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

The Early Operative Burden for Children Born with Cleft lip and Palate

OBJECTIVES

to audit the surgical management of infants born with non-syndromic cleft lip and palate (CLP) at an Australian cleft unit in a large tertiary paediatric hospital.

DESIGN

Retrospective cohort study.

SETTING

A tertiary Cleft centre.

PATIENTS

193 infants born with non-syndromic CLP were referred to the centre and underwent primary repair of their CLP between 2009 and 2020.Main Outcome Measures: (1) The timing and surgical repairs performed; (2) the frequency of postoperative complications; (3) the frequency of secondary Cleft surgery; and (4) the total Cleft-related operations performed for infants born with CLP.

RESULTS

Four different surgical repair techniques were performed by six surgeons, and postoperative complications were uncommon (n = 14). Rates of oronasal fistula surgery (10.5% at five years of age; 14.3% at eight years of age) and velopharyngeal insufficiency surgery (8.7% at five years of age; 14.3% at eight years of age) were not significantly different across the surgical repair groups (p-value >0.05) and were comparable to international Cleft centres. Children underwent an average of four operative procedures in this audit period, including primary Cleft repair, ear, nose and throat surgery, and dental care. Surgery for managing Eustachian tube dysfunction was the most common surgical intervention following primary Cleft repair.

CONCLUSIONS

Children born with non-syndromic CLP have a high early operative burden, with outcomes similar across the spectrum of techniques and surgeons.

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

OBJECTIVE

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

Evidence Mapping and Quality Analysis of Systematic Reviews on Various Aspects Related to Cleft Lip and Palate

BACKGROUND

Management of cleft lip and palate is interdisciplinary. An evidence-mapping approach was envisaged to highlight the existing gaps in this field, using only the highest level of evidence.

OBJECTIVES

To conduct evidence mapping and quality analysis of systematic reviews and meta-analyses related to any aspect of cleft lip and palate.

SEARCH METHODS

The cleft lip and palate field was divided into 9 domains and 50 subdomains and a method of categorization of systematic reviews was established. A comprehensive search strategy was carried out in seven databases along with the search of gray literature and references of included articles.

SELECTION CRITERIA

Systematic reviews related to any aspect of cleft lip and palate, conducted by a minimum of two reviewers, with a comprehensive search strategy and adequate quality analysis were included.

DATA COLLECTION AND ANALYSIS

A self-designed, pre-piloted data-extraction sheet was used to collect information that was analyzed through an expert group discussion. Quality analysis was performed using ROBIS-I, AMSTAR 2, and the PRISMA checklist.

RESULTS

A total of 144 systematic reviews published between 2008 and 2022 were included. The largest number of these could be categorized in the therapeutic domain (n = 58). A total of 27% of the studies were categorized as inconclusive, 40% as partially conclusive, and 33% as conclusive. As per ROBIS-I, 77% of reviews had high risk of bias while 58% were graded as critically low in quality as per AMSTAR 2. The majority of systematic reviews showed low reporting errors.

CONCLUSIONS

The majority of systematic reviews related to cleft lip and palate relate to therapeutic and prognostic domains and show high risk of bias and critically low quality regardless of the source journal. The results of this paper might serve as a starting point encouraging authors to carry out high-quality research where evidence is lacking.

REGISTRATION

A multidisciplinary expert-group formulated an a priori protocol, registered in Open Science Framework (DOI 10.17605/OSF.IO/NQDV2).

Speech and Burden of Secondary Surgical Interventions Following One-Stage Repair of Unilateral Cleft Lip and Palate and Alveolar Bone Grafting Performed at Different Timings

A comprehensive assessment of the treatment outcome in cleft lip and palate involves evaluating speech and the impact of speech-correcting surgical interventions. This retrospective case-control study compared the speech outcomes of 37 boys and 19 girls with unilateral cleft lip and palate (UCLP) who underwent one-stage cleft repair at an average age of 8.1 months and alveolar bone grafting either before or after 6 years of age, with a non-cleft control group at an average age of 10 years. Two experienced speech and language pathologists conducted perceptual speech assessments using a specialized test of 27 sentences designed for Polish-speaking cleft patients. The results revealed that 5.3% had severe hypernasality, 1.8% had severely impaired speech intelligibility, 10.7% exhibited retracted compensatory articulations, and 7.1% displayed facial grimacing. Mild hyponasality was observed in 12.3% of patients, while 16.1% exhibited voice abnormalities. Additionally, 12.5% of patients required orofacial fistula repairs, 3.6% underwent pharyngoplasties, and 28.6% received ear ventilation tube insertions. The study indicates that speech abnormalities in UCLP patients were relatively infrequent and not highly severe, suggesting that the primary UCLP repair method presented effectively reduced the need for further surgical interventions, leading to positive speech outcomes.

The effect of soft palate reconstruction with the da Vinci robot on middle ear function in children: an observational study

Cleft palate is associated with a high prevalence of middle ear dysfunction, even after palatal repair. The aim of this study was to evaluate the effects of robot-enhanced soft palate closure on middle ear functioning. This retrospective study compared two patient groups after soft palate closure with a modified Furlow double-opposing Z-palatoplasty technique. Dissection of the palatal musculature was performed using a da Vinci robot in one group and manually in the other. Outcome parameters were otitis media with effusion (OME), tympanostomy tube use, and hearing loss during 2 years of follow-up. At 2 years post-surgery, the percentage of children with OME had reduced significantly to 30% in the manual group and 10% in the robot group. The need for ventilation tubes (VTs) decreased significantly over time, with fewer children in the robot group (41%) than those in the manual group (91%) needing new VTs during postoperative follow-up (P = 0.026). The number of children presenting without OME and VTs increased significantly over time, with a faster increase in the robot group at 1 year post-surgery (P = 0.009). Regarding hearing loss, significantly lower hearing thresholds were recorded in the robot group from 7 to 18 months postoperatively. To conclude, beneficial effects of robot-enhanced surgery were recorded, suggesting a faster recovery when the soft palate was reconstructed using the da Vinci robot.

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

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

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

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

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

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

METHOD

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

RESULTS

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

CONCLUSION

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

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

BACKGROUND

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

The prevalence and risk factors for congenital hearing loss in neonates: A birth cohort study based on CHALLENGE study

OBJECTIVES

To determine the prevalence and risk factors of congenital hearing loss (HL) in neonates based on China Longitudinal Environmental, Genetic, and Economic Cohort (CHALLENGE cohort).

METHODS

Maternal and neonatal data were collected based on the CHALLENGE cohort study from July 2018 to September 2020. Total 7287 neonates underwent the universal newborn hearing screening (UNHS). Babies who did not pass the initial screening and the rescreening were given the formal audiological diagnosis for possible HL. The data was analyzed to find out the prevalence and risk factors for congenital HL in this cohort study.

RESULTS

The prevalence of congenital HL was 3.43‰, and temporary HL was 0.07‰ (5 neonates). The statistical data showed that risk factors, including craniofacial anomalies, neonatal intensive care unit (NICU) admission, family history and advanced maternal age (AMA), could be associated with congenital HL. Additionally, exchange transfusion, assisted ventilation and NICU admission, these three factors could be associated with congenital sensorineural HL (SNHL). Risk factors including craniofacial anomalies, NICU admission, family history and AMA might be contributed to congenital conductive HL(CHL).

CONCLUSION

There were several common risk factors could be contributed to congenital HL, which were consistent with previous studies. However, some risk factors were no longer causing congenital HL due to the improvement of medical treatment and prenatal care. This study has not only helped explain the status quo of the prevalence of congenital HL in China but also laid foundation for future studies.

Characterization of hearing status in children under 3 years of age with cleft palate

OBJECTIVES

To describe the hearing thresholds of children under 3 years of age with cleft palate with or without cleft lip.

METHODS

This retrospective study from a tertiary care children's hospital included children with cleft palate ± cleft lip born between January 01, 2008, and December 31, 2015. All patients who had the initial palate repair at our institution and at least one behavioral audiogram were included. Behavioral audiograms collected either in the sound field or under insert earphones showed results from the better hearing ear. We collected demographic information, cleft type, parent report of newborn hearing screen, syndrome diagnosis, comorbid conditions, and dates of tympanostomy tube placement and palatoplasty. The main outcome measure was hearing status as measured by behavioral audiograms, and, for a subset of patients, brainstem auditory evoked responses (BAER). Results were grouped by test type (behavioral vs BAER) and characteristics at time of testing (pre- or post-palatoplasty, with or without tympanostomy tube placement) to evaluate the range of severity of hearing loss.

RESULTS

Three hundred and sixty patients were included in the cohort. The cohort had two groups: Group 1 included 37 patients who had BAER results prior to surgery and behavioral audiogram results post-surgery; Group 2 included 322 patients who had behavioral audiograms pre-surgery (n = 206) and/or post-surgery (n = 215). The median age of patients at time of BAER in Group 1 was 3.00 months [IQR: 1.00,3.75]; pre-surgery BAER results showed mild (45.9%, n = 17) or moderate hearing loss (29.7%, n = 11) by this age. Patients in Group 2 with pre-surgery behavioral audiograms had a median age of 12.00 months [IQR: 11.00, 14.00] at time of audiogram. Most patients had a mild (33.5%, n = 69) or moderate hearing loss (31.1%, n = 64). Post-surgery, patients had a median age of 13.00 months [IQR: 11.00, 15.00] at time of hearing assessment and typically had normal hearing (86.0%, n = 185). In most patients, hearing improved after palate repair with concurrent tympanostomy tube placement.

CONCLUSIONS

Most patients with cleft palate ± cleft lip had evidence of mild or moderate hearing loss prior to cleft palate repair, and hearing loss was evident from early infancy. Hearing improved after concurrent tympanostomy tube placement and palatoplasty. Further research is needed to understand the clinical significance of untreated transient hearing loss during the first year of life in this patient population.

Clinical Practice Guideline: Tympanostomy Tubes in Children (Update)

OBJECTIVE

Insertion of tympanostomy tubes is the most common ambulatory surgery performed on children in the United States. Tympanostomy tubes are most often inserted because of persistent middle ear fluid, frequent ear infections, or ear infections that persist after antibiotic therapy. All these conditions are encompassed by the term otitis media (middle ear inflammation). This guideline update provides evidence-based recommendations for patient selection and surgical indications for managing tympanostomy tubes in children. The guideline is intended for any clinician involved in managing children aged 6 months to 12 years with tympanostomy tubes or children being considered for tympanostomy tubes in any care setting as an intervention for otitis media of any type. The target audience includes specialists, primary care clinicians, and allied health professionals.

PURPOSE

The purpose of this clinical practice guideline update is to reassess and update recommendations in the prior guideline from 2013 and to provide clinicians with trustworthy, evidence-based recommendations on patient selection and surgical indications for managing tympanostomy tubes in children. In planning the content of the updated guideline, the guideline update group (GUG) affirmed and included all the original key action statements (KASs), based on external review and GUG assessment of the original recommendations. The guideline update was supplemented with new research evidence and expanded profiles that addressed quality improvement and implementation issues. The group also discussed and prioritized the need for new recommendations based on gaps in the initial guideline or new evidence that would warrant and support KASs. The GUG further sought to bring greater coherence to the guideline recommendations by displaying relationships in a new flowchart to facilitate clinical decision making. Last, knowledge gaps were identified to guide future research.

METHODS

In developing this update, the methods outlined in the American Academy of Otolaryngology-Head and Neck Surgery Foundation's "Clinical Practice Guideline Development Manual, Third Edition: A Quality-Driven Approach for Translating Evidence Into Action" were followed explicitly. The GUG was convened with representation from the disciplines of otolaryngology-head and neck surgery, otology, pediatrics, audiology, anesthesiology, family medicine, advanced practice nursing, speech-language pathology, and consumer advocacy.

ACTION STATEMENTS

The GUG made strong recommendations for the following KASs: (14) clinicians should prescribe topical antibiotic ear drops only, without oral antibiotics, for children with uncomplicated acute tympanostomy tube otorrhea; (16) the surgeon or designee should examine the ears of a child within 3 months of tympanostomy tube insertion AND should educate families regarding the need for routine, periodic follow-up to examine the ears until the tubes extrude.The GUG made recommendations for the following KASs: (1) clinicians should not perform tympanostomy tube insertion in children with a single episode of otitis media with effusion (OME) of less than 3 months' duration, from the date of onset (if known) or from the date of diagnosis (if onset is unknown); (2) clinicians should obtain a hearing evaluation if OME persists for 3 months or longer OR prior to surgery when a child becomes a candidate for tympanostomy tube insertion; (3) clinicians should offer bilateral tympanostomy tube insertion to children with bilateral OME for 3 months or longer AND documented hearing difficulties; (5) clinicians should reevaluate, at 3- to 6-month intervals, children with chronic OME who do not receive tympanostomy tubes, until the effusion is no longer present, significant hearing loss is detected, or structural abnormalities of the tympanic membrane or middle ear are suspected; (6) clinicians should not perform tympanostomy tube insertion in children with recurrent acute otitis media who do not have middle ear effusion in either ear at the time of assessment for tube candidacy; (7) clinicians should offer bilateral tympanostomy tube insertion in children with recurrent acute otitis media who have unilateral or bilateral middle ear effusion at the time of assessment for tube candidacy; (8) clinicians should determine if a child with recurrent acute otitis media or with OME of any duration is at increased risk for speech, language, or learning problems from otitis media because of baseline sensory, physical, cognitive, or behavioral factors; (10) the clinician should not place long-term tubes as initial surgery for children who meet criteria for tube insertion unless there is a specific reason based on an anticipated need for prolonged middle ear ventilation beyond that of a short-term tube; (12) in the perioperative period, clinicians should educate caregivers of children with tympanostomy tubes regarding the expected duration of tube function, recommended follow-up schedule, and detection of complications; (13) clinicians should not routinely prescribe postoperative antibiotic ear drops after tympanostomy tube placement; (15) clinicians should not encourage routine, prophylactic water precautions (use of earplugs or headbands, avoidance of swimming or water sports) for children with tympanostomy tubes.The GUG offered the following KASs as options: (4) clinicians may perform tympanostomy tube insertion in children with unilateral or bilateral OME for 3 months or longer (chronic OME) AND symptoms that are likely attributable, all or in part, to OME that include, but are not limited to, balance (vestibular) problems, poor school performance, behavioral problems, ear discomfort, or reduced quality of life; (9) clinicians may perform tympanostomy tube insertion in at-risk children with unilateral or bilateral OME that is likely to persist as reflected by a type B (flat) tympanogram or a documented effusion for 3 months or longer; (11) clinicians may perform adenoidectomy as an adjunct to tympanostomy tube insertion for children with symptoms directly related to the adenoids (adenoid infection or nasal obstruction) OR in children aged 4 years or older to potentially reduce future incidence of recurrent otitis media or the need for repeat tube insertion.

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

Objective

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

Method

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

Results

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

Conclusion

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

Clinical Practice Guidelines on the Treatment of Patients with Cleft Lip, Alveolus, and Palate: An Executive Summary

Significant treatment variation exists in the Netherlands between teams treating patients with cleft lip, alveolus, and/or palate, resulting in a confusing and undesirable situation for patients, parents, and practitioners. Therefore, to optimize cleft care, clinical practice guidelines (CPGs) were developed. The aim of this report is to describe CPG development, share the main recommendations, and indicate knowledge gaps regarding cleft care. Together with patients and parents, a multidisciplinary working group of representatives from all relevant disciplines assisted by two experienced epidemiologists identified the topics to be addressed in the CPGs. Searching the Medline, Embase, and Cochrane Library databases identified 5157 articles, 60 of which remained after applying inclusion and exclusion criteria. We rated the quality of the evidence from moderate to very low. The working group formulated 71 recommendations regarding genetic testing, feeding, lip and palate closure, hearing, hypernasality, bone grafting, orthodontics, psychosocial guidance, dentistry, osteotomy versus distraction, and rhinoplasty. The final CPGs were obtained after review by all stakeholders and allow cleft teams to base their treatment on current knowledge. With high-quality evidence lacking, the need for additional high-quality studies has become apparent.

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.

The effect of intervelar veloplasty under magnification (Sommerlad's Technique) without tympanostomy on middle ear effusion in cleft palate patients

Objective

Different surgical techniques and management approaches have been introduced to manage the cleft palate (CP) and its complications, such as otitis media with effusion (OME) and auditory problems. The optimal method, as well as the ideal time for palatoplasty and ventilation tube insertion, are the subject of controversy in the literature. We aimed to evaluate The Effect of Intervelar Veloplasty under Magnification (Sommerlad’s Technique) without Tympanostomy on Middle Ear Effusion in Cleft Palate Patients.

Methods

non-syndromic cleft palate patients from birth to 24 months who needed primary palatoplasty from April 2017 to 2019 were enrolled in this study. intravelar veloplasty (IVVP) surgery under magnification has been done by the same surgeon. Likewise, Otoscopy, Auditory Brainstem Response (ABR), and tympanometry were performed for all the patients before and six months after palatoplasty.

Results

Tympanograms were classified into two categories according to shape and middle ear pressure, and it was done in 42 children (84 ears). Type B curve was seen in 40 cases (80 ears) before surgery which reduced significantly (P < 0.005) to 12 cases in the left ear and 14 cases in the right ear after surgery. So, after surgery, 70 % of the tympanogram of left ears and 66.6 % of the tympanogram of Rt ears were in normal condition (type A tympanometry). ABR was done for 43 patients (86 ears) before surgery and six months after palatoplasty. Data were shown that 40 of the patients had mild to moderate hearing loss before surgery, which reduced significantly (P < 0.005) to 9 in the left ear and 11 in the right ear after palatoplasty. So, after surgery, 79 % of ABR of left ears and 73.8 % of ABR of right ears were in normal status (normal hearing threshold).

Conclusions

Intervelar veloplasty under magnification (Sommerlad’s technique) significantly improved the middle ear effusion without the need for tympanostomy tube insertion.

Assessing Adherence to Audiologic Parameters of Care for Children With Cleft Palate: A Quality Improvement Initiative

OBJECTIVE

To evaluate and increase adherence to an evidence-based audiologic management protocol for children with cleft palate.

DESIGN

Prospective, multidisciplinary quality improvement initiative.

SETTING

Tertiary pediatric hospital.

PATIENTS, PARTICIPANTS

Children with cleft palate (with or without cleft lip) between the ages of 0 and 5 years (n = 205).

INTERVENTIONS

A multidisciplinary team identified key drivers for nonadherence to recommended audiological follow-up and implemented interventions to improve adherence. Key drivers included provider practices and preferences, clinic logistics and flow, and patient/family awareness and education. Several interventions were implemented between 2016 and 2020, including developing an evidence-based audiologic protocol, maximizing access to audiologic clinic visits across multiple departments, cleft team education, and improved team communication.

MAIN OUTCOME MEASURE(S)

Completion of recommended audiologic assessment at 5 separate care milestones.

RESULTS

After implementation of interventions between 2016 and 2020, adherence to recommended audiologic follow-up increased from 59% to 84%. Analysis of individual care milestones revealed that increased access to audiologic testing during team clinics resulted in the largest increase in adherence to recommended follow-up. Additionally, cause-effect analysis revealed that nonadherence due to provider-related causes decreased over the project period to a greater extent than patient/family-related causes.

CONCLUSIONS

Implementation of an evidence-based audiologic care protocol and improvements in access to early hearing care are feasible in a high-volume multidisciplinary cleft clinic. Adherence to recommended audiologic management can be improved by establishing strategies to improve access to care, team member and family education, and enhanced team communication.

Missense Variants Within GJB2 Gene Locus and the Risk of Hearing Defects in Nonsyndromic Cleft Lip and Palate

AIM

The aim of the study was to investigate the role of variants in GJB2 gene in the etiology of hearing defects in nonsyndromic cleft lip/palate.

METHOD

Saliva samples were obtained from cases (subjects with orofacial clefts) and control (subjects without orofacial clefts) who consented to the study. Deoxyribonucleic acid (DNA) was extracted using standardized protocol at Butali Lab (Iowa, IA). Primers for the coding region of GJB2 was designed using Primer 3 (http://bioinfo.ut.ee/primer3-0.4.0/) and optimized in the Butali lab using a gradient polymerase chain reaction to determine the annealing temperature for each primer set (forward and reverse). We measured the DNA concentration using Qubit and XY genotyping done for quality control. A concentration of 5 ng/μL of DNA was used for Sanger sequencing.

RESULTS

A total of 150 subjects were sequenced (66 cases; 84 controls). Mutations in GJB2 gene were detected in 2 individuals with cleft palate. We found p.Arg165Trp variant in 1 case and p.Leu81Val variant in the second case. Although p.Arg165Trp was predicted to be either benign or tolerated by SIFT/POLYPHEN, the single nucleotide change from C>T, that is, CGG>TGG leads to a premature stop codon preventing the protein formation. The p.Leu81Val variant was predicted to be probably damaging/ deleterious.

CONCLUSIONS

The present study implicates variants in the GJB2 gene in the etiology of hearing defects in nonsyndromic cleft lip and palate in the Nigerian population. Screening for variations in GJB2 gene is important for genetic counseling especially in high-risk families.

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

OBJECTIVE

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

METHODS

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

RESULTS

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

CONCLUSION

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

Pre-operative and post-operative audiological assessment in cleft lip and palate patients-a prospective study

Purpose

To assess association of audiological defects in cleft lip and palate (CLP) following two stage cheiloplasty and palatoplasty using clinical evaluation and otoscopy and effect of the surgical repair at an interval of one year.

Materials and methods

A pilot research study was performed on sixty CLP patients of 1-6 years of age reporting at Craniofacial & Research Centre, Dharwad, India between October 2016 to October 2018.Subjects were assessed based on history, clinical examination and otoscopy for audiometric defects including Serous otitis media (SOM), retraction pockets, impacted wax pre-palatoplasty and findings were compared with control group. Study group were followed up postoperatively at 1, 3, 6 and 12 months and statistical analysis was carried.

Results

Higher incidence of conductive audiological defects were noted in study group (96.6%) to control group (8.33%). Of the sixty cleft patients subjected to screening otoscopy, 58 subjects had significant findings like serous otitis media(12.07%), retraction pockets(23.14%), impacted wax(62.04%), bulging of tympanic membrane(3.45%) which were clinically unnoticed. Post palatoplasty no changes were noted at 1 and 3 months, however at 6- and 12months significant improvement was noted (55.17%), with three subjects lost to follow up (6.90%) and none presenting with permanent deafness.results.

Conclusion

Cleft anomalies occur in different degrees of severity and configuration with greater incidence of conductive hearing defects of 97%. Positive correlation was noted in cleft palate cases with significant improvement after palatoplasty at an earlier age. However, future long term studies are warranted for long term assessment of Eustachian tube function.conclusion.

Auditory and language skills in children with cleft lip and palate

OBJECTIVES

to investigate auditory and language skills in children with repaired cleft lip and palate.

METHODS

The sample was composed of 22 children registered at the hospital where the study was conducted, seven to nine years old, 50% being female, with repaired unilateral cleft lip and palate (right or left), without associated malformations. Auditory skills were assessed using four central auditory processing tests: Random Gap Detection Test, Dichotic Digit Test, Dichotic Non-Verbal Test, Sustained Auditory Attention Ability Test. Language performance was evaluated by four standardized instruments: Illinois Psycholinguistic Skills Test, Peabody Picture Vocabulary Test, Token Test and Phonological Skills Profile. The association between auditory and language skills was evaluated by the Fisher exact test at a significance level of 5% (p<.05).

RESULTS

The central auditory processing tests evidenced that only one child presented adequate performance in all skills analysed, five children presented impaired performance in all skills, and 16 exhibited deteriorations in one to three auditory skills, highlighting that temporal resolution was the most impaired skill (81%). Concerning language, three children presented adequate performance in all tests applied, and Visual Association and Auditory Association were the most impaired skills (40%). No association was observed between deteriorations in auditory and language skills.

CONCLUSION

There was high occurrence of impairment of auditory skills, which compose the central auditory processing, as well as of language skills, with greatest impairment of receptive language.

Auditory phenotype of Smith-Lemli-Opitz syndrome

Smith-Lemli-Opitz syndrome (SLOS) is an autosomal recessive multiple congenital malformation and intellectual disability syndrome resulting from variants in DHCR7. Auditory characteristics of persons with SLOS have been described in limited case reports but have not been systematically evaluated. The objective of this study is to describe the auditory phenotype in SLOS. Age- and ability-appropriate hearing evaluations were conducted on 32 patients with SLOS. A subset of 21 had auditory brainstem response testing, from which an auditory neural phenotype is described. Peripheral or retrocochlear auditory dysfunction was observed in at least one ear of 65.6% (21) of the patients in our SLOS cohort. The audiometric phenotype was heterogeneous and included conductive, mixed, and sensorineural hearing loss. The most common presentation was a slight to mild conductive hearing loss, although profound sensorineural hearing loss was also observed. Abnormal auditory brainstem responses indicative of retrocochlear dysfunction were identified in 21.9% of the patients. Many were difficult to test behaviorally and required objective assessment methods to estimate hearing sensitivity. Individuals with SLOS are likely to have hearing loss that may impact communication, including speech and language development. Routine audiologic surveillance should be conducted to ensure prompt management of hearing loss.

An overview of cleft lip and palate

Cleft lip and palate are types of craniofacial birth defects that affect thousands of children worldwide each year. These conditions are sensitive topics of conversations, often affected by the stigma of physical birth deformities and cultural myths. This article reviews the pathophysiology of cleft lip and palate, and describes the traditional management of patients with oral-facial clefts, including the extensive supportive care and an interprofessional team or cleft team approach that extends beyond the surgical correction.

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.

Change in Initial Tympanostomy Tube Placement Timing Yields Decreased Burden of Care Without Increased Complications in Patients With Cleft Lip and Palate

Objective:

To report a practice audit of the consequences of a change in protocol in the timing of placement of tympanostomy tubes in infants with cleft lip and palate.

Participants:

All children with a diagnosis of cleft lip and palate, treated between November 1998 and May 2006 under the old protocol, and between December 2012 and July 2016 under a new protocol. Under the old protocol, tympanostomy tubes were first inserted at the time of lip repair at around age 2 months. Under the new protocol, tympanostomy tubes were deferred until the time of palate repair around the age of 9 months. Children with syndromic diagnoses other than Stickler syndrome and Van der Woude syndrome, and children who failed newborn hearing screen were excluded.

Main Outcome Measures:

Incidence of otorrhea from birth to 6 months after palate repair and presence of hearing loss at ages 1 and 2.

Results:

Deferral of tympanostomy tubes until the time of palate repair decreases the burden of care due to otorrhea as compared to early tympanostomy tubes at the time of lip repair. There was no significant difference in the incidence of hearing thresholds at or below 15 dB at age 1 or 2.

Conclusions:

Placement of tympanostomy tubes at the time of palate repair balances the goals of minimizing the adverse effects from middle ear effusion and minimizing the burden of care on our patients and their families.

The Comparison of Pierre Robin Sequence and Non-Syndromic Cleft Palate

INTRODUCTION

The aim of this study was to evaluate pre-operative nutritional status, associated syndromes and abnormalities, and post-operative outcomes of patients with Pierre Robin Sequence (PRS) versus those with non-syndromic isolated cleft palate (CIP).

METHODS

Between January 1995 and December 2013, patients with a cleft palate Veau I-II according to the Veau classification with and without PRS who underwent primary repair were retrospectively analyzed. The nutrition status, age at the time of palatoplasty, additional anomalies, gestational complications, and post-operative speech abnormalities and outcomes were evaluated.

RESULTS

A total of 59 patients with PRS (PRS group) and 132 patients without PRS (non-PRS group) were included in the study. Of all patients, 92 were males and 99 were females with a mean age of 14 ± 4.18 (range, 6 to 26) years. The rate of gestational complications, enteral nutrition, complete cleft, additional anomalies, and velopharyngeal insufficiency was significantly higher in the PRS group (P < 0.05). However, the incidence of fistulas and age at the time of palatoplasty did not significantly differ between the groups.

CONCLUSION

Based on our study results, enteral nutrition, respiratory problems, pregnancy complications, velopharyngeal insufficiency, and additional anomalies, but not post-operative palatal fistulas, are more frequently seen in patients with PRS. Although pre-operative care and treatment and rehabilitation in patients with PRS are more complicated than those with the CIP, our experience demonstrates that meticulous repair and follow-up can minimize complications, such as fistulas.

Hearing Thresholds in Young Children With Otitis Media With Effusion With and Without Cleft Palate

Objective:

To investigate hearing thresholds in children born with cleft palate and in children with otitis media with effusion but no cleft palate.

Design:

Prospective longitudinal group comparison study.

Setting:

University hospital.

Participants:

Sixteen children born with nonsyndromic cleft palate with or without cleft lip (CP±L) and 15 age-matched children with otitis media with effusion (OME) but without cleft.

Main Outcome Measures:

Hearing was tested at repeated occasions beginning with neonatal auditory brainstem response (ABR) at 1-4 months of age, and age-appropriate hearing tests from 9 to 36 months of age.

Results:

The median ABR thresholds in both groups were elevated but did not differ significantly. At 12 months of age, the median 4 frequency averages at 500-1000-2000-4000 Hz (4FA) were indicative of mild hearing loss but significantly better in the CP±L-group than in the group without cleft ( P < .01). There were no significant group-wise differences regarding the median 4FA at 24 and 36 months of age, and at 36 months, the median 4FA were normal in both groups. Both groups exhibited a significant improvement over time from the neonatal ABR thresholds to the 4FA at 36 months (CP±L-group P < .05; without CP±L-group P < .01).

Conclusion:

The hearing loss in children with CP±L was not more severe than among children with OME but without cleft palate; rather, at 12 months of age, the thresholds were significantly better in the CP±L-group than those in the group without cleft. The air conduction thresholds improved with age in both groups.

ABM Clinical Protocol #17: Guidelines for Breastfeeding Infants with Cleft Lip, Cleft Palate, or Cleft Lip and Palate-Revised 2019

A central goal of the Academy of Breastfeeding Medicine is the development of clinical protocols for managing common medical problems that may impact breastfeeding success. These protocols serve only as guidelines for the care of breastfeeding mothers and infants and do not delineate an exclusive course of treatment or serve as standards of medical care. Variations in treatment may be appropriate according to the needs of an individual patient.

Contribution of the Use of a Pen-Type Endoscope to Evaluate and Treat Ears Simultaneously During Cleft Palate Surgery in Late Presented Cases

BACKGROUND

The prevalence of secretory otitis media is very high among the nonoperated cleft palate patients.

METHODS

Ninety-one cleft palate operations were performed on late presented cases in Sudan, Africa. The surgeries were performed according to the Veau-Wardill-Kilner push-back technique. A laptop connected pen-type endoscopic camera was used to evaluate the tympanic membrane and address middle ear disease in all patients simultaneously. The procedure was performed after removing wax from the external auditory canal. A small incision was made with a myringotomy knife through the layers of the tympanic membrane if any sign of fluid collection was observed, after which the middle ear effusion was evacuated and the ventilation tube was inserted.

RESULTS

This procedure was undertaken in 182 ears; 41 ears (22.5%) were healthy, 19 ears (10.5%) had chronic perforations, 122 ears (67%) underwent myringotomy procedures, and 54 (44.2%) were treated by inserting a ventilation tube. Despite the challenging work environment, standard monitoring facilities were available and all operations were completed with no early complications.

CONCLUSION

The pen-type camera instead of an operating microscope was a tremendous contribution, as it was easy to handle and contributed to the good outcomes. The use of this technique is strongly recommended in surgical camps.

LEVEL OF EVIDENCE

III.

Otitis media with effusion in children: Pathophysiology, diagnosis, and treatment. A review

Otitis media with effusion (OME) is a frequent paediatric disorder. The condition is often asymptomatic, and so can easily be missed. However, OME can lead to hearing loss that impairs the child's language and behavioural development. The diagnosis is essentially clinical, and is based on otoscopy and (in some cases) tympanometry. Nasal endoscopy is only indicated in cases of unilateral OME or when obstructive adenoid hypertrophy is suspected. Otitis media with effusion is defined as the observation of middle-ear effusion at consultations three months apart. Hearing must be evaluated (using an age-appropriate audiometry technique) before and after treatment, so as not to miss another underlying cause of deafness (e.g. perception deafness). Craniofacial dysmorphism, respiratory allergy and gastro-oesophageal reflux all favour the development of OME. Although a certain number of medications (antibiotics, corticoids, antihistamines, mucokinetic agents, and nasal decongestants) can be used to treat OME, they are not reliably effective and rarely provide long-term relief. The benchmark treatment for OME is placement of tympanostomy tubes (TTs) and (in some cases) adjunct adenoidectomy. The TTs rapidly normalize hearing and effectively prevent the development of cholesteatoma in the middle ear. In contrast, TTs do not prevent progression towards tympanic atrophy or a retraction pocket. Adenoidectomy enhances the effectiveness of TTs. In children with adenoid hypertrophy, adenoidectomy is indicated before the age of 4 but can be performed later when OME is identified by nasal endoscopy. Children must be followed up until OME has disappeared completely, so that any complications are not missed.

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

Objective

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

Study Design

Case series with chart review.

Setting

Single academic center.

Subjects and Methods

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

Results

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

Conclusion

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

Clinical outcomes of otitis media with effusion following palatoplasty in patients with incomplete cleft palate

BACKGROUND

Diagnosis and treatment strategies for CP with OME and the timing of ear tube insertion remain controversial.

OBJECTIVES

To analyze the clinical outcomes of otitis media with effusion in children with incomplete cleft palate after palatoplasty prospectively.

METHODS

A total of 30 children (10 months-2 years old) with incomplete CP were enrolled in this study and received at least 6 months of follow-up evaluations after palatoplasty.

RESULTS

The overall improvement rate of OME was as high as 26% in this group. Average air conduction hearing threshold was significantly better than that before surgery in the 8 patients with improved OME (p < .05). Among the 8 children with improved OME, 7 (87.5%) were found to have middle ear effusion that improved within 6 months after CP repair. There was no significant difference in the improvement rate between the severe degree II group and the mild group.

CONCLUSION

A 6-month follow-up period is recommended. The severity of incomplete CP is not fully related to the function of the eustachian tube.

SIGNIFICANCE

The overall improvement rate was as high as 26%, and effusion in the tympanic cavity subsided in 7 out of 8 cases within 6 months after the CP repair.

Influence of infancy care strategy on hearing in children and adolescents: A longitudinal study of children with unilateral lip and /or cleft palate

OBJECTIVES

To evaluate the relation between ventilation tube insertion, otitis media with effusion duration and otologic outcomes in unilateral cleft lip and/or cleft palate children from infancy to teenage age.

DESIGN AND POPULATION

Retrospective longitudinal charts review of patients from the multidisciplinary cleft team of the University Hospital of Lausanne over a 30-year period. 146 charts from consecutive patients with non-syndromic unilateral cleft lip and/or cleft palate who were born between January 1986 and January 2003 were included.

RESULTS

The earlier in life a cleft child experience his first otitis media with effusion (OME), the worse his long-term hearing will be. Along with the age of onset of OME, we disclosed an influence of the duration of OME without ventilation tube (VT) insertion on short and long-term hearing outcomes. Different patterns were observed between cleft palate (CP) and cleft lip palate children (CLP), with a higher incidence of otitis media with effusion for the CLP group than the CP group. Direct positive relationship between VT insertion and hearing were disclosed and evaluation of long-term complications did not reveal significant relation with VT insertion. Of note, OME in CLP children led to a higher rate (but not statistically significant) of chronic ear complications than in the CP group, that may indicate more persistent OME or different adverse effect on the middle ear mucosa between CP and CLP children.

CONCLUSIONS

Individualized counseling should take into account different factors such as the type of cleft, the age of onset of OME and duration of OME, keeping in mind the adverse effect of persistent middle ear fluid. In the present report, results prone an early ventilation tube insertion to prevent short and long-term injury to the middle ear homeostasis, hearing loss and related issues.

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

OBJECTIVE

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

METHODS

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

RESULTS

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

CONCLUSION

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

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.

Otolaryngology Service Usage in Children With Cleft Palate

Objectives:

To determine the usage of otolaryngology services by children with cleft palate at a pediatric tertiary care facility.

Design:

Retrospective case series.

Setting:

Specialty clinic at a pediatric tertiary care hospital.

Patients:

Children born between January 1, 1999, and December 31, 2002, with the diagnosis of cleft palate or cleft lip and palate. A total of 41 female and 48 male patients were included.

Main Outcome Measures:

Total number of otolaryngology clinic visits and total number of otolaryngologic surgeries (tympanostomy tube placements and other otologic or upper airway procedures).

Results:

In the first 5 years of life, these children utilized an average of 8.2 otolaryngology clinic visits (SD = 5.0; range: 1-22) and underwent 3.3 tympanostomy tube surgeries (SD = 2.0; range: 0-10). Seventy-three had their first tube placed at the time of palate repair, and 4 at the time of lip repair. Fifty-one (57.3%) required other otologic or upper airway procedures, including tonsillectomy and/or adenoidectomy (27 children), removal of tympanostomy tubes (24 children), tympanomastoidectomy (3 children), and tympanoplasty (14 children). Of the children who underwent other procedures, they underwent a mean of 1.67 (SD = 0.84; range: 1-4) surgeries.

Conclusions:

Children with cleft palate are at increased risk for eustachian tube dysfunction, frequently utilize otolaryngology care, and typically receive multiple sets of tympanostomy tubes. This study found that children with cleft palate receive on average of approximately 3 sets of tympanostomy tubes, and the majority required another otologic or upper airway surgery.

Panel 7: Otitis Media: Treatment and Complications

Objective We aimed to summarize key articles published between 2011 and 2015 on the treatment of (recurrent) acute otitis media, otitis media with effusion, tympanostomy tube otorrhea, chronic suppurative otitis media and complications of otitis media, and their implications for clinical practice. Data Sources PubMed, Ovid Medline, the Cochrane Library, and Clinical Evidence (BMJ Publishing). Review Methods All types of articles related to otitis media treatment and complications between June 2011 and March 2015 were identified. A total of 1122 potential related articles were reviewed by the panel members; 118 relevant articles were ultimately included in this summary. Conclusions Recent literature and guidelines emphasize accurate diagnosis of acute otitis media and optimal management of ear pain. Watchful waiting is optional in mild to moderate acute otitis media; antibiotics do shorten symptoms and duration of middle ear effusion. The additive benefit of adenoidectomy to tympanostomy tubes in recurrent acute otitis media and otitis media with effusion is controversial and age dependent. Topical antibiotic is the treatment of choice in acute tube otorrhea. Symptomatic hearing loss due to persistent otitis media with effusion is best treated with tympanostomy tubes. Novel molecular and biomaterial treatments as adjuvants to surgical closure of eardrum perforations seem promising. There is insufficient evidence to support the use of complementary and alternative treatments. Implications for Practice Emphasis on accurate diagnosis of otitis media, in its various forms, is important to reduce overdiagnosis, overtreatment, and antibiotic resistance. Children at risk for otitis media and its complications deserve special attention.

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.

The Primary Care Pediatrician and the Care of Children With Cleft Lip and/or Cleft Palate

Orofacial clefts, specifically cleft lip and/or cleft palate (CL/P), are among the most common congenital anomalies. CL/P vary in their location and severity and comprise 3 overarching groups: cleft lip (CL), cleft lip with cleft palate (CLP), and cleft palate alone (CP). CL/P may be associated with one of many syndromes that could further complicate a child's needs. Care of patients with CL/P spans prenatal diagnosis into adulthood. The appropriate timing and order of specific cleft-related care are important factors for optimizing outcomes; however, care should be individualized to meet the specific needs of each patient and family. Children with CL/P should receive their specialty cleft-related care from a multidisciplinary cleft or craniofacial team with sufficient patient and surgical volume to promote successful outcomes. The primary care pediatrician at the child's medical home has an essential role in making a timely diagnosis and referral; providing ongoing health care maintenance, anticipatory guidance, and acute care; and functioning as an advocate for the patient and a liaison between the family and the craniofacial/cleft team. This document provides background on CL/P and multidisciplinary team care, information about typical timing and order of cleft-related care, and recommendations for cleft/craniofacial teams and primary care pediatricians in the care of children with CL/P.

Grommet Surgery in Children with Orofacial Clefts in England

Objective

To assess grommet insertion practice in the first 5 years of life among children with an orofacial cleft in England.

Design

Analysis of national administrative data of hospital admissions.

Setting

National Health Service hospitals, England.

Patients

Patients born between 1997 and 2005 who underwent surgical cleft repair.

Intervention

Children receiving grommets before the age of 5 years.

Outcome Measures

The proportion of children receiving grommets before the age of 5 years, the timing of the first grommet insertion, and the proportion of children having repeat grommet insertions were examined according to cleft type, the absence or presence of additional anomalies, socioeconomic deprivation, and region of residence.

Results

The study included 8,269 children. Before the age of 5 years, 3,015 (36.5%) children received grommets. Of these, 33.2% received their first grommets at primary cleft repair and 33.3% underwent multiple grommet insertion procedures. The most common age for the first procedure was between 6 and 12 months. Children with a cleft affecting the palate were more likely to receive grommets than children with a cleft lip alone (45.5% versus 4.5%). Grommet insertion practice also varied according to year of birth, absence or presence of additional anomalies, socioeconomic deprivation, and region of residence.

Conclusion

Grommets practice in children with a cleft appears to vary according to their clinical characteristics. The differences in practice observed according to deprivation and region of residence need to be further explored.

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

CONCLUSION

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

OBJECTIVES

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

SUBJECTS AND METHODS

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

RESULTS

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

Clinical Practice Guideline: Otitis Media with Effusion (Update)

OBJECTIVE

This update of a 2004 guideline codeveloped by the American Academy of Otolaryngology-Head and Neck Surgery Foundation, the American Academy of Pediatrics, and the American Academy of Family Physicians, provides evidence-based recommendations to manage otitis media with effusion (OME), defined as the presence of fluid in the middle ear without signs or symptoms of acute ear infection. Changes from the prior guideline include consumer advocates added to the update group, evidence from 4 new clinical practice guidelines, 20 new systematic reviews, and 49 randomized control trials, enhanced emphasis on patient education and shared decision making, a new algorithm to clarify action statement relationships, and new and expanded recommendations for the diagnosis and management of OME.

PURPOSE

The purpose of this multidisciplinary guideline is to identify quality improvement opportunities in managing OME and to create explicit and actionable recommendations to implement these opportunities in clinical practice. Specifically, the goals are to improve diagnostic accuracy, identify children who are most susceptible to developmental sequelae from OME, and educate clinicians and patients regarding the favorable natural history of most OME and the clinical benefits for medical therapy (eg, steroids, antihistamines, decongestants). Additional goals relate to OME surveillance, hearing and language evaluation, and management of OME detected by newborn screening. The target patient for the guideline is a child aged 2 months through 12 years with OME, with or without developmental disabilities or underlying conditions that predispose to OME and its sequelae. The guideline is intended for all clinicians who are likely to diagnose and manage children with OME, and it applies to any setting in which OME would be identified, monitored, or managed. This guideline, however, does not apply to patients <2 months or >12 years old.

ACTION STATEMENTS

The update group made strong recommendations that clinicians (1) should document the presence of middle ear effusion with pneumatic otoscopy when diagnosing OME in a child; (2) should perform pneumatic otoscopy to assess for OME in a child with otalgia, hearing loss, or both; (3) should obtain tympanometry in children with suspected OME for whom the diagnosis is uncertain after performing (or attempting) pneumatic otoscopy; (4) should manage the child with OME who is not at risk with watchful waiting for 3 months from the date of effusion onset (if known) or 3 months from the date of diagnosis (if onset is unknown); (5) should recommend against using intranasal or systemic steroids for treating OME; (6) should recommend against using systemic antibiotics for treating OME; and (7) should recommend against using antihistamines, decongestants, or both for treating OME.The update group made recommendations that clinicians (1) should document in the medical record counseling of parents of infants with OME who fail a newborn screening regarding the importance of follow-up to ensure that hearing is normal when OME resolves and to exclude an underlying sensorineural hearing loss; (2) should determine if a child with OME is at increased risk for speech, language, or learning problems from middle ear effusion because of baseline sensory, physical, cognitive, or behavioral factors; (3) should evaluate at-risk children for OME at the time of diagnosis of an at-risk condition and at 12 to 18 months of age (if diagnosed as being at risk prior to this time); (4) should not routinely screen children for OME who are not at risk and do not have symptoms that may be attributable to OME, such as hearing difficulties, balance (vestibular) problems, poor school performance, behavioral problems, or ear discomfort; (5) should educate children with OME and their families regarding the natural history of OME, need for follow-up, and the possible sequelae; (6) should obtain an age-appropriate hearing test if OME persists for 3 months or longer OR for OME of any duration in an at-risk child; (7) should counsel families of children with bilateral OME and documented hearing loss about the potential impact on speech and language development; (8) should reevaluate, at 3- to 6-month intervals, children with chronic OME until the effusion is no longer present, significant hearing loss is identified, or structural abnormalities of the eardrum or middle ear are suspected; (9) should recommend tympanostomy tubes when surgery is performed for OME in a child <4 years old; adenoidectomy should not be performed unless a distinct indication exists (nasal obstruction, chronic adenoiditis); (10) should recommend tympanostomy tubes, adenoidectomy, or both when surgery is performed for OME in a child ≥4 years old; and (11) should document resolution of OME, improved hearing, or improved quality of life when managing a child with OME.