between tracheotomy and myringotomy with tube placement was 8 months (IQR 5-11). Sixty-seven (31%) patients required myringotomy with tympanostomy tube placement within the first two years after tracheotomy. Fifty-eight (87%) patients who underwent myringotomy with tympanostomy tubes were younger than 2 years at the time of the procedure. Logistical regression found younger age at time of tracheotomy to be a risk factor (OR: 0.71, 95% CI: 0.5-0.9, p < 0.006). The combination of tracheostomy with gastric tube increased the risk of requiring myringotomy with tubes 2.79 fold (p < 0.009). Craniofacial abnormalities (p < 0.001), known genetic syndrome (p = 0.009), cleft palate (p < 0.001), age at time of tracheotomy (p < 0.001) and gastric tubes (p = 0.002) were all independently found to increase risk of myringotomy with tubes. Patients' gestational age (p = 0.411), ventilator dependence (p = 0.33), and airway structural abnormalities (p = 0.632) did not increase this risk.

CONCLUSION

This study reports a high incidence of myringotomy with tubes in children with tracheostomy relative to the general pediatric population. Many comorbid conditions that often accompany the need for tracheotomy place these patients at a higher risk for ear disease requiring surgical intervention. Risk factors for operative middle ear disease in this population included age at time of tracheostomy, craniofacial abnormalities, and presence of a G-tube.

The effect of intervelar veloplasty under magnification (Sommerlad's Technique) without tympanostomy on middle ear effusion in cleft palate patients

Objective

Different surgical techniques and management approaches have been introduced to manage the cleft palate (CP) and its complications, such as otitis media with effusion (OME) and auditory problems. The optimal method, as well as the ideal time for palatoplasty and ventilation tube insertion, are the subject of controversy in the literature. We aimed to evaluate The Effect of Intervelar Veloplasty under Magnification (Sommerlad’s Technique) without Tympanostomy on Middle Ear Effusion in Cleft Palate Patients.

Methods

non-syndromic cleft palate patients from birth to 24 months who needed primary palatoplasty from April 2017 to 2019 were enrolled in this study. intravelar veloplasty (IVVP) surgery under magnification has been done by the same surgeon. Likewise, Otoscopy, Auditory Brainstem Response (ABR), and tympanometry were performed for all the patients before and six months after palatoplasty.

Results

Tympanograms were classified into two categories according to shape and middle ear pressure, and it was done in 42 children (84 ears). Type B curve was seen in 40 cases (80 ears) before surgery which reduced significantly (P < 0.005) to 12 cases in the left ear and 14 cases in the right ear after surgery. So, after surgery, 70 % of the tympanogram of left ears and 66.6 % of the tympanogram of Rt ears were in normal condition (type A tympanometry). ABR was done for 43 patients (86 ears) before surgery and six months after palatoplasty. Data were shown that 40 of the patients had mild to moderate hearing loss before surgery, which reduced significantly (P < 0.005) to 9 in the left ear and 11 in the right ear after palatoplasty. So, after surgery, 79 % of ABR of left ears and 73.8 % of ABR of right ears were in normal status (normal hearing threshold).

Conclusions

Intervelar veloplasty under magnification (Sommerlad’s technique) significantly improved the middle ear effusion without the need for tympanostomy tube insertion.

Prevalence of Tympanostomy Tube Placement in Relation to Cleft Width and Type

OBJECTIVES/HYPOTHESIS

The prevalence of tympanostomy tube surgery (TTS) in patients with a cleft deformity was investigated, in relation to cleft width and cleft type.

STUDY DESIGN

Retrospective review of medical health records.

METHODS

Retrospective review of medical health records. Seventy-eight patients with non-syndromic cleft deformity of the palate and/or alveolus and lip between 2003 and 2017 were investigated. All available medical documents were analyzed. The study group was divided into subgroups: 1) patients with isolated cleft palate (CP) and patients with a cleft palate with cleft lip and alveolus (CLP). 2) According to Veau's classification (I-IV), further subgroups were defined. Cleft width was measured using plaster cast models.

RESULTS

TTS was performed in 55% of the patients (n = 43). Considering Veau's classification, TTS was conducted as follows: Veau I 65.2% (n = 15/23), Veau II 55.0% (n = 11/20), Veau III 47.6% (n = 10/21), and Veau IV 50.0% (n = 7/14). Cleft classifications, maxillary arch width, and absolute/relative cleft width had no statistical impact on TTS occurrence. Although no significant correlation could be found, patients in our study group with CP (Veau I and II) underwent TTS more often (60.5%, n = 26/43) than patients with CPL (Veau III and IV; 48.6%, n = 17/35) during a three-year follow-up.

CONCLUSION

None of the cleft characteristics examined had a significant impact on the proportion of patients who received TTS. Nevertheless, patients with lower Veau classification and CP received tympanostomy tubes more often. Therefore, otolaryngologists and pediatricians treating children with cleft palate should maintain a high level of suspicion for chronic middle ear effusion, even in patients with small clefts.

LEVEL OF EVIDENCE

3 Laryngoscope, 2021.

Optimizing speech outcomes for cleft palate

PURPOSE OF REVIEW

Cleft lip with or without palate is one of the most common pediatric birth anomalies. Patients with cleft palate often have speech difficulties from underlying anatomical defects that can persist after surgery. This significantly impacts child development. There is a lack of evidence exploring, which surgical techniques optimize speech outcomes. The purpose of this update is to report on recent literature investigating how to optimize speech outcomes for cleft palate.

RECENT FINDINGS

The two-flap palatoplasty with intravelar veloplasty (IVVP) and Furlow double-opposing Z-plasty has the strongest evidence for optimizing speech. One-stage palatal repair is favored at 10-14 months of age, while delays are associated with significant speech deficits. For postoperative speech deficits, there is no significant difference between the pharyngeal flap, sphincter pharyngoplasty, and posterior pharyngeal wall augmentation. Surgical management should be guided by closure pattern and velopharyngeal gap but few studies stratify by these characteristics.

SUMMARY

According to recent evidence, the two-flap palatoplasty with IVVP and Furlow palatoplasty result in the best speech. The pharyngeal flap, sphincter pharyngoplasty, and posterior pharyngeal wall augmentation are all viable techniques to correct residual velopharyngeal insufficiency. Future research should focus on incorporating standardized measures and more robust study designs.