Early placement of ventilation tubes in cleft lip and palate patients: does palatal closure affect tube occlusion and short-term outcome?

Timing of First Set of Pressure Equalization Tubes in Pediatric Patients With Cleft Deformities

OBJECTIVES

Children with cleft palates often have comorbid eustachian tube dysfunction requiring pressure equalization tubes (PETs). PETs can relieve middle ear effusions that impede hearing. Ideal PET placement timing in this population is controversial. In this study, the audiologic exam passing rates of patients with cleft palate prior to and following PET insertion were assessed. Rates for patients receiving PETs at different ages were compared. It was hypothesized that earlier PET placement may benefit patients with additional months of improved hearing.

METHODS

A retrospective chart review was performed of patients with cleft palate between November 22, 2016 and November 22, 2021 at a tertiary center. Statistical analysis compared passing/normal audiologic exams in patients receiving PETs at different ages.

RESULTS

A total of 348 patients had cleft palate diagnoses, received PETs, and had adequate hearing data for inclusion. Those with PETs inserted at 3 months of age or less had an increase in percent of patients passing audiologic exams following versus prior to PET insertion of 13% (1.3 times improvement). Those receiving PETs between 7- and 12-months had the largest rate of improvement (42%) (2.4 times improvement); other groups had changes in passing rates between 31% and 40%. The rate of passing audiologic exams following PET insertion was high across all groups, ranging from 66% to 81%.

CONCLUSION

This is one of the first studies exploring the timing of PET placement in this population and showed that patients receiving PETs at 3 months of age or younger passed subsequent audiologic exams at similar rates relative to those receiving PETs later in life.

LEVEL OF EVIDENCE

3 Laryngoscope, 134:3391-3394, 2024.

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.

Tympanostomy Tubes: Are They Necessary? A Systematic Review on Implementation in Cleft Care

OBJECTIVE

To understand the indication for and the effects of early ventilation tube insertion (VTI) on hearing and speech for patients with cleft lip and/or palate (CLP).

DESIGN

We conducted a Preferred Reporting Items for Systematic Reviews and Meta-Analysis (PRISMA)-guided systematic review of relevant literature.

SETTING

Setting varied by geographical location and level of clinical care across studies.

PATIENTS, PARTICIPANTS

Patients with CLP who underwent VTI were included.

INTERVENTIONS

No interventions were performed.

MAIN OUTCOME MEASURE(S)

Primary outcome measures were hearing and speech following VTI. Secondary outcome measures were tube-related and middle ear complications. Early VTI occurred before or at time of palatoplasty while late VTI occurred after palatoplasty.

RESULTS

Twenty-three articles met inclusion criteria. Articles varied among study design, outcome measures, sample size, follow-up, and quality. Few studies demonstrated support for early VTI. Many studies reported no difference in hearing or speech between early and late VTI. Others reported worse outcomes, greater likelihood of complications, or needing repeat VTI following early tympanostomy placement. Several studies had significant limitations, including confounding variables, small sample size, or not reporting on our primary outcome.

CONCLUSIONS

No consistency was found regarding which patients would benefit most from early VTI. Given the aforementioned variability and sub-optimal methodologies, additional studies are warranted to provide stronger evidence regarding VTI timing in cleft care.

Hearing Status and Ventilation Tube at Time of Palatoplasty in Cleft Lip and Palate Patients: A Retrospective Study

Background and Objectives: There is no consensus regarding the indications for and timing of ventilation tube (VT) insertion in cleft lip and palate (CLP) patients. Our aim was to search for clinical and surgical (i.e., VT insertion) characteristics that influence the hearing status in CLP. Materials and Methods: We reviewed the hearing outcome of consecutive CLP cases operated on at a single referral center. Univariate and multivariate analysis were applied as appropriate. Results: We included 285 consecutive CLP patients, 109 female and 176 male; the mean age at last follow-up was 16.2 years. Unilateral CLP was found in 249 cases and bilateral CLP in 36. Early VTs (i.e., at the time of hard palate surgery) were applied in 75 (26.3%) patients. Late VTs (i.e., after hard palate surgery during follow-up) were applied in 69 (24.2%) children, at a mean age of 6.7 years old. Hearing loss (pure-tone average > 20 dB) was found in 114 (40%) CLP patients at last available follow-up (mild hearing loss in 96 patients, moderate in 18). In univariate and multivariate analyses, we found that only the absence of early VT insertion (p = 0.0003; OR = 18.2) was an independent prognostic factor of hearing loss in CLP patients. Furthermore, when early VTs were not inserted, there was a high risk of late VT (p = 0.002; OR 13.6). Conclusions: According to our results, the absence of VT insertion at the time of hard palate surgery is an independent prognostic risk factor of hearing loss in CLP patients. Early VT placement in CLP patients may prevent hearing loss and related consequences. These findings should be tested in a large, randomized clinical trial.

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.

Clinical practice guidelines for the diagnosis and management of otitis media with effusion (OME) in children in Japan - 2022 update

This is an update of the 2015 Guidelines developed by the Japan Otological Society and Oto-Rhino-Laryngeal Society of Japan defining otitis media with effusion (OME) in children (younger than 12 years old) and describing the disease rate, diagnosis, and method of examination. Recommended therapies that received consensus from the guideline committee were updated in consideration of current therapies used in Japan and based on available evidence.

METHOD

Regarding the treatment of OME in children, we developed Clinical Questions (CQs) and retrieved documents on each theme, including the definition, disease state, method of diagnosis, and medical treatment. In the previous guidelines, no retrieval expression was used to designate a period of time for literature retrieval. Conversely, a literature search of publications from March 2014 to May 2019 has been added to the JOS 2015 Guidelines. For publication of the CQs, we developed and assigned strengths to recommendations based on the collected evidence.

RESULTS

OME in children was classified into one group lacking the risk of developing chronic or intractable disease and another group at higher risk (e.g., children with Down syndrome, cleft palate), and recommendations for clinical management, including follow-up, is provided. Information regarding management of children with unilateral OME and intractable cases complicated by adhesive otitis media is also provided.

CONCLUSION

In clinical management of OME in children, the Japanese Clinical Practice Guidelines recommends management not only of complications of OME itself, such as effusion in the middle ear and pathologic changes in the tympanic membrane, but also pathologic changes in surrounding organs associated with infectious or inflammatory diseases.

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.

Relationship between cleft palate width and otitis media

Objectives

To investigate the relationship between cleft width and otitis media (OM) and to determine whether a wide cleft palate (CP) is a risk factor of the incidence, type, amount of middle ear effusion, and prolonged morbidity in OM.

Study Design

Retrospective cohort study.

Methods

Children with CP who underwent palatoplasty between 2014 and 2018 were analyzed. Cleft width was measured at palatoplasty. The incidence of otitis media with effusion (OME) and acute otitis media (AOM), the type and amount of middle ear effusion, and OME duration and age at resolution were assessed in relation to cleft width.

Results

One hundred eighteen children were included. The CP types were Veau I in 16, II in 35, III in 48, and IV in 19 patients. The incidence of OME and AOM before palatoplasty was 83.1% and 49.2%, respectively. Cleft width did not differ significantly between patients with or without OME but was significantly greater in those with, than in those without, AOM (p < .001), in those with mucoid, than in those with serous, effusion (p = .012), and in those with complete, than in those with partial, effusion (p = .01). Regardless of cleft width or type, OME persisted for a median duration of 50 months.

Conclusions

Cleft width was significantly associated with the incidence of AOM and the type and amount of middle ear effusion before palatoplasty. However, it was not significantly related to the incidence, age at resolution, or duration of OME. Regardless of cleft width or type, OM in children with CP requires long-term follow-up. Level of Evidence: 2b.

How long do tympanostomy ventilation tubes last in pediatric patients with otitis media with effusion or adhesion? A study using Kaplan-Meier survival analysis

OBJECTIVE

The purpose of this study was to evaluate the functional duration and survival rate of tympanostomy ventilation tubes and the complications associated with their use in pediatric patients who underwent tube insertion for otitis media with effusion (OME). Complications were analyzed including recurrence and tympanic membrane perforation after the tube removal or extrusion.

METHODS

Altogether, 447 ears from 234 pediatric patients younger than 15 years of age were studied retrospectively. All patients had undergone long-term tympanostomy ventilation tube: the Goode T-tube insertion for OME at the Osaka Women's and Children's Hospital, which is the pediatrics specialty hospital between April 2014 and March 2016. They were typically followed up every 3-4 months or more frequently if necessary due to otorrhea or tube infection. Subsequently, the tube duration, survival rates of the tube especially at 22 months after insertion defined as "full-term placement", and the rates of recurrence and perforation were calculated and statistically evaluated.

RESULTS

Of 447 ears, 335 ears from 184 patients underwent their first tube insertion, and 112 ears from 64 patients underwent their second or subsequent tube insertion within the targeted period. Two hundred ears from 106 patients were associated with a cleft palate. The survival rate at full-term placement was 51.7%. The recurrence rate was 56.3%, and the rate of the tympanic perforation was 8.5%.

CONCLUSIONS

Approximately half of the tubes survived for 22 months. The perforation rate was relatively low; however, recurrence of OME was seen in more than half the ears.

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.

Speech and Audiology Outcomes After Single-Stage Versus Early 2-Stage Cleft Palate Repair

PURPOSE

The timing and management of patients with cleft palates have been controversial. Early soft palate closure at the time of cleft lip repair followed by hard palate closure at a second stage has been hypothesized to improve speech and audiology outcomes. This study compares cleft palate patients who have undergone single-stage versus 2-stage cleft palate repairs and the outcomes on speech and hearing.

METHODS

A retrospective chart review identified patients with diagnosis of cleft lip with complete cleft palate who underwent either single or 2-stage repair from 2006 to 2012. Data collected included age at each surgery, necessity of further speech surgery for velopharyngeal insufficiency, frequency of tympanostomy tube placement, presence of hearing loss, and speech assessment data graded per the validated Americleft speech scale.

RESULTS

A total of 84 patients were identified and subdivided into groups of single-stage and 2-stage repair. The mean age at the time of single-stage palate repair was 13.3 months. For the 2-stage group, the mean ages were 4.2 and 11.8 months for the soft palate and hard palate repairs, respectively. Comparing the single-stage versus 2-stage palate repairs, there was no significant difference in all speech parameters including hypernasality, hyponasality, nasal air emission, articulation, expressive language, receptive language, speech intelligibility, and speech acceptability for both unilateral and bilateral cleft lip/palate patients. Two-stage repair was associated with increased number of tympanostomy tube placement compared with single-stage repair (relative risk, 1.74; P = 0.009), and the first set of tubes was performed at a statistically significantly younger age, 4.5 months in the 2-stage repair compared with 16.9 months in the single-stage (P = 0.012) with 87.5% performed with first stage of repair. However, there was no difference in the types, degrees of hearing loss, or the presence of at least mild conductive hearing loss at latest follow-up audiograms between the groups.

CONCLUSIONS

There was no significant benefit with respect to speech or hearing outcomes between single-stage and 2-stage cleft palate repairs. This advocates for surgeon and family preference in the timing of cleft palate repair.

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.

Otological outcome in cleft lip and palate children with middle ear effusion

OBJECTIVE

To evaluate the factors contributing to middle ear pathology, hearing and speech development among cleft palate children treated for middle ear effusion.

METHOD

A prospective cross-sectional otoscopic and audiological analysis was conducted on 102 cleft palate children (204 ears) aged 1-18 years old who were treated for middle ear effusion at our centre. Retrospective chart review was done to determine patient characteristics and prior patient management. The aim was to assess the effect of ventilation tube insertion (VTI) on hearing, speech and chronic otitis media; comparing the timing and number of ventilation tubes per ear and determining other factors affecting the short-term and long-term outcome.

RESULTS

68 children or 130 ears (63% of all cases) were selectively treated with ventilation tube insertion. Repeat procedures (more than 2) were performed in 41 ears. Among children with VTI performed, the incidence of chronic otitis media in children after the age of 4 was 17%. Overall, abnormal tympanic membrane findings and hearing loss were detected in nearly half the cases who were previously treated with VTI. Early ventilation tube insertion at less than 1 year of age, resulted in a better middle ear and hearing outcome in children less than 4 years old (p < 0.05), however there was no significant difference in children more than 4 years old. Early surgical repair of cleft palate prior to the age of one year resulted in favourable results in both age groups (p < 0.05). There was a higher prevalence of chronic otitis media with repeated grommet insertion (3 or more) (p < 0.05). Speech and language milestones were achieved in 94% of all children above the age of four.

CONCLUSION

Treatment with early ventilation tube insertion prior to the age of one year provides a hearing benefit in children less than 4 years of age, but no significant difference after 4 years of age. Factors significantly affecting the outcome after 4 years of age was the timing of palatal closure and total number of tube insertions. We recommend a conservative approach especially when considering repeated tube insertions. A long-term follow-up paired with interval hearing assessment is advocated until early adulthood.

The Trend of Cleft Care at a Children's Referral Center in Thailand

OBJECTIVE

To investigate the trend in cleft care at a major children's referral center in Bangkok, Thailand.

STUDY DESIGN

Retrospective chart review.

PATIENTS AND METHODS

A review of 129 patients under 18 years of age who had underwent care by the senior author for cleft treatment between January 2015 and October 2017 was done. The impact of varying factors on patient care was analyzed. We compare our demographics and treatment timeline to that of previously published literature in more developed countries.

SETTING

Tertiary care medical center.

RESULTS

One hundred and two patient charts were reviewed with 53% male patients. Most patients had both cleft lip and cleft palate, 44%. Cleft lips most commonly were complete and occurred on the left side. In all, 77.4% of clefts were nonsyndromic. On average, primary cleft lip surgery was delayed being performed about 11 months of age. Sixteen percent of patients were treated with an obturator, while 11 patients had nasoalveolar molding use. Hearing screenings occurred on average at around 6 months of age. Abnormal tympanograms were evident in 32% of individuals. There was a significant difference in timing of surgery for patients who lived a distance greater than 30 kilometers from the hospital versus those from the Bangkok metropolis (P < .05).

CONCLUSION

Reviewing data from a high-volume referral center in Thailand reveals mild variance with regard to cleft care timing compared to published literature from the developed world. Distance traveled was found to impact timing of surgery.

Hearing status and behavioural patterns among school aged children with cleft lip and/or palate

OBJECTIVE

There is a dearth of studies on long term hearing status and behavioural patterns among cleft lip and/or palate children after their primary lip and palate closure in Malaysia. This study describes the audiology status and behavioural patterns in a group of school aged children with cleft lip and/or palate.

METHOD

A cross sectional study was carried out where caretakers of cleft lip and/or palate were asked to complete the translated Malay language version of Strength Difficulties Questionnaire. The hearing status of the children was analyzed based on recent pure tone audiometric and tympanogram results. The patients' age, gender, type of cleft pathology, age of palatal surgery and behavioural patterns were examined for their potential relationship with hearing status.

RESULTS

A total of 74 children (148 ears) aged between 7 and 17 years with cleft lip and/or palate were recruited. The result showed 37 ears (25.0%) had hearing loss with majority suffered from mild conductive hearing loss. There were 16 ears (10.8%) that had persistent middle ear effusion. Hearing improvement occurred when palatal repair was performed at the age of less than 1 year old. (p = 0.015) There was no significant relationship between patients' gender, age, type of cleft and history of myringotomy with their hearing status. In terms of behavioural patterns, 16.3% were abnormal for total behavioural score, 39.2% for peer problem and 17.6% for conduct problem. For prosocial behaviour, 16.3% were rated low and very low. There was fair correlation between age and hyperactivity problems (r = 0.44). Patients' gender, type of cleft pathology, had been teased apart and hearing status was found not related to behavioural problems.

CONCLUSION

Cleft lip and/or palate patients have a good longterm hearing outcome. Majority had normal hearing and if there is hearing impairment, it is only a mild loss. Early palatal repair surgery before the age of 1 year can significantly reduce the risk of hearing loss. Cleft lip and/or palate patients experienced peer problems. There was no significant correlation between behavioural difficulty and hearing status among school-aged children with cleft lip and palate.

Otologic Outcomes With Two Different Surgical Protocols in Patients With a Cleft Palate: A Retrospective Study

OBJECTIVE

To compare otologic outcomes in patients with cleft palate who underwent 2 different surgical protocols.

DESIGN

Monocentric retrospective analysis of medical reports.

PATIENTS, PARTICIPANTS

All consecutively treated patients affected by a cleft palate, born between January 1998 and December 2002 (group 1) and between January 2007 and December 2010 (group 2).

INTERVENTIONS

Patients in group 1 underwent Veau-Wardill-Kilner palatoplasty at 10 months and had ventilation tubes inserted in case of otitis media with effusion (OME) during surgery. Patients in group 2 underwent Sommerlad intravelar veloplasty at 5 months. Ventilation tubes were inserted only in case of persistent OME.

MAIN OUTCOME MEASURE(S)

The need for a second set of ventilation tubes to be inserted in case of persistent OME, the presence of OME at the age of 2 years, and tympanic abnormalities at the age of 5 years were analyzed.

RESULTS

There was no statistically significant difference either for the presence of OME at the age of 2 years (27 [45%] vs 32 [57.14%], respectively, in groups 1 and 2; P = .191) or for tympanic abnormalities at the age of 5 years (20 [33.33%] vs 15 [26.79%]; P = .433). Statistically significant difference was found for the need to insert a second set of ventilation tubes in case of persistent OME (29 [48.33%] vs 12 [21.42%], respectively; P = .02).

CONCLUSION

Early Sommerlad intravelar veloplasty may reduce persistent OME and consequently the need for ventilation tubes insertion, compared to later Veau-Wardill-Kilner palatoplasty.

Surveillance of Otitis Media With Effusion in Thai Children With Cleft Palate

Objective:

To study the incidence and outcome of management of otitis media with effusion in Thai children with cleft palate.

Design:

Retrospective cohort study in the tertiary care center.

Patients:

Ninety-five children with cleft palate were referred for ear evaluation, from June 1997 to January 2015. Fifteen children (15.8%) had associated craniofacial syndromic anomalies.

Main outcome measures:

Cumulative incidence of otitis media with effusion, rate of ventilation tube insertion, duration of indwelling tubes, hearing outcome, and complications of ventilation tubes.

Results:

Ear examinations were done every 8 to 12 weeks throughout the study. Cumulative incidence of otitis media with effusion was 53.7% in children within 12 months of age and 81.1% within 24 months of age. At the end of the study, all of the patients had at least 1 episode of otitis media with effusion. Eighty-eight children (92.6%) had palatoplasty, and there was no significant difference in the incidence of otitis media before and after palatoplasty. The mean hearing level at recruitment was 40.8 ±18.4 dB. Ventilation tube insertion was done in 76 patients (80%). The median time for indwelling tubes was 11.7 months. Rate of ventilation tube insertion was 0.5/year. The mean hearing level at last follow-up was 23.5 ± 14 dB. Otorrhea through tube was found in 24 cases (31.6%).

Conclusion:

Otitis media with effusion was common in Thai children with cleft palate. Surveillance of middle ear effusion and ventilation tube insertion contributed to a favorable hearing outcome.

Early Placement of Ventilation Tubes in Infants with Cleft Lip and Palate: A Systematic Review

Objective

Studies have shown that the majority of cleft lip and palate (CLP) children have middle ear fluid present at the time of lip repair (3-4 months). Despite hearing loss, the majority of children do not undergo ventilation tube treatment if required until the time of palate repair (9-12 months). We aimed to examine the effectiveness and potential complications of early ventilation tube placement prior to palatoplasty in infants with cleft lip and palate.

Data Sources

Medline (1946-2015), Embase (1980-2015), and EBM Reviews (Cochrane Central Register of Controlled).

Review Methods

Data sources were searched for publications that described the results of early ventilation tube placement in children with CLP prior to cleft palate repair. Two independent reviewers appraised the selected studies.

Results

Of 226 studies identified, 6 studies met the inclusion criteria. Early ventilation tube insertion in CLP gave similar speech and audiology outcomes to non-CLP children undergoing ventilation tube insertion and better outcomes than those children with CLP having later ventilation tube insertion at or after the time of palate closure. The main reported side effect was otorrhea, being higher for children with CLP having early ventilation tube insertion (67% vs 33%), with a reduction in otorrhea with increasing age. Larger studies with longer-term outcome reporting are required to fully address the study objectives.

Conclusion

Published data are limited but appear to support early insertion of ventilation tubes in children with CLP to restore middle ear function and maximize audiologic and speech outcomes.

Evaluation of Ventilation Tube Placement and Long-term Audiologic Outcome in Children with Cleft Palate

Objective

The purpose of this study was to assess the effect of ventilation tube (VT) placement on long-term hearing outcomes in children with cleft palate.

Study Design

Case series with chart review.

Setting

Genetic and dysmorphology database at Rady Children's Hospital–San Diego (RCHSD).

Patients

Children with cleft palate diagnosis who underwent surgery at RCHSD between 1995 and 2002.

Main Outcome Measure

The primary outcome studied was hearing acuity at 10 years of age. Independent variables studied included gender, age at palate repair and first VT placement, total number of VTs, number of complications, and presence of tympanic membrane perforation.

Results

An increased number of tubes was associated with a greater incidence of hearing loss at age 10, even after adjusting for total number of otologic complications. The timing of initial tube placement did not have a significant effect on long-term hearing outcome in this study.

Conclusions

While children with worse middle ear disease are more likely to receive more tubes and have long-term conductive hearing loss as a result of ear disease, the results of this study suggest that multiple tube placements may not contribute to improved long-term hearing outcomes. Further research focusing on long-term outcomes is needed to establish patient-centered criteria guiding decision making for ventilation tube placement in children with cleft palate.

Impact of pharyngofixation in cleft palate repair surgery on the development of chronic adhesive otitis media

BACKGROUND

A significant percentage of children with cleft palate suffer from otitis media with effusion and its consequences, such as deafness, chronic adhesive otitis and cholesteatoma. This study aimed to determine whether these effects can be minimised by selecting pharyngofixation as the surgical technique for cleft palate correction.

METHODS

A retrospective study was performed of 155 patients (308 ears) who underwent surgery from age 5 months to 8 years and were followed up for 36-84 months.

RESULTS

In all, 125 ears (41 per cent) had epitympanic retraction, 45 ears (14 per cent) had sinus tympani retraction and 5 patients (3 per cent) had cholesteatoma. Use of the pharyngofixation technique did not significantly correlate with (1) the severity of otological findings or (2) the incidence of retraction pockets in the epitympanum and sinus tympani (p = 0.53).

CONCLUSION

Pharyngofixation did not significantly alter the severity of long-term otological findings.

Resolution of Otitis Media With Effusion in Children With Cleft Palate Followed Through Five Years of Age

OBJECTIVE

To describe the temporal pattern of otitis media with effusion (OME) resolution for a cohort of nonsyndromic cleft palate children enrolled before palatoplasty and followed through 5 years of age.

DESIGN

This is a prospective, longitudinal study of the time course for OME resolution in infants and children with palatal clefts.

SETTING

Cleft Palate Craniofacial Center of a tertiary care pediatric hospital.

PARTICIPANTS

This study included 52 children with cleft palate (29 boys, 45 white, Veau 1 through 4) who had a Furlow-type palatoplasty between 10 and 24 months of age performed by one of six surgeons.

INTERVENTIONS

Standard cleft palate management was supplemented with study visits to the research clinic pre- and postpalatoplasty and then yearly to 6 years of age for assessments of middle ear status by interval history, otoscopy, and tympanometry.

MAIN OUTCOME MEASURE

The main outcome measure was age at otitis media resolution defined as the age in years at the first in a sequence of "disease-free" diagnoses not interrupted or followed by any other diagnosis.

RESULTS

The cumulative percent OME resolution for ears/children at ages <1, 1, 2, 3, 4, 5 years was 4.1/4.4, 14.3/10.9, 31.6/21.7, 45.9/37.0, 56.1/50.0, and 70.4/60.9%. OME resolution followed a simple linear time curve with slopes of 13.5% (confidence interval [CI] = 12.2% to 14.8%, r(2) = .99) and 11.9% (CI = 10.1% to 13.6%, r(2) = .99) resolutions per year for ears and children, respectively.

CONCLUSIONS

There is a natural, age-related pattern of resolution for persistent OME that affects most infants and young children with cleft palate that is not affected by palatoplasty.

Palatoplasty decreases the re-insertion rate of middle ear ventilation tube in cleft palate children - A population-based birth cohort study

CONCLUSION

Palatoplasty can significantly decrease their middle ear re-intubation rate with a relatively lower hazard ratio compared to children who underwent VTI only.

OBJECTIVES

In children with cleft palate, questions remain about the overall effect of ventilation tube insertion (VTI) and palatoplasty for their OME. A large-scale study might offer more evidence for the roles of palatal surgery.

SUBJECTS AND METHODS

This was a retrospective birth cohort study based upon a national database. We analyzed children born between 1999-2004 and diagnosed as cleft palate and/or lips. These children, according to their surgeries, were separated into two groups: (1) VTI only, and (2) VTI and palatoplasty. Kaplan-Meier analysis and log-rank test were used to calculate their cumulative tube re-insertion rates. Their hazard ratios of tube re-insertion were also analyzed.

RESULTS

In total, 1205 cleft children were collected, with 151 in the VTI only group and 1054 in the VTI + palatoplasty group. Ventilation tube re-insertion rates were significantly lower in the VTI + palatoplasty group (p = 0.002). The cumulative re-insertion rates also showed a significant difference (p = 0.001). When compared to the VTI only group, the adjusted hazard ratio was 0.528 in the VTI + palatoplasty group (p = 0.001).

ABR thresholds in infants born with CLP and OME and infants with OME

OBJECTIVES

The aim of this study was to investigate and compare auditory brainstem response (ABR) thresholds related to otitis media with effusion (OME) in infants with and without cleft palate and/or lip (CP±L).

METHODS

Forty-seven infants with CP±L and 67 infants with OME participated in the study. Hearing thresholds of ears of infants with OME were compared between groups and within the group with CP±L.

RESULTS

Infants with CP±L and OME presented with similar hearing thresholds as infants with OME and not CP±L. Within the cleft group, infants with isolated cleft palate and OME demonstrated significantly higher hearing thresholds than infants with unilateral cleft lip and palate and OME.

CONCLUSION

A high prevalence of infants with CP±L present with OME early in life. Hearing thresholds of these infants are similar to infants without CP±L, but with OME. The ear status and hearing thresholds of infants with CP±L needs to be monitored to be able to provide the best access to hearing in order to fully allow speech and language development.

The effect of early routine grommet insertion on management of otitis media with effusion in children with cleft palate

PURPOSE

The aim of the study is to compare long term otoscopic and audiological findings of cleft palate patients with or without early grommet insertion.

METHODS

Cleft palate patients followed-up in Hacettepe University between 2008 and 2013 were included in the study. Age, gender, cleft types and palate surgery data, grommet tube insertion history and otological - audiological evaluations of the patients were recorded. Patients were evaluated in three groups according to grommet insertion history: A-early routine grommet insertion, B-grommet insertion during follow-up, C-no grommet insertion. Otological and audiological findings were compared.

RESULTS

There were 154 patients in the study, with a median age of 7.7 years. There were 67 patients in group A (43.5%), 22 patients in group B (14.3%) and 65 patients in group C (42.2%). OME was identified significantly higher in group A and normal otoscopic examination findings were higher in group C. Complications showed a higher rate than other otoscopic findings in group B patients. There was no significant difference for any frequencies in between the groups in terms of mean air-bone gap (ABG) values. There were 20 grade I, 25 grade II, 77 grade III and 32 grade IV patients in the study according to the Veau classification.

CONCLUSION

Prophylactic grommet insertion may not be applied as some cleft palate patients with no OME. Wait and see protocol can be recommended for these patients, and they should be followed-up up closely to avoid complications. If the effusion does not recover or tympanic membrane changes occur in follow-up, grommet insertion should be considered.

Grommets for otitis media with effusion in children with cleft palate: a systematic review

BACKGROUND AND OBJECTIVE

No consensus has yet been reached with regard to the link between otitis media with effusion (OME), hearing loss, and language development in children with cleft palate. The objective of this study was to address the effectiveness of ventilation tube insertion (VTI) for OME in children with cleft palate.

METHODS

A dual review process was used to assess eligible studies drawn from PubMed, Medline via Ovid, Cumulative Index to Nursing and Allied Health Literature, Cochrane Library, and reference lists between 1948 and November 2013. Potentially relevant papers were selected according to the full text of the articles. Relevant data were extracted onto a data extraction sheet.

RESULTS

Nine high- or moderate-quality cohort studies were included in this study. VTI was administered in 38% to 53% of the OME cases, and more severe cases appeared more likely to undergo VTI. Compared with conservative forms of management (eg, watchful waiting), VTI has been shown to be beneficial to the recovery of hearing in children with cleft palate and OME. A growing body of evidence demonstrates the benefits of VTI in the development of speech and language in children with cleft palate and OME. These children face a higher risk of complications than those undergoing conservative treatments, the most common of which are eardrum retraction and tympanosclerosis, with an incidence of ∼ 11% to 37%.

CONCLUSIONS

This review provides evidence-based information related to the selection of treatment for OME in children with cleft palate. Additional randomized controlled trials are required to obtain bias-resistant evidence capable of reliably guiding treatment decisions. The conclusions in this review are based on underpowered cohort studies and very-low-strength evidence.

The Role of Screening Audiometry in the Management of Otitis Media with Effusion in Children with Cleft Palate in Northern Ireland

Objective

To determine uptake and outcome of hearing screening in the cleft palate population in Northern Ireland (NI) and the rate of ventilation tube (VT) insertion over a 3-year period.

Design

In NI, hearing screening is offered in the neonatal period, at 9 months in the community, and at 2.5 years in the joint cleft clinic.

Patients

Eighty-five children with cleft palate born between 2006 and 2008 in NI were eligible for all three screenings.

Methods

A retrospective case note review was performed of tympanograms, audiometry, and VT insertion rates at each of the three time points.

Results

In the neonatal period, all patients eligible were screened; 66 (77.6%) patients passed the screening, with 19 patients (22.4%) failing, resulting in direct referral to ENT for consideration of VT. Results of the 9-month community screening were not made routinely available to the regional cleft service. At the 2.5-year clinic screening, all attending patients (n = 80) had documented screening. Fifty-two (65%) patients passed screening, with 28 patients (35%) failing screening. Forty-six patients (57.5%) had documented VT, and 9 (11.25%) were awaiting ENT review for consideration of VT.

Conclusion

Ventilation tubes are not routinely inserted at the time of cleft repair in the NI population, and 57.5% of our cleft population has ventilation tubes inserted by 2.5 years. Cleft patients in NI have regular routine hearing assessments, and our current practice avoids universal ventilation tube insertion while identifying those who need further hearing management. Further research is needed to reach an international consensus on the insertion of VT in cleft patients.

Acquired middle ear cholesteatoma in children with cleft palate: experience from 18 surgical cases

OBJECTIVES

To review an institutional experience with the surgical management of middle ear cholesteatoma in children with cleft palate.

MATERIALS AND METHODS

We analyzed retrospectively 18 children diagnosed with cleft palate who underwent surgery for acquired middle ear cholesteatoma between 2000 and 2007. The following data were recorded: age, sex, history of ventilation tube insertion, status of the contralateral ear, cholesteatoma location and extension, and surgical technique involved. Cholesteatoma recidivism, stable mastoid cavity and hearing levels were the main outcomes measured.

RESULTS

Follow-up ranged from 5 to 12 years (mean 8 years). Twelve children underwent planned staged canal wall up mastoidectomy: a residual cholesteatoma was found and removed during the second-look procedure in 2 ears (16.6%); two children (16.6%) showed a recurrent cholesteatoma and required conversion to canal wall down mastoidectomy. A modified Bondy technique was chosen in two children with an epitympanic cholesteatoma with an intact tympano-ossicular system, while in the remaining four subjects a canal wall down mastoidectomy was performed because of an irreparable erosion of the postero-superior canal wall: no cases of recurrent cholesteatoma were observed in these 6 children; revision mastoidectomy was needed in one patient for cavity granulation. A postoperative air-bone gap result of 0-20dB was achieved in 11 children (61.1%); in 5 cases (27.7%) postoperative air-bone gap was between 21 and 30dB, while in 2 (11.1%) was >30dB. Bone conduction thresholds remained unaffected in all cases.

CONCLUSIONS

Our results indicate that most cleft palate children with cholesteatoma can be managed with a canal wall up mastoidectomy with low complication rates. In extensive disease with large erosion of the canal wall as well in presence of a retraction pocket in the contralateral ear, a canal wall down mastoidectomy should be considered. In epitympanic cholesteatomas with an intact tympano-ossicular system and mesotympanum free of disease, the modified Bondy procedure is an effective surgical option. As in the general pediatric population, improvement or preservation of hearing can be obtained in most patients.

Otitis media with effusion in children with cleft lip and palate: a narrative review

OBJECTIVE

Repair surgery of cleft lip and palate (CLP) can produce satisfactory cosmetic results but the problem of recurrent otitis media with effusion (OME) secondary to CLP may persist. This can cause long-term hearing loss and affect linguistic, academic, and personal development. The aim of this review is to provide the most recent information regarding OME in children with CLP.

METHODS

All papers referring to children with CLP and OME were identified from searches in Medline, PubMed, Cochrane Library, and Web of Science. Abstracts were read and relevant papers were obtained. Additional studies were obtained from the references of the selected articles.

RESULTS

Both current and previous research on OME in children with CLP focused on the controversy over treatment strategies. Evidence on the optimal treatment for OME in CLP children was lacking. Ventilation tube surgery using the same anesthetic as lip or palate procedures was not well-supported. After summarizing the literature review, a flowchart of management guidance for such patients is also recommended. Updated reviews such as this will provide clinicians and patients/parents with a valuable reference.

CONCLUSIONS

The lack of evidence on the optimal treatment for OME in children with CLP should prompt a relatively conservative approach. However, only a consensus between patients/parents and surgeons regarding the most suitable treatment strategy for OME can ensure the greatest benefit to individual patients.

Otitis media and ear tubes

The placement of myringotomy tubes remains an effective treatment of recurrent acute otitis media and chronic otitis media with effusion. Infants and young children are prone to these entities because of their immature anatomy and immunology. Several host, pathogenic, and environmental factors contribute to the development of these conditions. The identification and modification of some these factors can preclude the need for intervention. The procedure continues to be one of the most common outpatient pediatric procedures. Close vigilance and identification of potential complications is of utmost importance in the ongoing management of the child with middle ear disease.