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

An Enhanced Audiologic Protocol for Early Identification of Conductive Hearing Loss in Patients with Cleft Palate

OBJECTIVE

To characterize the onset and prevalence of conductive hearing loss (CHL) in pediatric patients with cleft palate (CP) prior to palatoplasty with an enhanced audiologic protocol.

DESIGN

Retrospective cohort study.

SETTING

Multidisciplinary cleft and craniofacial clinic at a tertiary care center.

PATIENTS

Patients with CP who received audiologic workup pre-operatively. Patients with bilateral permanent hearing loss, expiration prior to palatoplasty, or no pre-operative data were excluded.

INTERVENTIONS

Patients with CP born February 2019 to November 2019 who passed newborn hearing screening (NBHS) received audiologic testing at 9 months of age (standard protocol). Patients born December 2019 to September 2020 underwent testing prior to 9 months of age (enhanced protocol).

MAIN OUTCOME MEASURES

Age of identification of CHL in patients after implementation of the enhanced audiologic protocol.

RESULTS

The number of patients who passed their NBHS in the standard protocol (n = 14, 54%) and the enhanced protocol (n = 25, 66%) did not differ. Infants who passed their NBHS, but demonstrated hearing loss on subsequent audiologic testing did not differ between enhanced (n = 25, 66%) and standard cohort (n = 14, 54%). Of patients who passed NBHS in the enhanced protocol, 48% (n = 12) had CHL identified by 3 months, and 20% (n = 5) by 6 months of age. With the enhanced protocol, patients who did not undergo additional testing post NBHS significantly dropped from 44.9% (n = 22) to 4.2% (n = 2) (P < .0001).

CONCLUSION

Even with passed NBHS, CHL is still present for infants with CP pre-operatively. Earlier and more frequent testing for this population is recommended.

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.

Comparison of Superior Semicircular Canal Bone Thickness and Patterns in Unilateral and Bilateral Cleft Patients and Normal Controls: A CBCT Study

Superior Semicircular Canal Dehiscence (SSCD) is a recently-defined developmental defect may be associated with several craniofacial anomalies such as Cleft Lip/Palate (CLP). The present study aimed to compare subjects with unilateral and bilateral CLP and normal controls in terms of Superior Semicircular Canal (SSC) bone thickness and pattern.

A total of 238 Cone Beam Computed Tomography (CBCT) images were collected from 52 unilateral Cleft Lip and Palate (UCLP) subjects (104 temporal bones) and 38 Bilateral Cleft Lip and Palate (BCLP) (76 temporal bones) subjects and 148 healthy controls (296 temporal bones). The SSC bone thickness was measured twice and validated by a maxillofacial radiologist. The samples were then classified into five categories based on bone thickness: papyraceous or thin, normal, thick, pneumatized, and dehiscence. After all, the UCLP, BCLP, and normal control groups were compared concerning the SSC pattern and thickness.

The results revealed no significant difference among the three groups regarding the SSC pattern and thickness based on gender. The SSC patterns (P value = .001) and SSC thickness (0.01) were strongly correlated to the cleft type. The thinnest bone thickness and the highest incidence of SSCD were observed among the subjects with BCLP.

The results showed a significant association between the SSC patterns and SSC thickness and the study groups.

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.

Otology and Audiology: Complications, Challenges, and Concerns in the Patient With Cleft Lip and/or Palate

Cleft lip and/or palate, a treatable congenital condition, affects around 1 in 700 births, placing a large burden of care on those affected. A multidisciplinary approach to treating the patient involves not only cleft surgery but also a wide array of treatments and preventative therapies to prevent further disease. In this review, the otolaryngology subspecialties, otology and audiology, are discussed in relation to orofacial clefts. As patients with clefts carry a higher risk of permanent hearing loss and speech complications caused by the pathology of their cleft, management of additional diseases such as otitis media with effusion, conductive hearing loss, or infections requires timely evaluation, treatment, and follow-up. The current practice in otology and audiology is discussed with the challenges faced in delivering timely care-in any setting, low or higher income. Lack of consensus and controversies surrounding the use and timing of tympanostomy tubes are reviewed, as well as the palatoplasty types that show significant benefit for otitis media with effusion, audiometry, and speech outcomes. Lastly, a call for further research in clefts and otology and the urgency for its awareness and advocacy in low and middle-income countries is imperative.

Managing Chronic otitis media with Effusion in Children with non-Syndromic Cleft Palate: Short-Term Ventilation Tubes Versus Surveillance

OBJECTIVE

To compare the effectiveness of short-term ventilation tubes compared to surveillance on conductive hearing loss in children with non-syndromic orofacial clefting involving the muscular palate.

INTRODUCTION

Chronic otitis media with effusion is a common finding in children with cleft palate. The accepted convention is insertion of short-term ventilation tubes at the time of palate repair, but some centres are choosing conservative management. Each approach has its advantages but there is currently no consensus on the most appropriate management in children with non-syndromic cleft palate.

INCLUSION CRITERIA

Children <18 years with cleft lip and palate, or isolated cleft palate, not associated with a genetic syndrome, who have been diagnosed with chronic otitis media with effusion.

METHODS

A systematic search of MEDLINE, CINAHL, Embase and Scopus databases was conducted. Grey literature searches were conducted through Central Register of Controlled Trials, Clinicaltrials.gov and ProQuest. Two reviewers screened the studies, conducted critical appraisal, assessed the methodological quality, and extracted the data. Where possible, studies were pooled in statistical meta-analysis with heterogeneity being assessed using the standard Chi-squared and I2 tests.

RESULTS

Four studies met the inclusion criteria but were of low quality with a moderate risk of bias. Only data on hearing thresholds could be pooled for analysis which found no statistically significant difference. Other outcomes were presented in narrative form. Certainty of evidence for all outcomes was deemed low to very low using GRADE criteria.

CONCLUSIONS

No definitive conclusions can be drawn regarding most effective management at improving conductive hearing loss. Missing data and inconsistent reporting of outcomes limited capacity for pooled analysis.

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.

Hearing Outcomes in Patients with Cleft Lip and Palate in a Resource Limited Setting

To compare hearing outcomes of early versus late tympanostomy tube insertion in patients with cleft lip and palate in a resource limited setting.

Retrospective cohort study.

Conducted at Queen Sirikit National Institute of Child Health, a tertiary care hospital in Bangkok, Thailand.

Included 76 patients under 18 with cleft anomalies undergoing tympanostomy tube insertion between January 2018 and July 2022, categorized into early (n = 11) and late (n = 65) tympanostomy groups.

Early tympanostomy tube placement at ≤ 3 months old, coordinated with cleft lip repair, following failed transitory evoked otoacoustic emission (TEOAE) and Type B tympanogram. Late tympanostomy tube placement preceded by a diagnosis of middle ear effusion and typically a failed TEOAE and subsequent level of testing.

Primary outcomes: normal hearing rates and age at normal hearing. Secondary outcomes: repeated tympanostomy tube placement rate, postoperative complications, and length of hospital stays.

Early tympanostomy tube placement was associated with higher rates of normal hearing (100% vs. 75%. P = .103) and significantly younger age at normal hearing (11 vs. 19 months, P = .036). Time to normal hearing was shorter in the early group. Postoperative complications, including otorrhea, occurred more frequently in the early group, but differences were not significant.

Early tympanostomy tube insertion improves hearing outcomes in pediatric patients with cleft lip and palate, achieving normal hearing at a significantly younger age. This approach offers a valuable alternative in resource-limited settings with constrained audiological services. Further research on long-term speech outcomes and cost-effectiveness is warranted.

Outcomes and Prognostic Factors of Balloon Eustachian Tuboplasty Combined With Ventilation Tubes Insertion in Children: A Retrospective Study

Objective: To evaluate the efficacy and safety of balloon eustachian tuboplasty (BET) combined with ventilation tube (VT) insertion in pediatric population and to identify the predictive factors for symptom recurrence. Methods: We conducted a retrospective study between August 2018 and February 2022 at Shenzhen Children's Hospital. The study analyzed the data of pediatric patients who underwent BET + VT insertion, as well as the data of pediatric patients who underwent VT insertion alone. The outcomes were efficacy, safety, and predictive factors of BET combined with VT. Kaplan‒Meier curves were used to examine the failure-free survival rate. A multivariate Cox regression model was used to identify the independent predictors of BET failure. Results: We evaluated the data of 29 pediatric patients (48 ears) who underwent BET with VT insertion (BET + VT group) and the data of 29 pediatric patients (46 ears) who underwent VT insertion alone (VT group). The total effectiveness rates at the first follow-up after VT removal and at 12 months in the BET + VT group were 90.9% and 84.6%, respectively. The decrease in the air-bone gap (ABG) was more significant in the BET + VT group at 12 months (13.7 ± 10.8 vs 6.4 ± 15.3, P < .05). The subgroup analyses did not show any significant difference between the groups in high-risk. For non-high-risk patients, the decrease in the ABG was more significant in the BET + VT group (14.2 ± 10.6 vs 4.3 ± 13.1, P < .05) at 12 months. The multivariate analysis showed that a history of VT insertion was independently associated with a higher rate of recurrence in the BET + VT group (hazard ratio 3.177; 95% CI, 1.027-9.826; P < .05). Conclusions: BET + VT insertion is an effective procedure to decrease the ABG in pediatric patients with eustachian tube dysfunction (ETD) who have no risk factors for conventional therapy failure. Treatment of patients with ETDs who have coexisting risk factors remains a challenge that warrants further high-quality prospective research.

Adapting Elements of Cleft Care Protocols in Low- and Middle-income Countries During and After COVID-19: A Process-driven Review With Recommendations

A consortium of global cleft professionals, predominantly from low- and middle-income countries, identified adaptations to cleft care protocols during and after COVID-19 as a priority learning area of need.

A multidisciplinary international working group met on a videoconferencing platform in a multi-staged process to make consensus recommendations for adaptations to cleft protocols within resource-constrained settings. Feedback was sought from a roundtable discussion forum and global organizations involved in comprehensive cleft care.

Foundational principles were agreed to enable recommendations to be globally relevant and two areas of focus within the specified topic were identified. First the safety aspects of cleft surgery protocols were scrutinized and COVID-19 adaptations, specifically in the pre- and perioperative periods, were highlighted. Second, surgical procedures and cleft care services were prioritized according to their relationship to functional outcomes and time-sensitivity. The surgical procedures assigned the highest priority were emergent interventions for breathing and nutritional requirements and primary palatoplasty. The cleft care services assigned the highest priority were new-born assessments, pediatric support for children with syndromes, management of acute dental or auditory infections and speech pathology intervention.

A collaborative, interdisciplinary and international working group delivered consensus recommendations to assist with the provision of cleft care in low- and middle-income countries. At a time of global cleft care delays due to COVID-19, a united approach amongst global cleft care providers will be advantageous to advocate for children born with cleft lip and palate in resource-constrained settings.

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.

Oral Microbiome as a Tool of Systemic Disease on Cleft Patients: A New Landscape

The oral cavity microbiome comprises benign and pathogenic bacteria, with more than 700 species identified. However, the current literature regarding resident bacterial flora in the oropharyngeal cavities in cleft lip/palate (CLP) patients still needs to be completed. This review aims to evaluate the role of the oral microbiome of cleft patients as an indicator in systemic diseases for which cleft patients might be at higher risk in the short or long term. A literature review was performed in July 2020 using Biomedical Reference Collection Comprehensive, Cumulative Index to Nursing and Allied Health Literature (CINAHL) Complete, Dentistry & Oral Sciences Source via Elton B. Stephens Company/Online Database (EBSCO), Turning Research into Practice (TRIP), and PubMed. The keywords used were "oral, bacteria, microbiome, biota, flora, cleft, palate." The resulting 466 articles were deduplicated using Endnote. The total amount of articles' abstracts without duplicates was filtered using a set criterion. The title and abstract filter criteria included 1) cleft lip (CL) and/or cleft palate (CP) patients, 2) changes in the oral microbiome in CL and/or CP patients, 3) male and female patients 0-21 years old, and 4) English language. The full-text filter criteria included 1) CL and/or CP patients vs. non-cleft control patients, 2) oral bacteria, 3) nonprocedural measurements of microorganisms, and 4) case-control studies. A Preferred Reporting Items for Systematic Review and Meta-Analyses (PRISMA) flow chart was created using the EndNote data results. The final five articles of the systematic search indicated that the oral cavity of cleft lip and/or palate patients resulted in 1) contradicting levels of Streptococcus mitis and Streptococcus salivarius; 2) lower levels of Streptococcus gordonii, Bordetella dentium, Fusobacterium nucleatum, Veillonella parvula, Bacillus and Lautropia when compared to the control group; 3) higher levels of Staphylococcus epidermidis and Methicillin-sensitive Staphylococcus aureus compared to the control group; 4) presence of Enterobacter cloacae 36.6%, Klebsiella pneumoni 53.3%, and Klebsiella oxytoca 76.6% vs. absence in the control non-cleft group. Patients with CL and/or CP are at higher risk for caries, periodontal diseases, and upper and lower respiratory infections. The results from this review indicate that relative levels of certain bacteria may be associated with these issues. The lower levels of S. mitis, S. salivarius, S. gordini, and F. nucleatum in the oral cavity of cleft patients could be linked as a possible cause of the higher incidence of tooth decay, gingivitis and periodontal disease as high levels of these bacteria are associated with oral disease. Further, the higher incidence of sinusitis in cleft patients might be linked to low levels of S. salivarius in the oral profile of these patients. Likewise, E. cloacae, K. oxycota, and K. pneumoni have been linked with pneumonia and bronchiolitis, both of which are increased in cleft patients. The oral bacterial dysbiosis of cleft patients observed in this review may play a vital function in the oral microbiome's diversity, which could play a role in disease progression and disease markers. The pattern seen in cleft patients potentially demonstrates how structural abnormalities can lead to the onset of severe infection.

Impact of IL-17-producing γδ T cells on chronic otitis media induced by nontypeable Haemophilus influenzae in a mouse model

Nontypeable Haemophilus influenzae (NTHi) is considered a major pathogen underlying middle ear infection. This study aimed to investigate the impact of IL-17 on chronic otitis media (COM) induced by NTHi in mice. NTHi was inoculated into the tympanic bulla with eustachian tubal obstruction. Middle ear effusions (MEEs) and tissues were collected on days 3, 14, and at 1, 2, and 6 months after injection. The expression of interleukin-17A (IL-17A) in MEEs was significantly elevated compared to that in the control group at the translational and transcriptional levels during the experiments. The quantities of IL-17-producing γδ T cells were significantly increased compared to that in the control group during COM, but that of Th17 cells did not. Depletion of γδ T cells by anti-γδ T-cell receptor (TCR) monoclonal antibody (mAb) administration significantly decreased the bacteria counts and the concentrations of IL-1β, IL-6, IL-17A, TNF-α, and IL-10 in MEEs. Our results suggest that IL-17 may play an important role in prolonging the inflammation in the middle ear in COM and that IL-17-producing γδ T cells may contribute to the exacerbated inflammatory response in the middle ear. In this study, anti-γδ TCR mAb administration was found to improve chronic middle ear inflammatory conditions.

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.

Effectiveness of ventilation tube insertion for conductive hearing loss in children with chronic otitis media with effusion and non-syndromic cleft palate: a systematic review protocol

OBJECTIVE

This review will investigate the efficacy of ventilation tube insertion versus non-surgical options in the management of chronic otitis media with effusion in children with non-syndromic cleft palate by assessing the degree of conductive hearing loss.

INTRODUCTION

Chronic otitis media with effusion is common in children with cleft palate due to associated eustachian tube dysfunction. It can lead to impaired hearing and can hinder speech and language development. The main treatment options are drainage of effusion with ventilation tubes, surveillance, or amplification with hearing aids. Each of these approaches has its advantages but there is currently no consensus on the most appropriate management in children with cleft palate.

INCLUSION CRITERIA

Eligible studies will include children (<18 years) with cleft palate not associated with a genetic syndrome, diagnosed with chronic otitis media with effusion, who have undergone insertion of ventilation tubes compared with either surveillance or amplification with hearing aids.

METHODS

A comprehensive search of MEDLINE, CINAHL, Embase, and Scopus will be conducted to find published literature. Gray literature searches will be conducted through the Cochrane Central Register of Controlled Trials, ClinicalTrials.gov, and ProQuest Dissertations and Theses Global. Two reviewers will screen studies, conduct critical appraisal of eligible studies, assess the methodological quality, and extract the data. Where possible, studies will be pooled in statistical meta-analysis, with heterogeneity of data being assessed using the standard χ 2 and I2 tests.

SYSTEMATIC REVIEW REGISTRATION NUMBER

PROSPERO CRD42021255861.

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.

Formula Otorrhea in Pediatric Patients With Cleft Palate

The case series details 2 unusual cases of male newborns with cleft lip and palate (CLP) that later developed formula otorrhea. Both patients underwent bilateral myringotomies with the insertion of pressure equalizing (PE) tubes for chronic otitis media with effusion (OME). Chronic otorrhea associated with feeding occurred post-PE tube insertion and the otorrhea was later confirmed to be due to reflux of formula. Patients were treated with antibiotic ear drops, routine ear cleaning, anti-reflux medication, and reflux precautions. After definite cleft palate repair, formula otorrhea completely resolved. When patients with CLP develop chronic OME or otorrhea following PE tube placement, reflux of formula into the middle ear should be considered and treated accordingly.

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.

IL-17 is a Potential Therapeutic Target in a Rodent Model of Otitis Media with Effusion

Background

Otitis media with effusion (OME) is a non-suppurative inflammation of the middle ear that is characterized by middle ear effusion and hearing loss. However, the mechanisms of OME are not fully understood. The aim of this study was to determine the function and the mechanism of the IL-17 cytokine in the pathogenesis of OME and to investigate IL-17 as a potential strategy for the treatment of OME.

Methods

In this study, the OME rat model was induced by ovalbumin (OVA) as previously described. The severity of OME was determined with an oto-endoscope, by histochemical analysis, and by acoustic immittance. Kyoto Encyclopedia of Genes and Genomes (KEGG) analysis of RNA-sequencing (RNA-seq) data was carried out to analyze the signaling pathways related to the pathogenesis of OME, which indicated that IL-17 is involved in OME. The anti-IL-17A monoclonal antibody was administrated by nasal drip to block IL-17 to treat OME in the rat model. The rats were finally injected intraperitoneally with the inhibitor of Notch signaling pathway to study the mechanisms of IL-17-induced inflammation. Serum and lavage fluid were collected for the detection of related cytokines, and middle ear tissue was collected for Western blot, quantitative real-time PCR (qRT-PCR), and immunohistochemical and immunofluorescence analysis.

Results

KEGG analysis of RNA-seq data suggested that the IL-17 signaling pathway might be involved in the onset of OME. IL-17 expression was confirmed to be increased in both the serum and the middle ear of the rat model. The monoclonal antibody against IL-17 neutralized IL-17, inhibited the inflammation in the middle ear, and reduced the overall severity of OME in vivo. Furthermore, the Notch signaling pathway was activated upon IL-17 upregulation in OME and was suppressed by IL-17 blockage. However, there was no change in IL-17 expression after Notch inhibitor treatment, which reduced the severity of OME in the rat middle ear.

Conclusion

IL-17 plays a key role in the pathogenesis of the OVA-induced OME rat model. IL-17 induced inflammatory responses via the Notch signaling pathway and targeting IL-17 might be an effective approach for OME therapy.

[Discussion on timing and method of surgical treatment for infants with middle ear effusion]

Objective:To investigate the timing and method of surgical intervention for neonates diagnosed with middle ear effusion after hearing screening failure. Methods:① A total of 103 children were enrolled in this study and received follow-up evaluations for every month. ② After the first follow-up period for 3 months, the uncured cases were divided into three groups according to the course of the illness. Group Ⅰ is the group of improvement, group Ⅱ is the group of relapse, and the group Ⅲ is the persistent group. The infants will receive symptomatic treatment if necessary. After 6 months, surgical treatment would be recommended in the persistent cases and aggravation, the cases of improvement and cases that the parents don't receive the operation would continue to be observed. All patients were observed till they were cured or operated. The operation was performed with tympanostomy and ventilation tube insertion if necessary. ③The distribution of self-healing time was analyzed. Compare the difference of the number of the cases who followed up for 3 months, 6 months and finally recovered naturally. The self-healing rates of different influencing factors were compared. The final operation rate of group Ⅰ, groupⅡ and group Ⅲ were compared. Results:① The median distribution of self-healing time（month age） in 103 cases was 7.00[5.76, 8.24], and the number of self-healing cases decreased significantly after 9 months of age. There were 43 cases（41.75%）, 67 cases（65.5%） and 81 cases（78.64%） recovered naturally after 3 months, 6 months and follow-up in the end, and the difference was statistically significant. ②The self-healing rate of maxillofacial deformities was the lowest（8.33%）, and the difference was statistically significant compared with other factors. ③The final 22 cases underwent surgical treatment, including 1 case in group Ⅰ（3.45%）, 4 cases in group Ⅱ（30.77%）, and 17 cases in group Ⅲ（94.45%）, with statistically significant difference. ④17 children underwent tympanoplasty, 1 patient underwent tympanoplasty and adenoidectomy, and 4 children only underwent tympanotomy. The hearing of 22 cases returned to normal after operation, but 4 cases of patients with tympanotomy had recurrent tympanic effusion, among which 2 cases had serious effusion and had to be operated again. Conclusion:The infants diagnosed with tympanic effusion can be observed for more than 6 months before surgical intervention is considered. The characteristics of disease course and influencing factors during the follow-up period are of great significance to determine the time of surgical intervention for tympanic effusion in infants. Due to the long observation period, the operative method is suggested to perform tympanotomy tubes, and the possibility of recurrence after tympanotomy is high.

Nasal autoinflation devices for middle ear disease in cleft palate children: are they effective?

Objective

Cleft lip palate (CLP) and cleft palate (CP) patients have a higher incidence of otitis media with effusion (OME) and conductive hearing problems. This article aims to evaluate the effectiveness of a 6-month course of self-administered autoinflation therapy in paediatric CP/CLP patients in terms of conductive hearing loss (CHL) and OME prevalence.

Methods

Fifty-one patients with surgically corrected CP/CLP and diagnosis of OME received indication to 6-months autoinflation therapy with an Otovent^® device. Clinical evaluation, tympanogram and pure tone audiometry were carried out at the time of prescription (T0), at the end of treatment (T1) and at 6-month follow-up (T2). Patients were divided in 2 groups based on therapeutic compliance (29 compliant children, group A, vs 22 non-compliant children, group B).

Results

Case series showed better audiological results and tympanometries at both time points (p < 0.001). Group A showed better outcomes at tympanograms and at each frequency, but were statistically significant only in terms of CHL at 250 and 1000 Hz frequencies at T1 (respectively 0.024 and 0.012).

Conclusions

Nasal autoinflation therapy accelerates improvement of OME and hearing thresholds at short-/mid-term, leading to an earlier improved hearing performance.

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.

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.

Cone-Beam Computed Tomography Incidental Findings in Individuals With Cleft Lip and Palate

OBJECTIVES

The use of cone-beam computed tomography (CBCT) is well-established in clinical practice. This study seeks to categorize and quantify the incidental finding (IF) rate on CBCT in patients with cleft lip and palate (CLP) prior to orthodontic or surgical treatment.

METHODS

This is systematic retrospective review of head and neck CBCTs in patients with nonsyndromic CLP taken between 2012 and 2019 at a single tertiary referral center. All assessments were performed independently by 4 observers (a head and neck radiologist and 3 orthodontists, including 2 fellowship-trained cleft-craniofacial orthodontists ). The images were divided into 9 anatomical areas and screened using serial axial slices and 3D reconstructions. The absolute number of IFs was reported for each area and statistical analysis was performed.

RESULTS

Incidental findings were found in 106 (95.5%) of the 111 patients. The most common sites were the maxilla (87.4%, principally dental anomalies), paranasal sinuses (46.8%, principally inflammatory opacification), and inner ear cavities (18.9%, principally inflammatory opacification). Eleven patients had skull malformations. Thirty-three patients had IFs in 1 anatomical area, 49 patients in 2 anatomical areas, 19 patients in 3 areas, and 5 patients presented with IFs in 4 of the 9 anatomical areas.

DISCUSSION

In patients with CLP, IFs on CBCT exam were present in the majority of cases. Most patients with IFs had them in multiple anatomical areas of the head and neck. The maxillary dental-alveolar complex was the most common area. Inflammatory changes in the inner ear cavities and paranasal sinuses were also common; however, cervical spine and skull abnormalities were also identified. Clinicians caring for patients with CLP should be aware of IFs, which may warrant further investigation and treatment.

Evaluation of Multidisciplinary Team Clinic for Patients With Isolated Cleft Lip

OBJECTIVE

To report the incidences of secondary lip and nose operations, otolaryngology procedures, speech-language therapy, neurodevelopmental concerns, and dental and orthodontic issues in children with isolated cleft lip to inform multidisciplinary cleft team protocols.

SETTING

An American Cleft Palate-Craniofacial Association-approved team at a tertiary academic children's hospital.

DESIGN

Retrospective cohort study of patients evaluated through longitudinal clinic visits by a multidisciplinary cleft palate and craniofacial team between January 2000 and June 2018.

PATIENTS, PARTICIPANTS

Children with nonsyndromic cleft lip with or without cleft alveolus (n = 92).

RESULTS

Median age at final team visit was 4.9 years (interquartile range: 2.4-8.2 years). Secondary plastic surgery procedures were most common between ages 3 and 5 (135 per 1000 person-years), and the majority of these procedures were minor lip revisions. The rate of tympanostomy tube insertion was highest before age 3 (122 per 1000 person-years). By their final team visit, 88% of patients had normal hearing and 11% had only slight to mild conductive hearing loss. No patients had speech errors attributable to lip abnormalities. Psychological interventions, learning disabilities, and dental or orthodontic concerns were uncommon.

CONCLUSIONS

Most patients with isolated cleft lip may not require long-term, longitudinal evaluation by cleft team specialists. Cleft teams should develop limited follow-up protocols for these children to improve resource allocation and promote value-based care in this patient population.

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.

Cleft lip and palate associated hearing loss in Brazilian children

INTRODUCTION

Cleft lip and palate children have chronic otitis media related to Eustachian Tube dysfunction and associated conductive hearing loss. In this group of children, communicative skill development limitations, in association with orofacial aesthetics and functional disorders, can lead to behavioral, educational and social problems.

METHODS

We evaluated the minimum hearing threshold and the air-bone gap (ABG) in a range from 500 to 4000 Hz for 4-14 years old cleft lip and palate children (CLPC). This cross-sectional study took place in a multiprofessional tertiary care center and involved 89 CLPC with bilateral or unilateral postforamen or transforamen malformation, divided into two groups: those aged 4-7 and 8-14 years. The hearing tests of 89 children were evaluated: 53 (group I) aged from 4 to 7 years (67.9% male) and 36 (group II) aged from 8 to 14 years (55.6% female).

RESULTS

The minimum hearing threshold 500-4 KHz mean (MHT 500-4 KHz) was 19.4 dB for all children. MHT 500-4 KHz was 21.2 dB and 17.5 dB respectively for the group I and group II. Both groups demonstrated a minimum hearing threshold of up to 70 dB at certain frequencies. The global ABG 500-4 KHz average was 16.6 dB (SD 12.5): 19.7 dB (SD 12.9) in group I and 13.2 dB (SD 11.1) in group II.

CONCLUSION

The worst hearing thresholds were found in children of 4-7 years old: 21.2 dB MHT 500-4 KHz and 19.7 ABG 500-4 KHz, what is a disadvantage for them, as the normal hearing thresholds are up to 15 dB. The children of 8-14 years old had MHT 500-4 KHz of 17.5 dB, and ABG 500-4KHZ OF 13.2 with up to 70 dB of hearing loss.

Cholesteatoma Pearls: Practical Points and Update

The European Academy of Otology and Neurotology in collaboration with the Japanese Otological Society (EAONO/JOS) recently produced a joint consensus document outlining the definitions, classification and staging of middle ear cholesteatoma. The goals were to provide terminologies in the description of cholesteatoma, classify cholesteatoma into distinct categories to facilitate the comparison of surgical outcomes and to provide a staging system that reflects the severity, difficulty of complete removal and restoration of normal function. Cholesteatoma is considered a benign, expanding and destructive epithelial lesion of the temporal bone that is the result of a multifactorial process. If undetected and left treated, cholesteatoma may lead to significant complications including hearing loss, temporal bone destruction and cranial invasion. Recent advances in imaging modalities have allowed for high sensitivity and specificity in identifying the presence of cholesteatoma. Despite these advances, deficiencies exist around the world with access to health care facilities meaning cholesteatoma remains a serious and challenging entity to manage whether found within the pediatric or adult population. Proper diagnosis and management of each form of cholesteatoma is achieved by a thorough understanding of the etiology, classification, clinical presentation and histology, thereby facilitating prevention, early detection and appropriate treatment.

Centre-level variation in outcomes and treatment for otitis media with effusion and hearing loss and the association of hearing loss with developmental outcomes at ages 5 and 7 years in children with non-syndromic unilateral cleft lip and palate: The Cleft Care UK study. Part 2

OBJECTIVES

To explore centre-level variation in otitis media with effusion (OME), hearing loss and treatments in children in Cleft Care UK (CCUK) and to examine the association between OME, hearing loss and developmental outcomes at 5 and 7 years.

SETTING AND SAMPLE POPULATION

Two hundred and sixty-eight 5-year-old British children with non-syndromic unilateral cleft lip and palate (UCLP) recruited to CCUK.

MATERIALS AND METHODS

Children had air and bone conduction audiometry at age 5. Information on grommet and hearing aid treatment was obtained from parental questionnaire and medical notes. Hearing loss at age 5 was defined as >20 dB in the better ear and history of OME and hearing loss was determined from past treatment. Children with sensorineural hearing loss were excluded. Associations were examined with speech, behaviour and self-confidence at age 5 and educational attainment at age 7. Centre variation was examined using hierarchical models and associations between hearing variables and developmental outcomes were examined using logistic regression.

RESULTS

There was centre-level variation in early grommet placement (variance partition coefficient (VPC) 18%, P=.001) and fitting of hearing aids (VPC 8%, P=.03). A history of OME and hearing loss was associated with poor intelligibility of speech (adjusted odds ratio=2.87, 95% CI 1.42-5.77) and aspects of educational attainment.

CONCLUSIONS

Hearing loss is an important determinant of poor speech and treatment variation across centres suggest management of OME and hearing loss could be improved.

The Effects of Age at Cleft Palate Repair on Middle Ear Function and Hearing Level

Objective:

To investigate the age effects of cleft palate repair on middle ear function and hearing level in patients who underwent cleft palate repair at different ages by audiologic examination.

Methods:

Medical histories were gathered in detail, and audiologic tests (ie, tympanometry and pure tone hearing threshold) were conducted in 126 patients after palatoplasty. The patients were divided into the following 4 groups according to their ages when they underwent cleft palate repair: group I (0-3 years, 73 patients), group II (4-7 years, 29 patients), group III (8-11 years, 16 patients), and group IV (12 years and older, 8 patients). The data regarding tympanograms, hearing levels, and the average hearing thresholds of each group were analyzed using chi-square tests.

Results:

The prevalence of middle ear dysfunction and hearing loss in the patients who underwent palatoplasty before 3 years old (27.4% and 2.0% respectively) was significantly lower than that in patients who underwent palatopalsty at 12 years or older (75.0% and 43.7%, respectively). Linear-by-linear association revealed that the prevalences of middle ear dysfunction and hearing loss among the 4 groups were significantly different ( P < .05).

Conclusions:

The prevalence of middle ear dysfunction and hearing loss tended to increase with advancing age at the time of cleft palate repair. From an audiologist’s perspective, palatoplasty at an early age is very beneficial in helping children with cleft palates acquire better middle ear function and hearing level.

Clinical Study on Middle Ear Diseases in Children with Orofacial Clefts

Introduction

Orofacial clefts are associated with middle ear diseases, but the magnitude of this problem is not generally well appreciated. The aim of this study was to describe the middle ear findings and audiological profile in children with orofacial clefts.

Materials and methods

Children with orofacial clefts attending plastic surgery and otorhinolaryngology departments of a tertiary hospital over one-year duration were included in this study. Ninety-six children with orofacial clefts were identified. They were categorized age-wise as zero to five years, more than five years to 10 years, and more than 10 years to 15 years. They underwent a detailed ear, nose, and throat examination followed by audiological tests, including brainstem evoked response audiogram (BERA), pure tone audiogram (PTA), and tympanometry.

Results

Among 96 children with orofacial clefts, only 24 children (25%) had symptomatic ear problems, whereas on ear examination, 56 children (58.3%) had abnormal ear findings. Middle ear effusion (MEE) was the most common ear condition, and it was seen in 94 ears (48.9%). Cholesteatoma was noted in six children (3.1%). Out of 73 children in the zero to five age group, 58 children (79.5%) did not have any history of ear problem but 55.5% (81 ears) had features of MEE such as a dull tympanic membrane (TM). In the age group of more than five years to 10 years, only four children (28.5%) were symptomatic. Five children (55.5%) out of nine in the age group of more than 10 years had a symptomatic ear problem of which four children (44.4%) had chronic otitis media squamosal disease. The earlier age groups showed a trend of ear disease being asymptomatic compared to older children. Normal hearing was present in only 40 children (41.7%) and various degrees of hearing loss were seen in 56 children (58.3%). The mean air conduction threshold in the age group zero to five years, more than five years to 10 years, and more than 10 years were 33±8.3 decibels (dB), 25±6.2 dB, and 31.5±14 dB, respectively. Out of 144 ears (72 children) in the asymptomatic group, 67 ears (46.5%) had normal hearing. Seventy-seven ears (53.5%) had some degree of hearing loss. Mean air conduction hearing loss in the asymptomatic group was 29.8±7.3 dB.

Conclusion

This study highlights the higher incidence of middle ear diseases compared to the presenting symptoms in children with orofacial clefts. This stresses on the need for a detailed otological evaluation to identify any middle ear pathology so that timely intervention can be taken.

Otologic Disease Following Palatoplasty In International Cleft Palate Cohort

OBJECTIVE

Study the prevalence of otologic disease in a pediatric post-palatoplasty population with no prior ear tube placement in resource-deprived countries and assess patient characteristics associated with these abnormal results.

DESIGN

Retrospective data review.

PARTICIPANTS

Ecuadorian and Chinese children identified during humanitarian cleft lip and palate repair trips with cleft palates undergoing palatoplasty from 2007 to 2010.

INTERVENTIONS

Tympanometry and otoacoustic emission (OAE) testing performed following palatoplasty. Patients' parents administered surveys regarding perceived hearing deficits.

MAIN OUTCOME MEASURES

Age, gender, Veau classification, follow-up time, laterality, and country of origin were evaluated for possible association with type B tympanogram, "Refer" Otoacoustic results, and presence of hearing difficulty as identified by a parent. Significant predictors were further evaluated with multivariate analysis.

RESULTS

The cohorts included 237 patients (129 Ecuadorian, 108 Chinese); mean age: 3.9 years; mean follow-up: 4.2 years. Thirty-nine percent scored type B, 38% failed OAE testing, and 8% of parents noted hearing deficits. The country of origin and a younger age were identified as predictive variables regarding type B tympanogram. Follow-up time, country of origin, and bilateral OAE "Refer" results all significantly predicted parental questionnaire results. Subsequent multivariable analysis further demonstrated effect modification between the 2 variables of age at palatoplasty and country of origin when predicting type B vs type A tympanometry.

CONCLUSION

Without otologic intervention, cleft palate children in resource-deprived settings suffer type B tympanometry and failed OAE results with similar to increased incidences to other studied cleft palate populations with otologic interventions available.

Behavioral Signs of (Central) Auditory Processing Disorder in Children with Nonsyndromic Cleft Lip and/or Palate: A Parental Questionnaire Approach

Objective

Children with nonsyndromic cleft lip and/or palate often have a high prevalence of middle ear dysfunction. However, there are also indications that they may have a higher prevalence of (central) auditory processing disorder. This study used Fisher's Auditory Problems Checklist for caregivers to determine whether children with nonsyndromic cleft lip and/or palate have potentially more auditory processing difficulties compared with craniofacially normal children.

Methods

Caregivers of 147 school-aged children with nonsyndromic cleft lip and/or palate were recruited for the study. This group was divided into three subgroups: cleft lip, cleft palate, and cleft lip and palate. Caregivers of 60 craniofacially normal children were recruited as a control group. Hearing health tests were conducted to evaluate peripheral hearing. Caregivers of children who passed this assessment battery completed Fisher's Auditory Problems Checklist, which contains 25 questions related to behaviors linked to (central) auditory processing disorder.

Result

Children with cleft palate showed the lowest scores on the Fisher's Auditory Problems Checklist questionnaire, consistent with a higher index of suspicion for (central) auditory processing disorder. There was a significant difference in the manifestation of (central) auditory processing disorder-linked behaviors between the cleft palate and the control groups. The most common behaviors reported in the nonsyndromic cleft lip and/or palate group were short attention span and reduced learning motivation, along with hearing difficulties in noise.

Conclusion

A higher occurrence of (central) auditory processing disorder-linked behaviors were found in children with nonsyndromic cleft lip and/or palate, particularly cleft palate. Auditory processing abilities should not be ignored in children with nonsyndromic cleft lip and/or palate, and it is necessary to consider assessment tests for (central) auditory processing disorder when an auditory diagnosis is made for this population.

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.

Cleft lip and palate subjects prevalence of abnormal stylohyoid complex and tonsilloliths on cone beam computed tomography

INTRODUCTION AND OBJECTIVES

Tonsilloliths and abnormal stylohyoid complex may have similar symptoms to others of different aetiology. Individuals with cleft lip and palate describe similar symptoms because of the anatomical implications that are peculiar to this anomaly. The aim of this study was to determine the prevalence of abnormal stylohyoid complex and tonsilloliths on cone beam computed tomography in individuals with cleft lip and palate.

METHODS

According to the inclusion and exclusion criteria, 66 CT scans out of of 2,794 were analysed, on i- Cat ® vision software with 0.8 index Kappa intra-examiner.

RESULTS

The total prevalence of ossification of the incomplete stylohyoid complex in individuals with cleft lip and palate was 66.6%; the prevalence of these findings in females was 75% and 61.9% in males. The total prevalence of tonsilloliths was 7.5%.

CONCLUSION

It is important to ascertain calcification of the stylohyoid complex and tonsilloliths in the radiological report, due to the anatomical proximity and similarsymptomatology to other orofacial impairments inindividuals with cleft lip and palate, focusing on females with oral cleft formation, patients with incisive trans foramen cleft and incisive post foramen cleft because they are more prevalent. Greater knowledge of the anatomical morphometry of individuals with cleft lip and palate greatly contributes towards the selection of clinical behaviours and the quality of life of these patients, since cleft lip and palateis one of the most common anomalies.

Otitis media with effusion and atopy: is there a causal relationship?

Otitis Media with Effusion (OME) is an inflammatory condition of the middle ear cleft, acute or chronic, with collection of fluid in the middle ear with an intact tympanic membrane. It is a very common disease in childhood, the most frequent cause of hearing loss in childhood and often requiring surgery. OME is called chronic when the fluid in the middle ear persists for more than three months or when the episodes recur six or more times in one year. The current article covers various aspects of OME including definition, epidemiology. Pathomechanisms, risk factors, role of allergy in OME, impact of upper airway disease on OME, eosinophilic otitis media and management of OME.

Hearing thresholds and ventilation tube treatment in children with unilateral cleft lip and palate

OBJECTIVE

Children with cleft lip and palate have a high prevalence of otitis media with effusion (OME) which is often associated with a fluctuating, conductive hearing loss in the low and mid-frequencies and a risk for permanent hearing loss in the higher frequencies. Although common, there is no consensus on the treatment of OME with ventilation tubes. The aim of this study is to document if the risk for permanent hearing loss and acquired cholesteatoma increases due to treatment with ventilation tubes (VT treatments) during childhood in a group of children with cleft lip and palate.

METHODS

A retrospective medical chart review of 33 children (25 boys and 8 girls) born with unilateral cleft lip and palate (UCLP) was completed. Audiological data (results of hearing sensitivity tests, the total number of hearing tests, and number of VT treatments) were extracted from medical records from when the children were 4-7 and >7-10 years of age.

RESULTS

The hearing thresholds in the speech frequencies improved with age (p < 0,05) but a minority of the children continued to present with elevated hearing thresholds in the higher frequencies at >7-10 years of age. There were no significant correlations between number of VT treatments and hearing thresholds at >7-10 years. Four of the 33 children presented with complications: two children exhibited perforations of the ear drum (6.1%) and two children developed unilateral cholesteatoma (6.1%).

CONCLUSION

In the current study, the hearing sensitivity of children with cleft lip and palate improved with age. However, this improvement was not seen in the higher frequencies. Twelve percent of the children experienced complications following VT treatments. Due to these complications, it is recommended that all children with cleft palate should have routine follow-ups by an ENT doctor and audiologist. As part of the routine follow-up care, hearing assessments should be performed before and after VT treatments.

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.

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.

Prevention of early episodes of otitis media by pneumococcal vaccines might reduce progression to complex disease

Otitis media is a common childhood infection of the middle ear and a major cause of morbidity. This multifactorial disease manifests as a spectrum of clinical syndromes from uncomplicated acute otitis media to more complex recurrent and chronic cases (frequently polymicrobial), with the major pathogens involved being Streptococcus pneumoniae and non-typeable Haemophilus influenzae. Pneumococcal conjugate vaccines (PCVs) target only a few serotypes that cause otitis media; however, results from studies suggest that existing PCVs can prevent early episodes of disease associated with vaccine serotypes, resulting in a reduction of subsequent complex cases caused by non-vaccine serotypes and other otopathogens, which contribute considerably to the disease burden. In this Review, we discuss the role of pneumococcus in the disease continuum and assess clinical evidence showing the effect of prevention of early episodes on the complex interplay between bacterial species implicated in otitis media.

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

Objective

Otitis media with effusion is common in infants with an unrepaired cleft palate. Although its prevalence is reduced after cleft surgery, many children continue to suffer from middle ear problems during childhood. While the tensor veli palatini muscle is thought to be involved in middle ear ventilation, evidence about its exact anatomy, function, and role in cleft palate surgery is limited.

This study aimed to perform a thorough review of the literature on (1) the role of the tensor veli palatini muscle in the Eustachian tube opening and middle ear ventilation, (2) anatomical anomalies in cleft palate infants related to middle ear disease, and (3) their implications for surgical techniques used in cleft palate repair.

Materials and methods

A literature search on the MEDLINE database was performed using a combination of the keywords “tensor veli palatini muscle,” “Eustachian tube,” “otitis media with effusion,” and “cleft palate.”

Results

Several studies confirm the important role of the tensor veli palatini muscle in the Eustachian tube opening mechanism. Maintaining the integrity of the tensor veli palatini muscle during cleft palate surgery seems to improve long-term otological outcome. However, anatomical variations in cleft palate children may alter the effect of the tensor veli palatini muscle on the Eustachian tube’s dilatation mechanism.

Conclusion

More research is warranted to clarify the role of the tensor veli palatini muscle in cleft palate-associated Eustachian tube dysfunction and development of middle ear problems.

Clinical relevance

Optimized surgical management of cleft palate could potentially reduce associated middle ear problems.

Accumulation of Regulatory T Cells and Chronic Inflammation in the Middle Ear in a Mouse Model of Chronic Otitis Media with Effusion Induced by Combined Eustachian Tube Blockage and Nontypeable Haemophilus influenzae Infection

Nontypeable Haemophilus influenzae (NTHi) is associated with chronic otitis media (COM). In this study, we generated a murine model of COM by using eustachian tube (ET) obstruction and NTHi (10(7) CFU) inoculation into the tympanic bulla, and we investigated the relationship between regulatory T cells (Treg) and chronic inflammation in the middle ear. Middle ear effusions (MEEs) and middle ear mucosae (MEM) were collected at days 3 and 14 and at 1 and 2 months after inoculation. Untreated mice served as controls. MEEs were used for bacterial counts and to measure the concentrations of cytokines. MEM were collected for histological evaluation and flow cytometric analysis. Inflammation of the MEM was prolonged throughout this study, and the incidence of NTHi culture-positive MEE was 38% at 2 months after inoculation. The levels of interleukin-1β (IL-β), tumor necrosis factor alpha, IL-10, and transforming growth factor β were increased in the middle ear for up to 2 months after inoculation. CD4(+) CD25(+) FoxP3(+) Treg accumulated in the middle ear, and the percentage of Treg in the MEM increased for up to 2 months after inoculation. Treg depletion induced a 99.9% reduction of bacterial counts in MEEs and also significantly reduced the ratio of NTHi culture-positive MEE. The levels of these cytokines were also reduced in MEEs. In summary, we developed a murine model of COM, and our findings indicate that Treg confer infectious tolerance to NTHi in the middle ear.

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.

Multidimensional staging system for pediatric acquired cholesteatoma: A 30-year verification data

OBJECTIVE

This article presents a points-based prognostic prediction model for pediatric acquired cholesteatoma, incorporating the multidimensional factors that contribute to surgical failure.

METHODS

This study included 132 ears with acquired cholesteatoma from 128 children (≤18 years) identified between 1982 and 2012. Each case was scored for the extent of the cholesteatoma, history of grommet insertion, age of the patient, ossicular destruction, and otorrhea. The patients were classified as stage I, II, or III. We compared differences between stages regarding the cumulative rates of recidivism and linear trends in these rates.

RESULTS

Among stage I cases, the rate of cumulative recidivism was 0%; however, among stage 2 cases, this increased with time, eventually leveling off at 15.7% after 18 years of follow-up. The same was observed among stage III cases, which leveled off at 34.1% after 17 years of follow-up. In the second half of the cohort and the entire cohort, differences in the cumulative recidivism curves reached statistical significance, as did the linear trends (all p<0.05).

CONCLUSIONS

Our findings demonstrate the efficacy of the proposed multidimensional staging system in linking the severity of cholesteatoma to outcomes, thereby enabling the stratification of patients according to prognosis in order to identify children at risk of recidivism.