When not to do middle-ear surgery

Outcomes of Tympanoplasty After Cleft Palate Repair: A Systematic Review and Meta-analysis

OBJECTIVE

To analyze graft success rates and hearing outcomes in patients with a history of cleft palate (CP) repair undergoing tympanoplasty.

DATA SOURCES

PubMed, Scopus, and CINAHL.

REVIEW METHODS

Per PRISMA guidelines, the databases were searched from date of inception through December 14, 2021. Studies of patients with previous CP repair who underwent tympanoplasty were included. Meta-analysis of proportions, continuous measures, odds ratios (ORs), and meta-regression were used to analyze graft success and hearing outcomes after tympanoplasty.

RESULTS

A total of 323 patients with CP repair and 1169 controls were included. The proportion of graft success was 86.7% (95% CI, 76.1%-94.5%) in patients with CP repair and 88.8% (95% CI, 76.9-96.8) in controls. There was no difference in odds of graft success between patients with CP repair and controls (OR, 1.0 [95% CI, 0.5-1.8]; P = .870). Age was not a significant moderator of graft success in patients with CP repair (r = 0.1 [95% CI, -0.2 to 0.3]; P = .689) or controls (r = -0.0 [95% CI, -0.1 to 0.1]; P = .952). Comparing mean differences between pre- and postoperative air-bone gap was not statistically significant in patients with CP repair and controls (0.2 dB [95% CI, -3.1 to 3.4]; P = .930). Odds of functional success (postoperative air-bone gap <20 dB) were not different between the groups (OR, 0.8 [95% CI, 0.5-1.4]; P = .450).

CONCLUSION

This meta-analysis does not endorse anatomic or functional differences between patients with CP repair and controls after tympanoplasty. However, there is a paucity of evidence for younger children. Further studies are warranted to elucidate specific risk factors for tympanoplasty outcomes in young patients with previous CP repair.

Retrospective analysis of tympanoplasty in children with cleft palate: a 24-year experience. II. Cholesteatomatous cases

BACKGROUND

Contradictory experience has been published on the outcomes of ear surgery in patients with cleft palate.

OBJECTIVES

The authors of this study investigated whether there were differences in the short- and long-term outcomes of tympanoplasty performed due to cholesteatoma in children with or without cleft palate.

SETTING

Tertiary care medical centre.

METHODS

The authors retrospectively analyzed the first author's 24-year experience of paediatric tympanoplasty using the software programme developed by the fourth author. The outcomes of 268 tympanoplasties on 172 ears with cholesteatoma in 151 'NoCleft' patients were compared to the outcomes of 35 tympanoplasties on 20 ears of 19 'Cleft' patients. The average age of the patients was 10.7±3.6 years and 9.5±2.7 years respectively. The average follow-up time was 4 and 4.1 years.

RESULTS

Preoperative PTA-ABGs (31.22/34.88 dB; p=0.058), best postoperative PTA-ABGs (17.04/16.4 dB; p=0.499), last postoperative PTA-ABGs (19.93/20.98 dB; p=0.298), the final hearing improvement (11.29/13.9 dB; p=0.193) and postoperative PTA-ABG deterioration with time (2.89/4.58 dB; p=0.117) were statistically compared between the 'NoCleft' and 'Cleft' groups. The same parameters were analyzed separately in the case of tympanoplasty performed with intact ossicular chain and the different type of columella ossiculoplasty. No significant differences were found between the two groups in any of these parameters. However, significant difference was found in the necessity for grommet insertion (8-fold difference, p≈0), and conversion to open techniques (p≈0).

CONCLUSIONS

The authors conclude that the achievable audiological outcomes of tympanoplasty in children with cleft palate and cholesteatoma do not differ significantly from those of the general child population. However, this more frequently requires ventilation tube insertion and more frequent follow-up visits. The latter is ensured by patient care within the frameworks of the 'Cleft Palate Team'. We have to accept that in some cases Eustachian tube dysfunction caused by the underlying disease (cleft palate) 'takes over' and we have to resort to open techniques.

Retrospective analysis of tympanoplasty in children with cleft palate: a 22-year experience: I. Mesotympanic (non-cholesteatomatous) cases

BACKGROUND

Contradictory data have been published on the outcomes of ear surgeries in cleft patients.

OBJECTIVES

To investigate whether there are differences in the short and long term outcomes of tympanoplasty performed due to childhood chronic mesotympanic otitis media in patients without and with cleft palate.

SETTING

Tertiary care pediatric medical centre.

METHODS

The authors retrospectively analysed the first author's data on pediatric tympanoplasties of the past 22 years with the help of a computer programme developed by the third author. The outcomes of 159 'NoCleft' tympanoplasties (119 patients, 144 ears) were compared to the outcomes of 31 'Cleft' tympanoplasties (21 patients, 27 ears) with the average age of the patients being 10.8 and 10.7 years accordingly.

RESULTS

The preoperative ABG (28.76/28.94dB, p = 0.468), the best postoperative ABG (12.78/10.04dB, p = 0.096), the last postoperative ABG (15.59/13.19dB, p = 0.192), the final hearing gain (13.17/15.75dB, p = 0.253) and the postoperative ABG deterioration associated with time (2.81/3.15dB, p = 0.376) were statistically compared in the 'NoCleft'/'Cleft' groups. No significant difference was found between the outcomes of the two groups. The same parameters were examined separately after tympanoplasties performed with intact ossicular chain and after those requiring columella ossiculoplasty. The 'Cleft' group did not have worse outcomes in this respect, either. The average follow-up period of the patients was more than 3 years in both groups. The graft take rate was 100%, reperforation occurred in 3.5% of the cases in both groups. In their study, grommet insertion was more likely to be necessary in the 'Cleft' group.

CONCLUSION

The authors concluded that there was no significant difference between the expectable outcomes of pediatric tympanoplasties in patients with and without cleft palate regarding mesotympanic cases; therefore, the indications for tympanoplasty are the same in the two groups. They outline the importance of the therapeutic management of cleft patients in the frameworks of a "Cleft Palate Team" and the necessity for their lifelong otorhinolaryngological care due to their vulnerable Eustachian tube function. They are planning to publish the same comparative analysis of their patients with cholesteatoma in a following study.

Myringoplasty in children with cleft palate and craniofacial anomaly

OBJECTIVES

Analyze the anatomical and audiological success rates of myringoplasty in children with craniofacial anomaly, cleft palate and compare them to a control group.

METHODS

Retrospective review of medical records for all children who underwent myringoplasty between 1997 and 2007. The following data was recorded: sex, age, perforation side, size, location and etiology, surgical approach, type of myringoplasty, graft material, season of surgery, preoperative status of the operated and contralateral ear, history of previous otologic surgery, and adenoidectomy or tonsillectomy.

RESULTS

Myringoplasty outcomes of 22 craniofacial anomaly patients (15/22 were cleft palate patients) were compared to 144 controls. Children in the craniofacial anomaly group demonstrated a tendency towards surgery at an older age. Children in the craniofacial anomaly and cleft palate groups had a significant positive history of previous otologic procedures to both operated and contralateral ears. Peroperative subannular ventilation T-tubes were more frequently recorded in patients with craniofacial anomaly than patients in the control group. The craniofacial anomaly, cleft palate and control group had comparable mean preoperative and postoperative ABG and their ABG improvement was statistically significant. Children with craniofacial anomaly, cleft palate and control group shared similar anatomical and audiological success rates (ABG<20 dB) at 6, 12 and 24 months.

CONCLUSIONS

Although children in the craniofacial anomaly and cleft palate groups are predisposed to middle ear disease, their disease responds well to surgical intervention. Their audiological and anatomical success rates were equivalent to the ones observed in the control group. In light of our results, we recommend that myringoplasty in children with craniofacial anomaly and cleft palate be performed after the age of 12.

Tympanoplasty results in patients with cleft palate: an age- and procedure-matched comparison of preliminary results with patients without cleft palate

OBJECTIVE

Because of continued eustachian tube abnormalities, the presence of a cleft palate repair has been thought to be associated with poor outcomes after tympanoplastic surgery. However, little published data exist regarding the results of major otologic surgery in patients with cleft palate. The objective of this study was to review our results of otologic surgery in these patients and compare results with those of age- and procedure-matched controls.

METHODS

Our otologic database was used to identify patients with a repaired cleft palate who underwent otologic surgery between March 1994 and December 1999. Two control patients were identified for each cleft palate patient. Results of hearing, graft take, and need for postoperative pressure-equalizing tubes were compared.

RESULTS

No significant difference existed between patients with a repaired cleft palate and control patients with regard to postoperative air-bone gap (P = 0.6805), graft survival rate (P = 1.00), and need for postoperative intubation (P = 0.457).

CONCLUSION

Results in patients with cleft palate appear to be similar to those in patients without cleft palate.

Results of surgery for chronic otitis media in patients with a cleft palate

The long-term results of surgical treatment of 19 chronic ears in 16 patients with a cleft palate were analysed. The mean follow-up period was 6.5 years. The patients were found to be significantly younger than other patients with chronic otitis media. Granulating otitis media was the indication for surgery in 11 ears and cholesteatoma in 7 ears. A successful outcome after the primary operation was found in 68% of the patients. Four patients required a revision operation which was successful in all of them. Hearing results of patients with cleft palate did not differ significantly from those obtained in other patients. It is concluded that middle ear surgery should be offered to patients with a cleft palate with the same indications as in other patients with chronic otitis media.