The role of the tensor veli palatini muscle in the development of cleft palate-associated middle ear problems

Effect of prosthetic management and its timing on otological and audiological outcomes in infants with cleft lip and palate: A clinical trial

PURPOSE

To evaluate how prosthetic management affects the otological and audiological state of infants with cleft lip and palate by preventing or treating otitis media (OM).

MATERIALS AND METHODS

Thirty infants with cleft lip and palate (L/P) were assigned to three equal groups according to the age of prosthetic intervention; Group I: immediately after birth, Group II: 2 months old, Group III: 5 months old. Assessment of middle ear function by tympanometry and hearing quality by auditory brainstem response (ABR) under natural sleep was conducted before and after prosthetic treatment every month till 10 months of age. Data from the study groups were compared.

RESULTS

No statistically significant differences were found between Gp I and Gp II in the 2nd, 3rd, and 4th months for right and left ears (p > 0.05). In the 5th month, statistically significant differences between the three groups were found in tympanometry for right (p = 0.011) and left (p = 0.024) ears also, in ABR for right (p = 0.007) and left (p = 0.011) ears. Tympanometric readings starting from the 6th till the 10th month showed no statistically significant differences between the three groups (p >0.05). The final ABR outcomes of the 10th month indicated statistically significant differences between the three groups for both ears (p = 0.027).

CONCLUSIONS

Early prosthetic care could delay the development of OM, so it could potentially improve the otological and audiological state in infants with cleft L/P. However, prosthetic treatment may not be able to completely prevent or eliminate middle ear disorders.

Does Primary Cleft Palate Repair by Furlow Z-Plasty Technique With a Buccinator Myomucosal Flap Change Speech and Middle Ear Outcomes?

BACKGROUND

Children with repaired cleft lip and palate may present with middle ear effusion and disturbed speech due to velopharyngeal (VP) insufficiency. Furlow Z-palatoplasty with a buccinator myomucosal flap is one of the effective surgical techniques for primary cleft palate repair and lengthening of the palate.

PURPOSE OF THE STUDY

This study aimed to evaluate the effect of Furlow Z-palatoplasty with buccal myomucosal flap as a primary cleft palate repair technique on the VP function during speech and the Eustachian tube function.

MATERIALS AND METHODS

Forty patients with non-syndromic cleft lip and palate aged 3 to 7 years surgically repaired with Furlow palatoplasty with a buccinator myomucosal flap were assessed. Perceptual speech assessment, nasopharyngoscopic examination, otoscopic examination, and tympanometry were done for all patients to assess the speech and middle ear function.

RESULTS

The percentage of mild hypernasality was significant in 22.5% of children with repaired cleft lip and palate, while 77.5% showed no hypernasality. Speech intelligibility was normal in 77.5% and mildly affected in 22.5% of children with repaired cleft palate. Compensatory misarticulations were recorded in 12.5% of children. Nasopharyngoscopic examination revealed adequate VP closure in 75% of children with repaired cleft palate. Twenty-five percent of children with repaired cleft lip and palate had middle ear effusion and required myringotomy with insertion of tympanostomy tubes.

CONCLUSION

Primary cleft palate repair with Furlow Z-palatoplasty with buccal myomucosal flap had beneficial effects on speech outcomes. It was associated with a low prevalence of middle ear effusion, and a low number of tympanostomy tubes were needed.

A tradeoff evolution between acoustic fat bodies and skull muscles in toothed whales

Toothed whales have developed specialized echolocation abilities that are crucial for underwater activities. Acoustic fat bodies, including the melon, extramandibular fat body, and intramandibular fat body, are vital for echolocation. This study explores the transcriptome of acoustic fat bodies in toothed whales, revealing some insight into their evolutionary origins and ecological significance. Comparative transcriptome analysis of acoustic fat bodies and related tissues in a harbor porpoise and a Pacific white-sided dolphin reveals that acoustic fat bodies possess characteristics of both muscle and adipose tissue, occupying an intermediate position. The melon and extramandibular fat body exhibit specific muscle-related functions, implying an evolutionary connection between acoustic fat bodies and muscle tissue. Furthermore, we suggested that the melon and extramandibular fat body originate from intramuscular adipose tissue, a component of white adipose tissue. The extramandibular fat body has been identified as an evolutionary homolog of the masseter muscle, supported by the specific expression of MYH16, a pivotal protein in masticatory muscles. The intramandibular fat body, located within the mandibular foramen, shows possibilities of the presence of several immune-related functions, likely due to its proximity to bone marrow. Furthermore, this study sheds light on leucine modification in the catabolic pathway, which leads to the accumulation of isovaleric acid in acoustic fat bodies. Swallowing without chewing, a major toothed whale feeding ecology adaptation, makes the masticatory muscle redundant and leads to the formation of the extramandibular fat body. We propose that the intramuscular fat enlargement in facial muscles, which influences acoustic fat body development, is potentially related to the substantial reorganization of head morphology in toothed whales during aquatic adaptation.

Effect of prosthetic management of congenital cleft lip and palate on the middle ear function of infants: A clinical trial

STATEMENT OF PROBLEM

Infants with a cleft palate often experience middle ear disease, a condition of great significance, and early prosthetic management of these infants is essential. However, any correlation between prosthetic palatal obturation and middle ear function is unclear.

PURPOSE

The purpose of this clinical trial was to assess whether prosthetic palatal obturation with a feeding appliance prevented or improved middle ear problems in infants with a cleft lip and palate.

MATERIAL AND METHODS

Ten infants with congenital cleft lip and palate (20 ears) were referred to the Prosthodontics department immediately after birth. Assessment of the middle ear function by tympanometry as well as hearing quality by auditory brainstem response (ABR) was conducted before the prosthetic treatment (control readings). The middle ear function and hearing quality was followed up after the prosthetic treatment every month until surgical palatal closure (tenth month). The Friedman test was applied to compare data from the various study periods. When the results were significant, the Dunn post hoc test was conducted to compare the control first week readings with those of the later periods (α=.05 for all tests).

RESULTS

The preprosthetic readings of tympanometry in the first week were 90% Type A and 10% Type B for both right and left ears. Readings starting from the first to the fifth month revealed no statistically significant differences compared with the first week readings (P>.05). However, tympanometry readings starting from the sixth month (20% Type A and 80% Type B) until the tenth month (90% Type B and 10% Type C) for both ears represented a statistically significant difference compared with the first week readings (P≤.05). The preprosthetic readings of ABR in the first week showed that 90% of ears had normal hearing status and 10% had mild hearing loss. Readings starting from the first until the fifth month revealed no statistically significant differences compared with the first week readings (P>.05). However, ABR readings starting from the sixth month (20% normal hearing, 70% mild hearing loss, and 10% moderate hearing loss) until the tenth month (0% normal hearing, 80% mild hearing loss, and 20% moderate hearing loss) for both ears revealed a statistically significant difference compared with the first week readings (P≤.05).

CONCLUSIONS

Prosthetic palatal obturation with a feeding appliance plays a role in delaying rather than preventing the occurrence of otitis media with effusion in infants with a cleft lip and palate and could reduce the need for ventilation tubes.

Factors related to the surgical outcomes of type I tympanoplasty for tympanic membrane perforation in children

BACKGROUND

Factors related to surgical outcomes of type I tympanoplasty for tympanic membrane (TM) perforation in children are controversial.

OBJECTIVES

To investigate factors related to anatomical results of type I tympanoplasty for TM perforation 1 year after surgery.

MATERIAL AND METHODS

We examined 68 ears. Anatomical results were determined based on the presence or absence of re-perforation, atelectasis, and otitis media with effusion. We retrospectively analyzed factors based on age (≤8 and >8 years), cause and size of TM perforation (<50% and ≥50%), history of asthma and cleft palate, and size of mastoid air cell system in bilateral ears before tympanoplasty. Audiological prognosis was evaluated in ears with anatomical success 1 year after surgery.

RESULTS

Anatomical success was achieved in 80.9% (55/68) of the ears. No significant differences were observed between these factors and anatomical results. All children with cleft palate had anatomical success. Mean pure-tone average (0.5-4 kHz) was 16.25 dB HL for ears with both TM perforations <50% and ≥50%.

CONCLUSION AND SIGNIFICANCE

We observed no significant relationship between factors considered and surgical outcomes. However, audiological prognosis was favorable for anatomical success regardless of TM perforation size. Accordingly, type I tympanoplasty is considered useful for TM perforation in children.

What We Learned from Performing the Inverse Malek Procedure to Repair Bilateral Cleft Lips and Palates: A Single-Center Retrospective Study

Background: This study reviews the surgical and functional outcomes of children diagnosed with a bilateral cleft lip and palate and treated by the same surgical team following specific surgical protocols 18 years after surgery and during the follow-up. Methods: Based on a single-center retrospective design, demographic and surgical data were gathered by the authors from international institutions. Most of the data were quantitative in nature, and descriptive statistical and non-parametric tests were employed for analysis. All children born with a bilateral cleft from 1982 to 2002 were considered. Children affected by a syndrome were excluded. Complications and speech results were the main items measured. Results: Thirty patients were selected; 73.3% were treated using the inverse Malek procedure, and 26.7% underwent a modified two-stage procedure. Seventy percent developed an oronasal fistula. An alveolar bone graft was performed in 83%, and 53.3% underwent Le Fort osteotomy. Thirty-six percent required a pharyngeal flap, with good speech results. The median number of times general anesthesia was used among all the interventions considered was 5.5 (4.25-6). Conclusions: This study presents the long-term results of using the inverse Malek procedure to treat children with a bilateral cleft lip and palate. It is shown that this is related to a high risk of developing a fistula, but has good long-term speech results.

Prevalence of Chronic Middle Ear Effusion in Cases of Cleft Palate

Chronic middle ear effusion is generally present in children with cleft palate (CP) associated with or without cleft lips. The aim of our study was to assessment of how common middle ear effusion is in patients with cleft palates and to evaluate the presence of these symptoms by performing a Basic Audiological Evaluation (BAE). A retrospective randomized study was conducted on 50 children (29 male and 21 female) aged 2 to 16 years who had CPs (associated with or without cleft lips) with symptoms of middle ear effusion. The study was conducted from March 2021 to February 2022. Data review included the results of otoscopic findings and BAE. The Fundamentals of BAE comprise the testing of middle ear function with tympanometry and a pure tone audiometry to determine the kind and degree of hearing impairment. Regarding the BAE, we found that 70% of the children with normal hearing, 24% with conductive type of hearing loss, and 6% with mixed type of hearing loss. The tympanometric results revealed that 66% of the children with type A tympanogram, 24% with type C tympanogram, and 10% with type B tympanogram. The contralateral stapedial reflex was present in 60% of the patients while in 40% of cases not present. The results confirmed the great prevalence of chronic middle ear effusion in children with CPs. Furthermore, the hearing impairment associated with middle ear effusion was visible, demonstrating that middle ear effusion was linked with the prevalence of moderate conductive type of hearing loss. The OME in cases of CP necessitates early prediction and in turn early treatment.

Impact of palatoplasty techniques on tympanic membrane findings and hearing prognosis in children with cleft palate

OBJECTIVE

Children with cleft palate (CP) are at high risk of developing otitis media with effusion (OME) due to Eustachian tube (ET) dysfunction. Palatoplasty has been reported to decrease the frequency of middle ear disease and improve ET function, and although various techniques have been developed, there is no consensus on the differences in the impact of different techniques on the middle ear. The purpose of this study was to determine the differential effects of palatoplasty on middle ear function and hearing.

METHODS

We performed a retrospective observational survey of pediatric patients who underwent palatoplasty for CP between June 2010 and October 2018 at Tohoku University Hospital. Cases were divided into three groups depending on the palatoplasty procedures performed: the push-back palatoplasty group, the two-flap palatoplasty group, and the Furlow double-opposing Z-plasty group. We examined the differences in clinical characteristics between patients who underwent each procedure. The primary outcome variable was tympanic membrane (TM) findings, and the secondary outcome was hearing test results.

RESULTS

Children who underwent the two-flap palatoplasty had a higher tympanostomy tube (TT) insertion rate and a higher total number of TT insertions than those who underwent the Furlow double-opposing Z-plasty or the push-back palatoplasty. The TM retraction rate tended to be lower in the Furlow double-opposing Z-plasty group than in the push-back palatoplasty group or the two-flap palatoplasty group. The hearing test results at the last visit were not significantly different among the three groups.

CONCLUSIONS

Children who underwent the two-flap palatoplasty had a higher rate of TT insertions, potentially increasing the risk of TM perforation. In contrast, the Furlow double-opposing Z-plasty group had a lower tendency for TM regression, possibly due to improved ET function and reduced incidence of OME. It is important to understand the advantages and disadvantages of each technique before selecting one suitable for the child's cleft and arch width. Additionally, it is important to conduct regular follow-up of TM findings and hearing test results even after palatoplasty.

Effects of RME on Hearing in UCLP Patients: A Pilot Study

OBJECTIVE

To assess the changes in hearing after rapid maxillary expansion (RME) and at the end of 6 months retention period in complete unilateral cleft lip and palate (UCLP) patients using pure tone audiometry and tympanometry test.

DESIGN

Prospective pilot study.

SETTING

Tertiary health care teaching hospital in New Delhi.

PATIENTS

This study was conducted on 6 UCLP patients in the age range of 6-14 years with normal ear anatomy. All 6 patients had undergone primary repair of cleft lip and palate and required no more than 5 mm expansion in the intermolar region.

INTERVENTION

RME was done using a Hyrax expander with daily activation of one-quarter turn per day for a period of 15-20 days (0.25 mm per day).

MAIN OUTCOME MEASURE

Audiometry and tympanometry readings at the baseline as compared to the post expansion and at the end of 6 months retention period.

RESULTS

There were no significant changes in the hearing levels on the audiometry test after RME on the cleft side (p-value -0.51) and the noncleft side ear (p-value -0.26). No significant changes were observed in the middle ear volume on the tympanometry test after RME on the cleft side (p-value -0.09) and the noncleft side ear (p-value -0.28).

CONCLUSION

There was no improvement or deterioration in the hearing levels after RME and at the end of 6 months retention period in UCLP patients as evaluated using pure tone audiometry and tympanometry test. Hence RME may be undertaken in UCLP patients safely in terms of hearing is concerned.

Effects of two flap palatoplasty versus furlow palatoplasty with buccal myomucosal flap on maxillary arch dimensions in patients with cleft palate at the primary dentition stage: a cohort study

OBJECTIVE

The objective of this study was to evaluate the effect of two flap palatoplasty (TFP) versus Furlow palatoplasty with buccal myomucosal flap (FPBF) on maxillary arch dimensions in children at the primary dentition stage with cleft palate, in comparison to matching subjects without any craniofacial anomalies.

MATERIAL AND METHODS

This study included 28 subjects with an age range of 5-6 years; 10 non-cleft subjects were included in the control group, 9 patients treated with TFP, and 9 patients treated with FPBF. For the included patients, the maxillary models were scanned using a desktop scanner to produce virtual models, and the maxillary dimension measurements were virtually completed. The produced measurements were compared between the 3 groups. Maxillary models of the 28 participants were evaluated.

RESULTS

Statistically insignificant differences were detected between the 3 groups for arch symmetry measurements. Differences were detected in the inter-canine width between the 2 surgical groups and non-cleft group. Both arch length and posterior palatal depth significantly differ while comparing the TFP to the control group, with no differences between FPBF and the non-cleft group.

CONCLUSION

Furlow palatoplasty with buccal myomucosal flap might be considered a better surgical option than two flap palatoplasty for patients with cleft palate while evaluating maxillary arch dimensions at the primary dentition stage as a surgical outcome.

CLINICAL RELEVANCE

This study gives insight into the surgical technique that has limited effect on the maxillary growth and dental arch dimension. Therefore, it decreases the need for orthodontic treatment and orthognathic surgery.

TRIAL REGISTRATION

clinicaltrials.gov ( NCT05405738 ).

How differences in anatomy and physiology and other aetiology affect the way we label and describe speech in individuals with cleft lip and palate

BACKGROUND

Speech in individuals with cleft lip and/or palate (CLP) is a complex myriad of presenting symptoms. It is uniquely associated with the structural difference of velopharyngeal insufficiency (VPI), together with a wide and heterogeneous range of other aetiologies which often co-occur. The nature of the speech sound disorder (SSD) including VPI may also change over the course of an individual's care pathway. Differences in terminology and approaches to analysis are currently used, resulting in confusion internationally. Additionally, current diagnostic labels and classification systems in SSD do not capture the complexity and full nature of speech characteristics in CLP.

AIMS

This paper aims to explore the different aetiologies of cleft palate/VPI speech and to relate aetiology with speech characteristic(s). In so doing, it attempts to unravel the different terminology used in the field, describing commonalities and differences, and identifying overlaps with the speech summary patterns used in the United Kingdom and elsewhere. The paper also aims to explore the applicability of current diagnostic labels and classification systems in the non-cleft SSD literature and illustrate certain implications for speech intervention in CLP.

METHODS AND PROCEDURES

The different aetiologies were identified from the literature and mapped onto cleft palate/VPI speech characteristics. Different terminology and approaches to analysis are defined and overlaps described. The applicability of current classification systems in SSD is discussed including additional diagnostic labels proposed in the field.

OUTCOMES AND RESULTS

Aetiologies of cleft palate/VPI speech identified include developmental (cognitive-linguistic), middle ear disease and fluctuating hearing loss, altered oral structure, abnormal facial growth, VPI-structural (abnormal palate muscle) and VPI-iatrogenic (maxillary advancement surgery). There are four main terminologies used to describe cleft palate/VPI speech: active/passive and compensatory/obligatory, which overlap with the four categories used in the UK speech summary patterns: anterior oral cleft speech characteristics (CSCs), posterior oral CSCs, non-oral CSCs and passive CSCs, although not directly comparable. Current classification systems in non-cleft SSD do not sufficiently capture the full nature and complexity of cleft palate/VPI speech.

CONCLUSIONS AND IMPLICATIONS

Our attempt at identifying the heterogeneous range of aetiologies provides clinicians with a better understanding of cleft palate/VPI speech to inform the management pathway and the nature and type of speech intervention required. We hope that the unravelling of the different terminology in relation to the UK speech summary patterns, and those used elsewhere, reduces confusion and provides more clarity for clinicians in the field. Diagnostic labels and classification require international agreement.

WHAT THIS PAPER ADDS

What is already known on the subject Speech associated with cleft palate/velopharyngeal insufficiency (VPI) is a complex myriad of speech characteristics with a wide and heterogeneous range of aetiologies. Different terminology and speech summary patterns are used to describe the speech characteristics. The traditional classification of cleft palate/VPI speech is Articulation Disorder, although evidence is building for Phonological Disorder and contrastive approaches in cleft speech intervention. What this paper adds to existing knowledge This paper explores the range of aetiologies of cleft palate/VPI speech (e.g., altered oral structure, abnormal facial growth, abnormal palate muscle and iatrogenic aetiologies) and attempts to relate aetiology with speech characteristic(s). An attempt is made at unravelling the different terminology used in relation to a well-known and validated approach to analysis, used in the United Kingdom and elsewhere. Complexities of current diagnostic labels and classifications in Speech Sound Disorder to describe cleft palate/VPI speech are discussed. What are the potential or actual clinical implications of this work? There needs to be a common language for describing and summarising cleft palate/VPI speech. Speech summary patterns based on narrow phonetic transcription and correct identification of aetiology are essential for the accurate classification of the speech disorder and identification of speech intervention approaches. There is an urgent need for research to identify the most appropriate type of contrastive (phonological) approach in cleft lip and/or palate.

An essential overview of orofacial clefting

An appreciation of the embryologic development of the face is essential to understanding the anatomic variation observed in this phenotypically broad condition. Embryologically, the nose, lip and palate are separated into the primary and secondary palate, which are divided anatomically by the incisive foramen. The epidemiology of orofacial clefting is reviewed together with the contemporaneous cleft classification systems that enable comparisons to be made between international centres for audit and research purposes. A detailed examination of the clinical anatomy of the lip and palate informs the surgical priorities for the primary reconstruction of both form and function. The pathophysiology of the submucous cleft palate is also explored. The seismic impact of the 1998 Clinical Standards Advisory Group report on the organisation of UK cleft care provision is outlined. The importance of the Cleft Registry and Audit Network database in auditing UK cleft outcomes is highlighted. The potential for the Cleft Collective study to establish the causes of clefting, the optimal treatment protocols, and the impact of cleft on patients is tremendously exciting for all health care professionals involved in the management of this challenging congenital deformity.

The Impact of Lateral Relaxing Incision on Middle Ear Function in Cleft Palate Repair

Children with cleft palate are susceptible to otitis media with effusion. This study aimed to investigate the effect of lateral relaxing incision (RI) on middle ear function in cleft palate patients who underwent palatoplasty using double-opposing Z-plasty (DOZ). This is a retrospective study of patients who underwent bilateral ventilation tube insertion concurrently with DOZ, wherein RI was selectively performed on the right side of the palate (Rt-RI group) or not (No-RI group). The frequency of VTI, duration of the first ventilation tube retention, and hearing outcomes at the last follow-up were reviewed. Outcomes were compared using the χ2 test and t test. A total of 126 treated ears from 63 non-syndromic children (18 male, 45 female) with cleft palate were reviewed. The mean age at surgery was 15.8±6.17 months. There were no significant differences in the frequency of ventilation tube insertion between the right and left ears within the Rt-RI group or between the Rt-RI and no-RI groups in the right ear. Subgroup analysis for ventilation tube retention time, auditory brainstem response thresholds, and air-conduction pure tone averages showed no significant differences. In the DOZ, the use of RI had no significant effects on middle ear outcomes during 3 years of follow-up. Relaxing incision seems to be safe without concern for middle ear function in children with cleft palate.

Functional cleft palate surgery

Cleft lip and palate (CLP) as a dislocation malformation confronts parents with a malformation of their child that could not be more central and visible: the face. In addition to the stigmatizing appearance, however, in cases of a CLP, food intake, physiological breathing, speech and hearing are also affected. In this paper, the principles of morphofunctional surgical reconstruction of the cleft palate are presented. With the closure of the palate, and restoration of the anatomy, a situation is achieved enabling nasal respiration, normal or near normal speech without nasality, improved ventilation of the middle ear, normal oral functions with coordinated interaction of the tongue with the hard and soft palate important for the oral and pharyngeal phases of feeding. With the establishment of physiological function, in the early phases of the infant and toddler, these activities initiate essential growth stimulation, leading to normalisation of facial and cranial growth. If these functional considerations are disregarded during primary closure, lifelong impairment of one or more of the abovementioned processes often follows. In many cases, despite secondary surgery and revision, it might not be possible to correct and achieve the best possible outcomes, especially if critical stages of development and growth have been missed or there has been significant tissue loss due to resection of existing tissue while primary surgery. This paper describes functional surgical methods and reviews long term, over many decades, results of children with cleft palate.

A retrospective analysis of speech and hearing in patients receiving surgery for submucous cleft palate

Submucous cleft palate (SMCP) is an uncommon subtype of cleft palate that is associated with symptoms of velopharyngeal insufficiency (VPI), the most common being hypernasal speech. A high proportion of patients also suffer from conductive hearing loss, which is thought to be due to eustachian tube dysfunction. A number of surgical techniques have been proposed to correct the anatomical defect that is responsible for VPI. This exploratory study aims to describe surgical techniques and clinical outcomes in a series of patients who underwent surgical repair of SMCP at a single regional specialist cleft centre between 1999 and 2018. Through a retrospective case note review, records of 57 patients who underwent SMCP repair between the ages of 6 months and 16 years were examined. Patients underwent one of the three surgical techniques: Intravelar Veloplasty, Furlow or a novel technique we have termed as "Hemi-Furlow". Hypernasality, measured on the Great Ormond Street Speech Assessment, showed evidence of improvement post-operatively in all three surgical groups (P<0.005), with no evidence to favour any specific approach. Post-operative complications, including wound dehiscence and fistulae, occurred in nine patients (15.8%). Nine patients (15.8%) required revisional surgery, either due to post-operative complications or persistent speech problems. Otological disease was present in 54.4% of patients, comprising conductive hearing loss due to otitis media with effusion (52.6%) and sensorineural hearing loss (1.8%). There is now a need for large, multi-centre studies with robust outcomes measures to further examine relationships between surgical techniques and clinical outcomes in people born with SMCP.

Impact of a Modified Restoration of Tensor Veli Palatini on Hearing and Middle Ear Function in Cleft Palate Children-a Retrospective Study

BACKGROUND

Many children with cleft palate also exhibit hearing loss and middle ear dysfunction, which could last for years. There are still arguments on how to treat this problem. This study aimed to evaluate the impact of a modified restoration of tensor veli palatine (TVP) on hearing and middle ear function in the cleft palate children.

METHODS

This retrospective study was completed using records of the cleft palate children who received surgery in Peking Union Medical College Hospital from May 2013 to December 2020. They were divided into 2 groups: Group 1: children who received cleft palate surgery without specific restoration of TVP; Group 2: children who received palate surgery with a specific TVP restoration technique. Perioperative information was collected. The conductive auditory brainstem response and the 226-Hz tympanometry before and after the cleft surgery were compared intragroup and intergroup.

RESULTS

Totally 42 children were included in this study, 21 children in each group. There were no significant differences considering clinical characteristics between the 2 groups. The modified TVP restoration didn't increase operation time or complication compared with no TVP restoration. Statistically, neither the auditory brainstem response air conduction hearing thresholds nor the 226-Hz tympanometry results had significant differences between the 2 groups after the surgery.

CONCLUSIONS

This modified restoration of TVP was not time-consuming and did not increase complications. The beneficial effect of the modified TVP restoration on the hearing or the middle ear function of cleft palate children was uncertain around 6 months after surgery compared with no restoration.

Middle Ear Status in Cleft Lip and Palate Patients: A Five-Year Follow-Up

INTRODUCTION

The best strategy to treat otitis media with effusion in cleft lip/palate patients is still under debate. This research aimed to evaluate the otologic outcomes in children at least five years post-repair.

MATERIALS AND METHODS

A retrospective study was conducted on 40 children who underwent palatoplasty between January 1, 2012, and January 1, 2014, at Children's Medical Center (Tehran, Iran). Patients had intervelar veloplasty under magnification (Sommerlad's Technique). Based on patients' charts, their age, gender, cleft type, date of palatoplasty, as well as the date and the frequency of ventilation tube (VT) insertion, were recorded. Furthermore, otomicroscopy, middle ear status, and tympanometry were assessed five years postoperatively.

RESULTS

There was no significant difference in middle ear status between children with complete and incomplete cleft palates. The mean age at the time of study and the mean follow-up duration were significantly higher in the normal middle ear group, compared to the abnormal middle ear group (7.7±1.6 vs. 6.8±0.9, P=0.03 and 6±1.15 vs. 5.42±0.9, P=0.04, respectively). Middle ear status was not significantly different between early or late palatoplasty patients. In addition, the frequency and timing of VT insertion were not significantly different between the two groups.

CONCLUSIONS

Middle ear status improved as patients grew older; however, the age of palatoplasty and the frequency of VT insertion were not significant prognostic factors in patients who underwent intervelar veloplasty under magnification.

High incidence of cleft palate and vomer deformities in patients with Eustachian tube dysfunction

Although the cleft palate is regarded as a contraindication for Eustachian tube ballooning, the presence of submucosal cleft palate may be overlooked while diagnosing Eustachian tube dysfunction. Therefore, we aimed to determine the incidence of the presence of a hard palate bony notch and vomer defect, which indicate the presence of submucosal cleft palate in patients with Eustachian tube dysfunction. In the Eustachian tube dysfunction group (n = 28), 4 patients (14.3%) exhibited a hard palate bony notch and a concurrent vomer defect. Three of them exhibited the presence of occult submucosal cleft palate, which had not been diagnosed previously. None of the control group (n = 39) showed any of these findings. The hard palate length of patients in the Eustachian tube dysfunction group was significantly lesser than that of those in the control group (34.2 ± 5.6 mm vs. 37.2 ± 2.1 mm, P = 0.016). Patients with Eustachian tube dysfunction have a high incidence of submucosal cleft palate and its occult variant, which are challenging to diagnose without any preexisting suspicion. Clinicians should evaluate the hard palate and vomer to exclude the presence of occult submucosal cleft palate while diagnosing Eustachian tube dysfunction.

Cleft palate and ventilation tubes: a prophylactic dilemma

OBJECTIVE

This study aimed to understand, in a long-term follow-up study, whether the placement of grommets had been necessary after cleft palate surgical correction.

METHOD

A case-control, retrospective study was carried out on consecutive paediatric patients who underwent surgical repair of a cleft palate.

RESULTS

The study population included 138 patients, divided into 2 groups: group 1 - patients in whom grommets were placed at the time of cleft palate surgery, and group 2 - patients in whom grommets were not placed at the time of cleft palate surgery. During the follow up, in groups 1 and 2, 65.2 per cent and 67.8 per cent, respectively, did not need subsequent grommet placement after cleft palate surgery.

CONCLUSION

Of patients, 56.5 per cent did not need ventilation tubes at any point during follow up. The placement of grommets is not innocuous; therefore, its use at the time of cleft palate surgical repair should be reconsidered.

Prognosis of otitis media with effusion in pediatric patients with cleft palate during language-acquisition period treated by simultaneous tympanostomy tube placement with palatoplasty

OBJECTIVE

Cleft palate (CP) in children is frequently complicated by otitis media with effusion (OME) due to Eustachian tube dysfunction. Although tympanostomy tube (TT) placement can be beneficial in the treatment of OME to prevent short-term hearing loss, there is no consensus regarding the indications for and timing of TT insertion. The present study was performed to define the safety and effectiveness of simultaneous TT placement with palatoplasty during the language-acquisition period.

METHODS

We retrospectively reviewed the medical charts of pediatric patients who underwent palatoplasty for CP in a tertiary medical center, Kyoto University Hospital, from June 2010 to October 2018. The TT retention time was estimated using the Kaplan-Meier method. The incidence of OME recurrence was compared among four Veau classification groups based on the patients' sex, type of CP, median TT retention time, and type of fluid.

RESULTS

Seventy-six subjects (150 ears) were enrolled in the study. The median follow-up duration was 48.7 months (range, 18.2-108.0 months) after the first TT placement. A first TT retention time of <20.1 months was a significant risk factor for OME recurrence. Subjects with maxillofacial anomaly complex and subjects with cleft lip and palate and an alveolar cleft showed a significantly higher OME recurrence rate than subjects with clefts only in the hard and/or soft palate. There was no significant difference in the occurrence of sequelae between subjects with only a single TT placement and subjects with more than one TT placement.

CONCLUSIONS

Based on the findings of the present study, it is reasonable to perform TT insertion at the same time as palatoplasty on patients who meet the indications. This technique may reduce the number of times the patient requires general anesthesia and maintain good middle ear condition during the period of language acquisition between 1 and 3 years of age.

Middle-ear effusion in children with cleft palate: congenital or acquired?

Objective

Cleft palates are one of the most common congenital malformations. Because of the loss of Eustachian tube function, middle-ear ventilation is reduced. The aim of this study was to determine if middle-ear effusions were present at birth or at the three-month audiological evaluation.

Method

A total of 53 children with a cleft palate were included. Data review included the results of newborn hearing screening, microscopic findings, a tympanometry, a free field audiometry and intra-operative findings.

Results

A total of 58.4 per cent of patients had a median, 26.4 per cent had a bilateral, 11.3 per cent had a unilateral and 3.8 per cent had a limited soft palate cleft. Newborn hearing screening showed a pass in 83.1 per cent of newborns bilaterally. The first ear microscopy showed a bilateral middle-ear effusion in 90.6 per cent of cases. During cleft surgery, bilateral paracentesis was performed in all cases, and in 90.6 per cent middle-ear effusion was sucked out.

Conclusion

The majority of children with a cleft palate do not present with middle-ear effusion at birth. It develops within several days or weeks of life.

The limits of pandemic precautions: Tympanostomy tube placement in children with cleft palate during COVID-19

PURPOSE

Coronavirus Disease-2019 (COVID-19) mitigation measures have led to a sustained reduction in tympanostomy tube (TT) placement in the general population. The present aim was to determine if TT placement has also decreased in children at risk for chronic otitis media with effusion (COME), such as those with cleft palate (CP).

MATERIALS AND METHODS

A cohort study with medical record review was performed including consecutive children, ages 0-17 years, undergoing primary palatoplasty at a tertiary children's hospital February 2019-January 2020 (pre-COVID) or May 2020-April 2021 (COVID). Revision palatoplasty (n = 29) was excluded. Patient characteristics and middle ear status pre-operatively and at palatoplasty were compared between groups using logistic regression or Wilcoxon rank-sum.

RESULTS

The pre-COVID and COVID cohorts included 73 and 87 patients, respectively. Seventy (44%) were female and median age at palatoplasty was 13.5 months for CP ± cleft lip (CP ± L) and 5.5 years for submucous cleft palate (SMCP). In patients with CP ± L, TT were placed or in place and patent at palatoplasty in 28/38 (74%) pre-COVID and 37/50 (74%) during COVID (P = 0.97). In patients with SMCP, these proportions were 5/35 (14%) and 6/37 (16%), respectively (P = 0.82). Examining only patients <2 years of age also revealed no difference in TT placement pre-COVID versus COVID (P = 0.99). Finally, the prevalence and type of effusion during COVID was similar to pre-COVID.

CONCLUSIONS

Reduced infectious exposure has not decreased TT placement or effusion at palatoplasty. Future work could focus on non-infectious immunologic factors underlying the maintenance of COME in these children.

Functional aspects of the Eustachian tube by means of 3D-modeling

The extent of dysfunction of the Eustachian tube (ET) is relevant in understanding the pathogenesis of secondary otological diseases such as acute or chronic otitis media. The underlying mechanism of ET dysfunction remains poorly understood except for an apparent genesis such as a nasopharyngeal tumor or cleft palate. To better describe the ET, its functional anatomy, and the biomechanical valve mechanism and subsequent development of diagnostic and interventional tools, a three-dimensional model based on thin-layer histology was created from an ET in this study. Blackface sheep was chosen as a donor. The 3-D model was generated by the coherent alignment of the sections. It was then compared with the cone-beam computed tomography dataset of the complete embedded specimen taken before slicing. The model shows the topographic relation of the individual components, such as the bone and cartilage, the muscles and connective tissue, as well as the lining epithelium with the lumen. It indicates a limited spiraling rotation of the cartilaginous tube over its length and relevant positional relationships of the tensor and levator veli palatine muscles.

Exceptionally early tympanostomy tube placement in pediatric patients with cleft lip and palate

OBJECTIVE

At our institution, cleft lip repair is performed at or before 8 weeks of age, and tympanostomy tubes (TT) have been inserted concurrently in some of these patients. Our objective was to determine the feasibility and present the preliminary results of TT placement at this early age.

METHODS

A retrospective review was conducted of 22 patients born with cleft lip and/or palate who had TT placement in the first 8 weeks of life. Data collected included complications and audiologic function post TT placement.

RESULTS

Subjects had a mean age of 3.9 weeks at the time of TT placement and cleft lip repair. Thirteen patients (59%) reported otorrhea during the follow-up period. Eighteen of 21 (86%) patients who underwent auditory evaluation had normal audiological function following TT placement. One patient had sensorineural hearing loss and 2 patients had mild conductive hearing loss due to bilateral extruded TT and OME at 15.9 and 39.2 months after surgery.

CONCLUSION

Exceptionally early TT is feasible. Placing TT at or before 8 weeks of age did not result in any major complications but demonstrated a high incidence of otorrhea. A randomized, prospective study with a larger sample size is necessary to determine the benefits of TT placement at this age.

Surgical management in submucous cleft palate patients

OBJECTIVES

The submucous cleft palate (SMCP) is considered to be the most subtle type of cleft palate. Early detection is important to allow on time intervention by speech therapy and/or surgical repair before the children already develop compensatory speech mechanisms. The purpose of this study was to investigate at what time children with a SMCP present, to determine when children are operated, and to analyze the postoperative outcomes for in SMCP children.

PATIENT AND METHODS

Medical records from 766 individuals registered in the cleft registry in the Wilhelmina's Children's' Hospital, Utrecht, were retrospectively reviewed. Inclusion criteria were children diagnosed with SMCP. The following data were collected: age at diagnosis, physical examination, age at surgery, surgical technique, speech therapy pre- and post-surgery, otitis media, secondary cleft surgery, family history, syndromes, and other anomalies.

RESULTS

In total, 56 SMCP children were identified. The mean age of diagnosis was 44.0 months (range 0-150, SD = 37.0). In 48 children (85.7%), surgical intervention was performed (Furlow plasty, intravelar veloplasty, pharyngoplasty, or Furlow combined with buccal flap).

CONCLUSION

This retrospective study reconfirms that SMCP often presents late, even in a country with a modern healthcare system and adequate follow-up of all newborns by the so-called youth doctors in "children's healthcare centers" up to the age of 4 years old. Almost 86% of patients ultimately needed palate surgery when SMCP was suspected.

CLINICAL RELEVANCE

Any child presenting with repeated episodes of otitis media, nasal regurgitation, or speech difficulties should have prompt consideration for SMCP as diagnosis.

Comparison of Eustachian tube ventilation function between cleft palate and normal patients using sonotubometry

Objective

To compare Eustachian tube ventilation function between cleft palate subjects and normal subjects using sonotubometry.

Method

A comparative cross-sectional study was conducted at the Department Otolaryngology-Head and Neck Surgery of Ciptomangunkusumo National Hospital, Universitas Indonesia, Jakarta, from June 2013 to January 2014.There were 31 subjects with cleft palate and 62 healthy subjects aged ≤18 years, and both groups were matched according to age. Each subject underwent ear, nose, and throat examination with Veau classification and sonotubometry, a new assembly test in Indonesia. The results of the sonotubogram (the number of Eustachian tube openings, amplitude enhancement in dB, and the duration of Eustachian tube opening in ms) were then analyzed with SPSS using chi-square and Mann–Whitney tests.

Results

Subjects with cleft palate had lower Eustachian tube function than healthy subjects using three sonotubometry parameters (p < 0.001). The proportion of Eustachian tube dysfunction based on the Veau classification was significant (p < 0.001). In multivariate analysis, several determinant factors of Eustachian tube dysfunction were found, such as adenoid hypertrophy (risk factor6.46), the number of Eustachian tube openings (risk factor 36.21), and higher Veau classification (risk factor 10.41).

Conclusion

Sonotubometry could be used to assess parameters of Eustachian tube function. Subjects with cleft palate have a higher risk of having Eustachian tube dysfunction, as do subjects with adenoid hypertrophy.

Long-term outcomes in children with and without cleft palate treated with tympanostomy for otitis media with effusion before the age of 2 years

BACKGROUND

Long-term outcomes of children with and without cleft palate receiving early treatment for otitis media with effusion (OME) are unclear.

OBJECTIVES

To compare long-term otological and audiological outcomes between children with and without cleft palate treated with tympanostomy for OME before the age of 2 years.

MATERIAL AND METHODS

Ninety-five children (180 ears) with cleft palate (study group) and 97 children (185 ears) without (control group) were followed-up to a maximum age of 7 years. We retrospectively analyzed the audiological outcomes at the age of 7 years, and the otological outcomes at the last examination.

RESULTS

The percentages of children with OME resolution before the age of 7 years were 47.4% and 60% in the study and control groups, respectively, and those of ears with healed tympanic membrane were 71.7% and 79.5% in the corresponding groups. Significantly more ears were subjected to retympanostomy in the study (31.1%) than in the control group (21.6%). Mean pure-tone average (0.5‒4 kHz) was 15.6 dB HL and 14.3 dB HL for the corresponding groups.

CONCLUSIONS/SIGNIFICANCE

Otological and audiological outcomes in both groups were similar. The audiological prognosis was favorable regardless of the cleft palate condition.

Efficacy and Safety in Combining Primary Palatoplasty and Myringotomy in Patients with Cleft Palate

Patients born with a cleft lip and palate undergo multiple surgical procedures, increasing the infants’ exposure to anesthesia and potential risk of neurocognitive delays. In addition, these numerous procedures lead to greater use of hospital resources. This study analyzes the differences in anesthetic exposure and perioperative characteristics between performing combined versus separate primary palatoplasty (PP) and placement of bilateral myringotomy tubes (BMT).

Cleft Palate Repair: A Study Between Two Surgical Procedures

OBJECTIVE

The purpose of this study was to categorize and compare outcomes and sequels in 2 groups of patients born with unilateral and bilateral complete cleft lip/palate, having their primary cleft palate repair performed in our hospital, by the same surgical team, during 2 different periods of time, to establish which of the 2 surgical reconstructive strategies employed was more effective to decrease sequels.

MATERIAL AND METHODS

This is a randomized clinical trial including a total of 291, nonsyndromic patients, primary assisted in our Hospital, between 2002 and 2013, and operated by the same senior surgeon.Two groups of patients of similar characteristics were treated utilizing 2 different surgical procedures according to the considered period. Isolated palates, syndromic patients, secondary and adult cases were considered as exclusion critters. Surgical data was obtained from medical records, and clinical examinations. All the patients were cautiously evaluated by a team expert to verify results, evolution, and sequels.

RESULTS

Statistically significant differences in the total percentage of complications were found between both groups. Group A: 54.85% and Group B: 21.90% (P value < 0.001).Each complication was also considered by groups and estimated as follow: CONCLUSIONS:: Based on the results of our research, we can suggest the Carstens' variant plus the introduced modifications by the authors, as a useful surgical procedure to be utilized in primary complete unilateral or bilateral cleft palate repair to prevent post op common complications.

Tensor Veli Palatinopexy as a Novel Treatment for Eustachian Tube Dysfunction: A Cadaveric Feasibility Study

OBJECTIVE

To demonstrate the feasibility of a novel procedure whereby a suture is placed transorally in the tensor veli palatini muscle to tighten it, thereby dilating the cartilaginous portion of the eustachian tube (ET).

STUDY DESIGN

The study design was a prospective cadaveric experiment to examine the feasibility of a novel treatment for ET dysfunction.

SETTING

Academic medical center in a research-oriented operating room with intraoperative computed tomography (CT) capabilities.

METHODS

Seven fresh-frozen cadaver heads were obtained, each of which was thawed for 36 hours prior to use. The preprocedural volumes of the cartilaginous ET were measured by filling the ET with an iodine-containing radiocontrast agent via the nasopharynx and then obtaining CT images. Submucosal flaps in the soft palate were raised, and sutures were placed in the tensor veli palatini bilaterally to increase tension. After completion of the procedure, contrast placement and CT imaging were repeated. Three-dimensional models of the ETs were created, and the volumes were measured and compared.

RESULTS

Of the 14 ETs evaluated, 13 showed an increase in postprocedure volume. On average, postprocedure volumes showed a 57% increase from preprocedure volumes (mean relative change, 57.1%; P = .013).

CONCLUSION

Placement of a tension-holding suture in the tensor veli palatini muscle can reliably dilate the cartilaginous portion of the ET. Such a procedure may be useful in the treatment of ET dysfunction.

Patulous Eustachian tube and palatine defect in a Dachshund with chronic unilateral otitis externa and otitis media

BACKGROUND

Patulous Eustachian tube (pET) is a rare dysfunction of the Eustachian tube described in humans. It is characterized by failure of the ET to close, resulting in unrestricted passage of air, sound and material between the nasopharynx and the middle ear.

OBJECTIVE

To report a case of pET associated with otitis in a dog.

ANIMAL

A 6-year old-female spayed Dachshund dog.

METHODS AND MATERIALS

Otoscopic examination, cytological evaluation, culture and susceptibility, computerized tomography (CT), video-otoscopic flushing and surgery.

RESULTS

Left ear otoscopic examination revealed erythema, purulent frothy discharge, ceruminous gland hyperplasia, stenosis and a partial tear of the tympanum. Cytological evaluation from the left external canal showed neutrophils, macrophages, rods and cocci. Aerobic culture showed predominantly multidrug-resistant Pseudomonas aeruginosa. The CT findings of the left ear included chronic changes in the external canal, marked lysis of the tympanic bulla and marked dilation of the ET. During video-otoscope flushing, saline drained through the mouth. Bilateral incomplete hypoplasia of the soft palate was noted. Total ear canal ablation and bulla osteotomy with ET dissection were curative. Histopathological findings were compatible with chronic otitis externa (OE) and media.

CONCLUSION AND CLINICAL IMPORTANCE

To the best of the authors' knowledge, this is the first case of pET described in animals. The ET dysfunction and palatine defect were likely the cause of the otitis in this dog. Clinicians should investigate pET in animals with signs of OE characterized by frothy liquid and food fragments in the ear canal in addition to sneezing after drinking water.

Eustachian Tube Dysfunction in Children With Unilateral Cleft Lip and Palate: Differences Between Ipsilateral and Contralateral Ears

Objective:

To evaluate Eustachian tube dysfunction in the ipsilateral and contralateral ears, in children with unilateral cleft lip and palate (UCLP).

Design:

Retrospective chart review.

Setting:

Tertiary care children’s hospital.

Patients:

Seventy-four consecutive patients with UCLP born between 2005 and 2011 and treated at UPMC Children’s Hospital of Pittsburgh Cleft-Craniofacial Center were included.

Main Outcome Measures:

Conductive hearing loss, tympanogram type, number of middle ear effusions, tympanostomy tubes, and complications. Hypothesis was formulated prior to data collection.

Results:

Conductive hearing loss was nearly twice as common in the ipsilateral ear (43.2%) compared with contralateral (23.0%; P = .001, McNemar test). There were no significant differences in the frequency of each type of tympanogram between the contralateral and ipsilateral ears. The proportions of ipsilateral (90.5%) and contralateral (91.9%) ears with effusion were not significantly different. The total number of tubes received was not significantly different between the 2 ears (median of 2 bilaterally). When combined, complications (retractions, perforations, and cholesteatomas) were significantly more common in the ipsilateral ear (29.7%) compared with the contralateral ear (18.9%; P = .039, McNemar test).

Conclusion:

In children with UCLP, there were significantly more instances of conductive hearing loss and complications on the cleft side compared to the noncleft side. This suggests that Eustachian tube dysfunction may indeed be more severe on the cleft side. Considering this information, clinicians may need to be especially observant of the ipsilateral ear.

Effects of maxillary expansion on hearing and voice function in non-cleft lip palate and cleft lip palate patients with transverse maxillary deficiency: a multicentric randomized controlled trial

INTRODUCTION

The association between the treatment of transverse maxillary deficiency and the recovery of hearing and voice functions has gained attention in recent years.

OBJECTIVE

This prospective controlled trial aimed to evaluate the effects of rapid maxillary expansion on hearing and voice function in children with non-cleft lip palate and bilateral cleft lip palate with transverse maxillary deficiency METHODS: 53 patients (26 non-cleft and 27 bilateral cleft lip palate; mean age, 11.1±1.8 years) requiring rapid maxillary expansion for correction of narrow maxillary arches were recruited for this trial. Eight sub-groups were established based on the degree of hearing loss. Pure-tone audiometric and tympanometric records were taken for each subject at four different time periods. The first records were taken before rapid maxillary expansion (T0), the second after expansion (T1) (mean, 0.8 months), the third after three months (T2) (mean, 3 months) and the fourth at the end of retention period (T3) (mean, 6 months). ANOVA and Tukey HSD post-hoc tests were used for data analysis. Additionally, voice analysis was done using an updated PRAAT software program in a computerized speech lab at T0 and T2. A paired-samplet-test was used for comparisons of mean values of T0 and T2 voice parameters within both groups.

RESULTS

Rapid maxillary expansion treatment produced a significant increase in the hearing levels and middle ear volumes of all non-cleft and bilateral cleft lip palate patients with normal hearing levels and with mild conductive hearing loss, during the T0-T1, T1-T2, T0-T2, and T0-T3 observation periods (p<0.05). The significant increase was observed in right middle ear volumes during the T0-T1, T0-T2 and T0-T3 periods in non-cleft patients with moderate hearing loss. For voice analysis, significant differences were observed only between the T0 and T2 mean fundamental frequency (F0) and jitter percentage (p<0.05) in the non-cleft group. In the cleft group, no significant differences were observed for any voice parameter between the T0 and T2 periods.

CONCLUSION

Correction of the palatal anatomy by rapid maxillary expansion therapy has a beneficial effect on both improvements in hearing and normal function of the middle ear in both non-cleft and bilateral cleft lip palate patients. Similarly, rapid maxillary expansion significantly influences voice quality in non-cleft patients, with no significant effect in BCLP patients.

The impact of cleft lip and/or palate on parental quality of life: A pilot study

BACKGROUND

Cleft lip and/or palate (CL/CP/CLP) is one of the most common congenital anomalies. Children may suffer from a variety of health problems including difficulties with feeding and speech, middle ear problems, hearing loss and associated psychosocial concerns. The extent of impact of this disorder on the parents, however, has not yet been thoroughly evaluated. This pilot study was performed to evaluate the impact of having a child with CL/CP/CLP on the parents' quality of life (QoL) and family functioning and to compare between cleft subgroups.

METHODS

Forty-five parents with children aged 6 months to 6 years with CL/CP/CLP, followed by the multidisciplinary orofacial cleft team of Ghent University Hospital, completed following standardized questionnaires: Impact on Family Scale (IOFS), Family Impact Scale (FIS) and Care-Related Quality of Life Instrument (CarerQoL). Subgroups were compared with diverse unpaired statistical tests.

RESULTS

Younger children (6m-2y) with CL/CP/CLP entail more impact on parental QoL compared to children aged 2-4y old (p=0.04, ε²=0.15/p=0.02, ε²=0.17/p=0.02, ε²=0.17). Families from children with a syndromic cleft also encounter more impact (p=0.04, r=0.32 /p=0.01, r=0.37 /p=0.008, r=0.40/p=0.003, r=0.45). Prenatal orofacial cleft diagnosis is associated with a higher reporting of family conflicts (p=0.04, r=0.32). In case of non-syndromic clefts, families having children with CLP report more family conflicts compared to CL or CP (p=0.02, ε²=0.46). Parental education and number of children within the household showed no significant impact on parental QoL.

CONCLUSION

This cross-sectional study confirms that having a child with CL/CP/CLP impacts the parental QoL. This study was performed as a pilot-study for larger multicentre studies, future development of effective screening tools and identification of subgroups at risk. Long-term multidisciplinary follow-up should involve family-centred support.

The Association Between Age at Palatoplasty and Speech and Language Outcomes in Children With Cleft Palate: An Observational Chart Review Study

Objective:

To determine whether timing of palatoplasty (early, standard, or late) is associated with speech and language outcomes in children with cleft palate.

Design:

Retrospective case series.

Setting:

Tertiary care children’s hospital.

Participants:

Records from 733 children born between 2005 and 2015 and treated at the Cleft Craniofacial Clinic of a tertiary children’s hospital were retrospectively reviewed. Exclusion criteria were cleft repair at an outside hospital, intact secondary palate, absence of postpalatoplasty speech evaluation, syndromes, staged palatoplasty, and introduction to clinic after 12 months of age. Data from 232 children with cleft palate ± cleft lip were analyzed.

Interventions:

Palatoplasty.

Main Outcome Measures:

Speech/language delays and disorders at 20 months and 5 years of age based on formal hospital or community-based testing or screening evaluation in the Cleft Craniofacial Clinic; additional speech surgery.

Results:

Median age at palatoplasty was 12.6 months (range: 8.8-21.9 months). Age at palatoplasty was classified as early (<11 months, n = 28), standard (11-13 months, n = 158), or late (>13 months, n = 46). Late palatoplasty was associated with increased odds of speech/language delays and speech therapy at 20 months, and language delays at 5 years, compared with standard or early palatoplasty ( P < .05 for all comparisons). However, speech sound production disorders, velopharyngeal incompetence, tube replacement, and hearing loss were not significantly associated with age at palatoplasty.

Conclusions:

Late palatoplasty may be associated with short- and long-term delays in speech/language development. Future studies with standardized surgical technique/timing and outcome measures are required to more definitively describe the impact of age at palatoplasty on speech/language development.

Differences in the Tensor Veli Palatini Muscle and Hearing Status in Children With and Without 22q11.2 Deletion Syndrome

PURPOSE

To investigate the dimensions of the tensor veli palatini (TVP) muscle using high image resolution 3-dimensional magnetic resonance imaging (MRI) of the soft palate among children with normal velopharyngeal and craniofacial anatomy and to compare values to individuals with a diagnosis of 22q11.2 deletion syndrome (22q11DS). We also sought to determine whether there is a relationship between hypoplasia of the TVP and severity of middle ear dysfunction and hearing loss.

METHODS

Three-dimensional MRI were used to collect and analyze data obtained across 53 children between 4 and 12 years of age, including 40 children with normal velopharyngeal and craniofacial anatomy and 13 children with a diagnosis of 22q11.2 DS. Tensor veli palatini muscle length, thickness, and volume as well as bihamular distance were compared among participant groups.

RESULTS

A Welch's t-test revealed that the TVP in participants with 22q11DS is significantly shorter (P = .005, 17.3 vs 19.0 mm), thinner (P < .001, 1.1 vs 1.8 mm), and less voluminous (P < .001, 457.5 vs 667.3 mm³) than participants without 22q11DS. Participants with 22q11DS also had a greater (P = .006, 27.7 vs 24.7 mm) bihamular distance than participants without 22q11DS. There was an inverse relationship between TVP abnormalities noted above and the severity of audiologic and otologic histories.

CONCLUSION

The TVP muscle is substantially reduced in volume, length, and thickness in children with 22q11DS. These findings serve as preliminary support for the association of patient hearing and otologic severity and TVP dysmorphology.

Ear- and hearing-related impact on quality of life in children with cleft palate: Development and pretest of a health-related quality of life (HRQOL) instrument

OBJECTIVES

To investigate to what extent middle ear problems and associated hearing loss affect quality of life (QoL) of children born with a cleft palate.

METHODS

Fifty-five children aged between 6 and 18 years, born with non-syndromic cleft palate ± cleft lip (CP/L) were included. A new health-related quality of life (HRQOL) questionnaire was generated with consideration of the following domains of QoL: communication, hearing loss, physical symptoms, limitation of activities and socio-emotional impact.

RESULTS

Major psychosocial problems were not reported in the majority of children as a result of their ear and hearing problems. However, according to their parents, 2 out of 3 children, had difficulty speaking clearly and understandably. These communication problems led to behavioural problems and social isolation in 1 out of 5 children. Scholastic achievement was negatively influenced by two factors: hearing loss and sleep disturbance due to ear problems.

CONCLUSIONS

To our knowledge this is the first study to quantitatively measure the ear- and hearing-related impact on QoL in children born with CP/L. Large-scale, multicentre studies are needed to further research and expand on the findings of this pilot study.

Abnormalities of the muscles of the soft palate and their impact on auditory function in patients operated on for cleft palate: a case-control study

Patients with cleft palate have a high incidence of otitis media (OM), which, even after palatal repair, can persist and lead to auditory dysfunction. We aimed to identify what predisposes such patients to develop OM and correlate it with auditory function. We designed a prospective case-control study of adults who had had their cleft palates repaired in childhood. We examined the anatomy of the eustachian tube and the paratubal muscles of the soft palate with magnetic resonance imaging (MRI), assessed auditory function, and correlated the results to evaluate the impact of the pathological anatomy on the function of the middle ear. A total of 64 ears in 32 patients were evaluated (Group A, n = 16) (Group B, controls = 16). MRI showed a short eustachian tube with a shortened tensor attachment in Group A when compared with Group B. The pterygoid hamulus was found to be intact in both groups, but extensive perihamular fibrosis was seen in Group A. A total of 15 ears in Group A had loss of hearing (prevalence ratio (PR) 1.08), (13 mild loss, and 2 moderate loss), and impedance audiometry showed effusion of the middle ear in 12 ears in 16 patients, and dysfunction of the eustachian tube with high negative pressure in the middle ear in four ears in the 16 patients (PR 4.6). These could be positively correlated with the pathological anatomy using Pearson's correlation coefficient. Otitis media is persistent and can lead to conductive hearing loss in adults who have been operated on for cleft palate. This can be attributed to abnormalities in the development of the eustachian tube and the paratubal musculature.

Children with Cleft Palate: Predictors of Otologic Issues in the First 10 Years

Objective

To evaluate the characteristics of children with cleft palate associated with persistent otologic issues in the first 10 years of life.

Study Design

Case series with chart review.

Setting

Single academic center.

Subjects and Methods

Children born with cleft palate from 2003 to 2007 and treated by the UC Davis Cleft and Craniofacial Team between January 2003 and December 2017 were included in the study. Data from 143 patients were analyzed via Wilcoxon rank sum and Fisher exact tests for univariate analysis and logistic regression to determine adjusted odds ratios.

Results

The median length of follow-up was 9.9 years, and the age at last ear examination was 10.7 years. At the last evaluation, unresolved otologic issues were common, with at least 1 ear having a tympanic membrane (TM) perforation (16.1%), a tympanostomy tube (36.2%), or conductive hearing loss (23.1%). After adjusting for demographic and clinical characteristics, history of palate revision or speech surgery was associated with having a TM perforation ( P = .02). The only clinical variables associated with conductive hearing loss was the presence of a TM perforation ( P < .01) or a genetic abnormality ( P = .02). Severity of palatal clefting was not associated with specific otologic or audiologic outcomes after adjusting for other characteristics.

Conclusion

A large proportion of children with cleft palate have persistent otologic issues at age 10 years and would benefit from continued close monitoring well after the age when most children have normalized eustachian tube function. Prolonged otologic issues were not found to be associated with cleft type.

Association between symptomatic submucous cleft palate and otologic disease: A retrospective review

INTRODUCTION

Submucous cleft palate (SMCP) is the most common congenital malformation of the posterior palate and characterized in part by palatal muscle diastasis. Patients with SMCP are considered symptomatic when suffering from velopharyngeal insufficiency which leads to hypernasality of speech and excess nasal air emission. SMCP results from defects in the muscles thought to be responsible for regulating the patency of the eustachian tube which can lead to a number of middle ear pathologies and ultimately hearing loss. Hearing loss, especially at a young age, can make speech acquisition a challenge. The purpose of this study was to review patients with symptomatic SMCP (SSMCP) who have presented to our center and report on the association between SSMCP and otologic disease.

METHODS

This study was a retrospective review of all patients presenting to our center between 2004 and 2016. Patients with SSMCP were identified through a patient database maintained on site. Inclusion criteria were diagnosis of SMCP and documentation of the presence or absence of otologic disease. Once identified patient records were reviewed and various demographic and patient factors were recorded. Patients were then grouped into cohorts of those with and without otologic disease and those requiring tympanostomy tubes and not. T-tests were then used to compare various factors between cohorts.

RESULTS

A total of 73 patients were identified and 58 met inclusion criteria (mean age 5.8 years, male:female 36:22). 27.5% of patients were diagnosed with a genetic condition. 69% of patients had otologic disease and 47% required at least one set of bilateral tympanostomy myringotomy tubes. The cohort with ear disease tended to have worse scores on ACPA testing though this was not statistically significant. There were no significant demographic differences between the cohorts.

CONCLUSIONS

Patients with symptomatic SMCP suffer from a higher incidence of otologic disease and bilateral myringotomy tube placement than the general population. This is an important potential comorbidity in SSMCP patients as it can act as a further barrier to speech acquisition. Further research is needed to determine if otologic disease can be used for prognostication or treatment purposes.

Internationally adopted children with cleft lip and/or cleft palate: Middle ear findings and hearing during childhood

OBJECTIVE

Adopted children with cleft lip and/or cleft palate form a diverse group of patients. Due to increased age at palatal repair, adopted children have a higher risk of velopharyngeal insuffiency and poor speech outcome. Delayed palate repair may also lead to longer lasting Eustachian tube dysfunction. Decreased function of the Eustachian tube causes otitis media with effusion and recurrent acute otitis media, which can lead to other middle ear problems and hearing loss.

METHODS

One-hundred-and-thirty-two adopted children treated by the Cleft palate team in Wilhelmina Children's Hospital during January 1994 and December 2014 were included. Retrospectively, middle ear findings, the need for ventilation tube insertion and hearing during childhood were assessed. Findings were compared with 132 locally born children with cleft lip and/or cleft palate.

RESULTS

Adopted children had a mean age of 26.5 months old when they arrived in our country. After the age of two the total number of otitis media with effusion episodes and the need for ventilation tube placement did not significantly differ among adopted and non-adopted children. Adopted children had significantly more tympanic membrane perforations. Hearing threshold levels normalized with increasing age. Although within normal range, adopted children showed significantly higher pure tone averages than locally born children when they were eight to ten years old.

CONCLUSION

In general, adopted patients with cleft lip and/or cleft palate did not have more middle ear problems or ventilation tubes during childhood. However, theyhave more tympanic membrane perforations.

Prevalence of hearing loss and clinical otologic manifestations in patients with 22q11.2 deletion syndrome: A literature review

BACKGROUND

Hearing loss and otitis media are frequently reported in patients with 22q11.2 deletion syndrome.

OBJECTIVE OF REVIEW

Our objective was to review the current literature on the prevalence of hearing loss and otologic manifestations in patients with 22q11.2 deletion syndrome.

TYPE OF REVIEW

Systematic review.

SEARCH STRATEGY

We conducted a systematic search in PubMed and Embase combining the term "22q11.2 deletion syndrome" and synonyms with "hearing loss" and "otologic manifestations" and synonyms.

EVALUATION METHOD

We screened title/abstract and full text of all retrieved articles on pre-defined in- and exclusion criteria. The remaining articles were assessed on risk of bias. Outcome measures included the prevalence of hearing loss and otologic manifestations such as otitis media.

RESULTS

Our search yielded 558 unique studies of which a total of 25 articles were included for critical appraisal and data extraction. Twenty-one studies reported on hearing loss, and 21 studies on otologic manifestations. The prevalence of hearing loss varied from 6.0% to 60.3%, where in most studies conductive hearing loss was most prevalent. Rates of recurrent or chronic otitis media varied from 2.2% to 89.8%.

CONCLUSION

Although a very broad range in prevalences is reported in different studies, hearing loss and recurrent or chronic otitis media are frequently present in patients with 22q11.2 deletion syndrome. Regular check-ups and audiometric testing are advised in these patients.

Hearing sensitivity in adults with a unilateral cleft lip and palate after two-stage palatoplasty

OBJECTIVE

To evaluate long-term hearing and middle ear status in patients treated for a unilateral complete cleft lip and palate (UCLP) by two-stage palatoplasty.

METHODS

Forty-nine UCLP patients aged 17 years and older were included in this retrospective study. Patients were invited for a multidisciplinary long-term follow-up of their treatment at a tertiary center for craniofacial surgery in the Netherlands. ENT assessment included tympanometry and pure-tone audiometry. Medical files were searched for medical and surgical history.

RESULTS

In total, 19.4% of the patients had significant long-term hearing loss (PTA > 20 dB), comprising conductive hearing loss in 21.5% of the patients. In the majority (70%), this hearing loss was more pronounced at higher frequencies. In 25% the high fletcher index showed hearing thresholds above 20 dB. Ventilation tubes were placed at least once in 78.7% of the patients. The frequency of tube insertion was positively correlated with the incidence of reduced tympanic compliance (tympanogram type B) and the need for a pharyngoplasty.

CONCLUSION

The present study reports long-term hearing outcomes in UCLP patients with hard palate closure at 3 years of age. Persistent hearing loss was observed in 19.4% of our patients (PTA > 20 dB), mainly at the higher frequencies. Ventilation tube placement was associated with reduced tympanic compliance and higher risk on hearing loss (PTA air conduction). Our high incidence of velopharyngeal incompetence during early childhood, which is likely associated with Eustachian tube dysfunction, might have contributed to these results.

Therapeutic efficacy of azithromycin and acetylcysteine in chronic otitis media with effusion

Otitis media with effusion (OME) is a common disease in childhood. There is no consensus on the optimal therapeutic option for OME. Considering the known efficacy of acetylcysteine (AC) and azithromycin (AZ) in the treatment of middle ear mucosa, the aim of the study was to assess their efficacy in the management of chronic OME. The study included 90 children with OME, both ears. They are divided into three groups of 30 children. Group 1 (AC) patients were treated with acetylcysteine per os, 3 × 100 mg, for 3 weeks; group 2 (AZ) with body weight adjusted dose of azithromycin for 3 days; and group 3 (AC + AZ) with a combination of acetylcysteine and azithromycin at doses described above. Three measurements were performed. On second measurement, tympanogram improvement was recorded in 45% of 60 ears in group I, 53.3% of 60 ears in group II, and 61.7% of 60 ears in group III. The percentage of improvement was highest in group III. Although between-group differences did not reach statistical significance, the results obtained appear to be clinically relevant. In conclusion, conservative therapy for chronic OME is reasonable. Although study results don't have a strong statistical differences and may not refer clinical improvement results suggest that this combination of drugs (antibiotics, bronchosecretolytics) can be useful in the treatment of OME.

Otologic and audiologic findings in 22q11.2 deletion syndrome

Hearing loss is frequently present in the 22q11.2 deletion syndrome. Our aim was to describe the audiologic and otologic features of patients with 22q11.2 deletion syndrome. We conducted a retrospective cohort study in a single tertiary referral center. We reviewed medical files of all patients with 22q11.2 deletion syndrome who visited an otolaryngologist, plastic surgeon or speech therapist, for audiologic or otologic features. Hearing loss was defined as a pure tone average (of 0.5, 1, 2, and 4 kHz) of >20 decibel hearing level. Audiograms were available for 102 of 199 included patients, out of which 163 ears were measured in the required frquencies (0.5-4 kHz). Median age at time of most recent audiogram was 7 years (range 3-29 years). In 62 out of 163 ears (38%), hearing loss was present. Most ears had conductive hearing loss (n = 58) and 4 ears had mixed hearing loss. The severity of hearing loss was most frequently mild (pure tone average of ≤40 decibel hearing level). In 22.5% of ears, otitis media with effusion was observed at time of most recent audiogram. Age was not related to mean air conduction hearing thresholds or to otitis media with effusion (p = 0.43 and p = 0.11, respectively). In conclusion, hearing loss and otitis media are frequently present in patients with 22q11.2 deletion syndrome. Moreover, our results suggest that children with 22q11.2 deletion syndrome remain susceptible for otitis media as they age.