Grommets and speech at three and six years in children born with total cleft or cleft palate

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.

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

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

Unilateral Cleft lip and Palate: Long-Term Results of the Malek Technique

To review at 18 years-old the results of surgery and follow-up of children born in our hospital with unilateral cleft lip and palate (uCLP). They were operated at the time by the same surgeon, following the same primary surgical procedure (Malek).

Retrospective cohort study.

Tertiary Children's Hospital.

All children born with uCLP between 1996 and 2001 and operated in our hospital. Syndromic children were excluded.

Results of the primary surgery, ear-nose-throat interventions, maxillo-facial surgery and final phonatory results.

Seventy-nine files of children born with a cleft were reviewed: 34 were taken into consideration for uCLP: 15 right and 19 left. They were operated in two stages, following the inverse Malek procedure. Sixty per cent had a fistula. Eighty-eight percent had grommets. Ninety-seven percent had an alveolar graft at a median age of nine (5-10) and 22% underwent a Le Fort osteotomy. Seven percent were operated for a pharyngeal flap, 29% for a secondary lip surgery at a mean age of 12.8 and 29% for a late rhinoplasty at a mean age of 14.8 years. A median of 5.7 multidisciplinary consultations was realized with a median number of general anesthesia of 7.1 (4-13).

This retrospective study shows that the Malek procedure for children born with uCLP is related to a high risk of fistula but good long-term phonatory results. Twenty percent of children were operated for a Le Fort procedure and one-third for a secondary lip procedure and rhinoplasty.

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.

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.

Assessing speech at three years of age in the cleft palate population: a scoping review of assessment practices

BACKGROUND

There is no consensus in the UK regarding the types of speech samples or parameters of speech that should be assessed at 3 years of age in children with cleft palate ± cleft lip (CP±L), despite cleft units routinely assessing speech at this age. The standardization of assessment practices would facilitate comparisons of outcomes across UK cleft units; earlier identification of speech impairments-which could support more timely treatments; and more reliable recording of therapy impacts and surgical interventions.

AIMS

To explore assessment practices used to assess speech in 3-year-old children with CP±L, including speech parameters, methods of assessment and the nature of the speech sample used.

METHODS & PROCEDURES

A broad examination of the literature was undertaken through the use of a scoping review conducted in accordance with Joanna Briggs Institute guidelines. Search terms were generated from a preliminary search and then used in the main search (Medline, CINAHL, Embase, AMED and PsycINFO).

MAIN CONTRIBUTION

A combination of approaches (medical, linguistic, developmental and functional) is required to assess CP±L speech at age 3. A developmental approach is recommended at this age, considering the complexity of speech profiles at age 3, in which typically developing speech processes may occur alongside cleft speech characteristics. A combined measure for both nasal emission and turbulence, and an overall measure for velopharyngeal function for speech, show potential for assessment at this age. Categorical ordinal scales are frequently used; the use of continuous scales has yet to be fully explored at age 3. Although single-word assessments, including a subset of words developed for cross-linguistic comparisons, are frequently used, more than one type of speech sample may be needed to assess speech at this age validly. The lack of consensus regarding speech samples highlights a need for further research into the types of speech samples 3-year-olds can complete; the impact of incomplete speech samples on outcome measures (particularly relevant at this age when children may be less able to complete a full sample); the impact of different speech samples on the validity of assessments; and the reliability of listener judgements.

CONCLUSIONS & IMPLICATIONS

Whilst a medical model and linguistic approaches are often central in assessments of age-3 cleft speech, this review highlights the importance of developmental and functional approaches to assessment. Cross-linguistic single-word assessments show potential, and would facilitate the comparison of UK speech outcomes with other countries. Further research should explore the impact of different speech samples and rating scales on assessment validity and listener reliability.

L-Shaped Septal Extension Spreader Graft for Improvement of Tip Symmetry in Unilateral Cleft Lip Nose Deformities

INTRODUCTION

The unilateral cleft lip nose is characterized by numerous complex and interdependent deformities. Secondary rhinoplasty techniques aim to correct cleft lip nose deformities by using multiple maneuvers combining septum and nasal spine medialization and alar cartilage, as well as soft tissue mobilization and repositioning. Moreover, cartilage grafting is frequently used to restore adequate tip projection and nasal symmetry. We present a technique of cartilage grafting commonly used in noncleft rhinoplasties that we modified for cases of moderate cleft lip nose deformities.

PATIENTS AND METHODS

We present a retrospective case study of 21 patients with moderate unilateral cleft lip nose deformities who underwent secondary septorhinoplasty with an L-shaped septal extension spreader graft combined with alar rim, alar batten graft, and soft tissue repositioning. Exclusion criteria were severe or complex septal deviation avoiding a stable fixation of the graft. Mean follow-up time was 28 months. Surgical outcomes were analyzed by anthropometric measurements of standardized preoperative and postoperative photographs.

RESULTS

All parameters improved except for the nostril height. The height between the alar base and the dome defining dome symmetry, as well as the angles between the lower lateral cartilage and the alar base (α) defining the orientation of the alar rim, improved significantly. The mean ratios of cleft/noncleft side of the height between the alar base and the dome and α showed statistically significant improvements from 0.833 (preoperative) to 0.994 (postoperative) (P < 0.0001) and from 0.883 to 1.02 (P = 0.0038), respectively.

CONCLUSIONS

The L-shaped septal extension spreader graft combined with alar batten graft and soft tissue repositioning is an option for secondary rhinoplasties in unilateral cleft lip nose deformities minimizing tip rigidity with significant improvement of the dome's height and its symmetry, as well as the alar side angle.