Late ear sequelae in cleft palate patients

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.

Effects of RME on Hearing in UCLP Patients: A Pilot Study

OBJECTIVE

To assess the changes in hearing after rapid maxillary expansion (RME) and at the end of 6 months retention period in complete unilateral cleft lip and palate (UCLP) patients using pure tone audiometry and tympanometry test.

DESIGN

Prospective pilot study.

SETTING

Tertiary health care teaching hospital in New Delhi.

PATIENTS

This study was conducted on 6 UCLP patients in the age range of 6-14 years with normal ear anatomy. All 6 patients had undergone primary repair of cleft lip and palate and required no more than 5 mm expansion in the intermolar region.

INTERVENTION

RME was done using a Hyrax expander with daily activation of one-quarter turn per day for a period of 15-20 days (0.25 mm per day).

MAIN OUTCOME MEASURE

Audiometry and tympanometry readings at the baseline as compared to the post expansion and at the end of 6 months retention period.

RESULTS

There were no significant changes in the hearing levels on the audiometry test after RME on the cleft side (p-value -0.51) and the noncleft side ear (p-value -0.26). No significant changes were observed in the middle ear volume on the tympanometry test after RME on the cleft side (p-value -0.09) and the noncleft side ear (p-value -0.28).

CONCLUSION

There was no improvement or deterioration in the hearing levels after RME and at the end of 6 months retention period in UCLP patients as evaluated using pure tone audiometry and tympanometry test. Hence RME may be undertaken in UCLP patients safely in terms of hearing is concerned.

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

OBJECTIVE

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

INTRODUCTION

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

INCLUSION CRITERIA

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

METHODS

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

SYSTEMATIC REVIEW REGISTRATION NUMBER

PROSPERO CRD42021255861.

Cleft palate and ventilation tubes: a prophylactic dilemma

OBJECTIVE

This study aimed to understand, in a long-term follow-up study, whether the placement of grommets had been necessary after cleft palate surgical correction.

METHOD

A case-control, retrospective study was carried out on consecutive paediatric patients who underwent surgical repair of a cleft palate.

RESULTS

The study population included 138 patients, divided into 2 groups: group 1 - patients in whom grommets were placed at the time of cleft palate surgery, and group 2 - patients in whom grommets were not placed at the time of cleft palate surgery. During the follow up, in groups 1 and 2, 65.2 per cent and 67.8 per cent, respectively, did not need subsequent grommet placement after cleft palate surgery.

CONCLUSION

Of patients, 56.5 per cent did not need ventilation tubes at any point during follow up. The placement of grommets is not innocuous; therefore, its use at the time of cleft palate surgical repair should be reconsidered.

Prognosis of otitis media with effusion in pediatric patients with cleft palate during language-acquisition period treated by simultaneous tympanostomy tube placement with palatoplasty

OBJECTIVE

Cleft palate (CP) in children is frequently complicated by otitis media with effusion (OME) due to Eustachian tube dysfunction. Although tympanostomy tube (TT) placement can be beneficial in the treatment of OME to prevent short-term hearing loss, there is no consensus regarding the indications for and timing of TT insertion. The present study was performed to define the safety and effectiveness of simultaneous TT placement with palatoplasty during the language-acquisition period.

METHODS

We retrospectively reviewed the medical charts of pediatric patients who underwent palatoplasty for CP in a tertiary medical center, Kyoto University Hospital, from June 2010 to October 2018. The TT retention time was estimated using the Kaplan-Meier method. The incidence of OME recurrence was compared among four Veau classification groups based on the patients' sex, type of CP, median TT retention time, and type of fluid.

RESULTS

Seventy-six subjects (150 ears) were enrolled in the study. The median follow-up duration was 48.7 months (range, 18.2-108.0 months) after the first TT placement. A first TT retention time of <20.1 months was a significant risk factor for OME recurrence. Subjects with maxillofacial anomaly complex and subjects with cleft lip and palate and an alveolar cleft showed a significantly higher OME recurrence rate than subjects with clefts only in the hard and/or soft palate. There was no significant difference in the occurrence of sequelae between subjects with only a single TT placement and subjects with more than one TT placement.

CONCLUSIONS

Based on the findings of the present study, it is reasonable to perform TT insertion at the same time as palatoplasty on patients who meet the indications. This technique may reduce the number of times the patient requires general anesthesia and maintain good middle ear condition during the period of language acquisition between 1 and 3 years of age.

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.

Subannular Tubes in Children With Cleft Palate

OBJECTIVE

To investigate subannular tube (SAT) placement as an alternative treatment of chronic middle ear disease in children with cleft palate.

DESIGN

Retrospective cohort study.

PARTICIPANTS

All children with cleft palate with intractable otitis media with effusion and/or with tympanic membrane retraction, operated for insertion of 1 or more sets of transtympanic tubes followed by SAT in a tertiary center.

MAIN OUTCOME MEASURES

Audiological outcomes, average duration of tubes, and postoperative complications were analyzed.

RESULTS

This study included 21 children with cleft palate, aged 3 to 14 years. A total of 38 ears was evaluated. The median time of follow-up was 42 months. During follow-up, 69.2% of the patients had no complications. Observed complications were otorrhea (13.5%) and tube obstruction (7.7%). In 7.9% of the cases, otitis media with effusion relapsed after tube extrusion. By the end of the study, 76.3% of the tubes remained in situ and 68.4% of the tympanic membranes had the SAT in place and had no significant alterations. The mean duration of SATs was 16 months, which was significantly superior to transtympanic tube duration. A significant sustained improvement in the hearing of children with SATs was observed.

CONCLUSION

Subannular tube insertion results in hearing improvement to normal range and tympanic retraction pockets reversion in children with cleft palate with persistent otitis media with effusion and tympanic retraction/atelectasis. This surgery appears to be safe and provides long-term efficient middle ear aeration. Strict postoperative follow-up is crucial for the success of the treatment.

Long-term outcomes in children with and without cleft palate treated with tympanostomy for otitis media with effusion before the age of 2 years

BACKGROUND

Long-term outcomes of children with and without cleft palate receiving early treatment for otitis media with effusion (OME) are unclear.

OBJECTIVES

To compare long-term otological and audiological outcomes between children with and without cleft palate treated with tympanostomy for OME before the age of 2 years.

MATERIAL AND METHODS

Ninety-five children (180 ears) with cleft palate (study group) and 97 children (185 ears) without (control group) were followed-up to a maximum age of 7 years. We retrospectively analyzed the audiological outcomes at the age of 7 years, and the otological outcomes at the last examination.

RESULTS

The percentages of children with OME resolution before the age of 7 years were 47.4% and 60% in the study and control groups, respectively, and those of ears with healed tympanic membrane were 71.7% and 79.5% in the corresponding groups. Significantly more ears were subjected to retympanostomy in the study (31.1%) than in the control group (21.6%). Mean pure-tone average (0.5‒4 kHz) was 15.6 dB HL and 14.3 dB HL for the corresponding groups.

CONCLUSIONS/SIGNIFICANCE

Otological and audiological outcomes in both groups were similar. The audiological prognosis was favorable regardless of the cleft palate condition.

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.

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.

Otologic Disease Following Palatoplasty In International Cleft Palate Cohort

OBJECTIVE

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

DESIGN

Retrospective data review.

PARTICIPANTS

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

INTERVENTIONS

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

MAIN OUTCOME MEASURES

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

RESULTS

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

CONCLUSION

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

Audiological Profile in Older Children and Adolescents with Unrepaired Cleft Palate

Objective

To study the audiological profile in the cleft population comprising older children and adolescents with unrepaired cleft palate and to arrive at a consensus regarding management of otitis media with effusion in this unique group.

Setting

Tertiary care institute in Chandigarh, Punjab, India.

Design

Prospective study based on all patients older than 7 years with unrepaired cleft palate, attending the plastic surgery outpatient department, Postgraduate Institute of Medical Education and Research (PGIMER), Chandigarh, Punjab, India, from January 2001 to December 2002. Patients with submucous cleft were excluded from the study. General characteristics, otoscopic findings, pure tone audiometry, and impedence audiometry of all patients were recorded.

Results

Patients’ ages ranged from 8 to 18 years, with a mean of 10.5 years. Regarding otological complaints, 86.7% were asymptomatic. Otoscopic findings revealed mild retraction as the most common finding in 50% of the ears. Type B curve was the most common tympanometric finding. The highest and lowest hearing thresholds recorded were 45 db and 15 db, respectively, with a mean of 27.11 db.

Conclusion

The audiological profile of this unique group, which neither had undergone palatoplasty nor had received treatment for the ear condition, demonstrates a mild to moderate hearing impairment. This definitely requires treatment, but owing to the lack of a prospective control group, it is difficult to conclude whether these patients are benefited by conservative treatment alone or by an early aggressive surgical treatment for otitis media with effusion (OME).

Should Children With Cleft Palate Receive Early Long-Term Tympanostomy Tubes

Objectives:

To determine whether children with cleft palate might benefit from early long-term tympanostomy tubes with the hypothesis that receiving multiple tubes is associated with shorter duration of first tubes.

Design:

Retrospective cohort study.

Setting:

Tertiary care children’s hospital.

Participants:

Records from 401 consecutive children with cleft palate ± cleft lip, born April 2005 to April 2010, were reviewed. After exclusion of children with cleft repair at an outside hospital, no follow-up after 5 years of age, intact secondary palate, no tubes, or tube replacement at palatoplasty, 105 children remained.

Main Outcome Measure:

Number of tubes.

Results:

Armstrong grommet tubes were placed at a median age of 6.7 months (range 2.3-19.6 months). Tubes were replaced in 55.3% of patients, with 34.0% receiving ≥3 sets. Duration of first tubes was significantly longer for children with 1 set of tubes compared with those with multiple sets (median 26 vs 19 months, P = .004). Otorrhea, but not perforation, was associated with longer duration of first tubes (median 27 vs 20.5 months, P = .028). Cleft type did not impact the proportion of patients with multiple tubes. Median age at last tube placement for children with multiple tubes was 5.0 years (range 1.9-8.7 years).

Conclusion:

Short duration of first tubes is associated with receiving multiple tubes. Because most patients require repeat tubes and many require tubes until school age, there is a significant need for controlled, prospective trials of early long-term tube placement in this population.

Speech camp for children with cleft lip and/or palate in Thailand

Background: There is a critical need for speech therapy services for people born with cleft lip and/or palate in developing countries.

Objective: Assess the effectiveness of a speech camp and follow-up session for children with cleft lip and/or palate.

Methods: A Community-Based Model for Speech therapy was implemented at Suwanaphum Hospital District, Roiet, Thailand. Thirteen children with cleft lip and/or palate (3; 6-13 years) attended a four-day speech camp and a one-day follow-up session (six months later) for remediation of their articulation disorders. Paraprofessional training was also provided. Pre- and post-tests were administered to the participants, caregivers, and paraprofessionals to determine the effectiveness of the program. A pre- and post-articulation test, as well as an audiological evaluation were administered. Five speech and language pathologists provided speech therapy, both individual and group, for a total of 18 hours during the four-day speech camp and six hours in the one-day follow-up session. The median difference of the number of articulation errors was determined by results of the Wilcoxon Signed-Rank Test.

Results: There was a significant decrease in articulation errors following both the main speech camp and the follow-up session (z = 3.11, p < 0.01; z = 2.87, p<0.01, respectively). Caregivers’ and health care providers’ satisfaction ratings for participation in the speech camps ranged from good to excellent.

Conclusion: A Community-Based Model of both a speech camp and follow-up session provided an effective speech therapy treatment for children with cleft lip and/or palate.

The management of Otitis Media with Effusion in children with cleft palate (mOMEnt): a feasibility study and economic evaluation

BACKGROUND

Cleft lip and palate are among the most common congenital malformations, with an incidence of around 1 in 700. Cleft palate (CP) results in impaired Eustachian tube function, and 90% of children with CP have otitis media with effusion (OME) histories. There are several approaches to management, including watchful waiting, the provision of hearing aids (HAs) and the insertion of ventilation tubes (VTs). However, the evidence underpinning these strategies is unclear and there is a need to determine which treatment is the most appropriate.

OBJECTIVES

To identify the optimum study design, increase understanding of the impact of OME, determine the value of future research and develop a core outcome set (COS) for use in future studies.

DESIGN

The management of Otitis Media with Effusion in children with cleft palate (mOMEnt) study had four key components: (i) a survey evaluation of current clinical practice in each cleft centre; (ii) economic modelling and value of information (VOI) analysis to determine if the extent of existing decision uncertainty justifies the cost of further research; (iii) qualitative research to capture patient and parent opinion regarding willingness to participate in a trial and important outcomes; and (iv) the development of a COS for use in future effectiveness trials of OME in children with CP.

SETTING

The survey was carried out by e-mail with cleft centres. The qualitative research interviews took place in patients' homes. The COS was developed with health professionals and parents using a web-based Delphi exercise and a consensus meeting.

PARTICIPANTS

Clinicians working in the UK cleft centres, and parents and patients affected by CP and identified through two cleft clinics in the UK, or through the Cleft Lip and Palate Association.

RESULTS

The clinician survey revealed that care was predominantly delivered via a 'hub-and-spoke' model; there was some uncertainty about treatment strategies; it is not current practice to insert VTs at the time of palate repair; centres were in a position to take part in a future study; and the response rate to the survey was not good, representing a potential concern about future co-operation. A COS reflecting the opinions of clinicians and parents was developed, which included nine core outcomes important to both health-care professionals and parents. The qualitative research suggested that a trial would have a 25% recruitment rate, and although hearing was a key outcome, this was likely to be due to its psychosocial consequences. The VOI analysis suggested that the current uncertainty justified the costs of future research.

CONCLUSIONS

There exists significant uncertainty regarding the best management strategy for persistent OME in children with clefts, reflecting a lack of high-quality evidence regarding the effectiveness of individual treatments. It is feasible, cost-effective and of significance to clinicians and parents to undertake a trial examining the effectiveness of VTs and HAs for children with CP. However, in view of concerns about recruitment rate and engagement with the clinicians, we recommend that a trial with an internal pilot is considered.

FUNDING

The National Institute for Health Research Health Technology Assessment programme. This study was part-funded by the Healing Foundation supported by the Vocational Training Charitable Trust who funded trial staff including the study co-ordinator, information systems developer, study statistician, administrator and supervisory staff.

The Importance of Integration of Stakeholder Views in Core Outcome Set Development: Otitis Media with Effusion in Children with Cleft Palate

Background

Approximately 75% of children with cleft palate (CP) have Otitis Media with Effusion (OME) histories. Evidence for the effective management of OME in these children is lacking. The inconsistency in outcome measurement in previous studies has led to a call for the development of a Core Outcome Set (COS). Despite the increase in the number of published COS, involvement of patients in the COS development process, and methods to integrate the views of patients and health professionals, to date have been limited.

Methods and Findings

A list of outcomes measured in previous research was identified through reviewing the literature. Opinion on the importance of each of these outcomes was then sought from key stakeholders: Ear, Nose and Throat (ENT) surgeons, audiologists, cleft surgeons, speech and language therapists, specialist cleft nurses, psychologists, parents and children. The opinion of health professionals was sought in a three round Delphi survey where participants were asked to score each outcome using a bespoke online system. Parents and children were also asked to score outcomes in a survey and provided an in-depth insight into having OME through semi-structured interviews. The results of the Delphi survey, interviews and parent/patient survey were brought together in a final consensus meeting with representation from all stakeholders. A final set of eleven outcomes reached the definition of “consensus in” to form the recommended COS: hearing; chronic otitis media (COM); OME; receptive language skills; speech development; psycho social development; acute otitis media (AOM); cholesteatoma; side effects of treatment; listening skills; otalgia.

Conclusions

We have produced a recommendation about the outcomes that should be measured, as a minimum, in studies of the management of OME in children with CP. The development process included input from key stakeholders and used novel methodology to integrate the opinion of healthcare professionals, parents and children.

Updates and knowledge gaps in cholesteatoma research

The existence of acquired cholesteatoma has been recognized for more than three centuries; however, the nature of the disorder has yet to be determined. Without timely detection and intervention, cholesteatomas can become dangerously large and invade intratemporal structures, resulting in numerous intra- and extracranial complications. Due to its aggressive growth, invasive nature, and the potentially fatal consequences of intracranial complications, acquired cholesteatoma remains a cause of morbidity and death for those who lack access to advanced medical care. Currently, no viable nonsurgical therapies are available. Developing an effective management strategy for this disorder will require a comprehensive understanding of past progress and recent advances. This paper presents a brief review of background issues related to acquired middle ear cholesteatoma and deals with practical considerations regarding the history and etymology of the disorder. We also consider issues related to the classification, epidemiology, histopathology, clinical presentation, and complications of acquired cholesteatoma and examine current diagnosis and management strategies in detail.

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

BACKGROUND AND OBJECTIVE

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

Hearing outcomes in patients with cleft lip/palate

Objective : Children with cleft lip and palate or cleft palate only have a high incidence of conductive hearing loss from otitis media with effusion. Studies demonstrating longitudinal results are lacking. This study was undertaken to investigate long-term longitudinal hearing outcomes of children with cleft lip and/or cleft palate and cleft palate only. Design : Retrospective chart review. Setting : Clinical charts of patients born with cleft lip and palate or cleft palate only in 1985 to 1994 who were referred to the cleft team in Bergen, Norway. Study findings include 15 years of follow-up. Participants : The study population consisted of 317 children of whom 159 had nonsyndromic cleft lip and palate and 158 had nonsyndromic cleft palate. Main Outcome Measures : Pure tone average calculated from pure tone audiometry at ages 4, 6, and 15 years. Results : The median pure tone average significantly improved with increasing age. For the cleft lip and palate group, the median pure tone average at ages 4, 6, and 15 years was 16 dB hearing level (HL), 13 dB HL, and 9 dB HL, respectively (P ≤ .001). In the cleft palate group the median pure tone average at ages 4, 6, and 15 years was 15 dB HL, 12 dB HL, and 9 dB HL, respectively (P ≤ .001). There was no significant difference in the hearing levels between the two groups. Patients who had surgical closure of the palate at age 18 months had a significantly better pure tone average outcome at age 15 compared with patients who had surgery at 12 months. Conclusions : Hearing improves significantly from childhood to adolescence in patients with cleft lip and palate and cleft palate only.

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

OBJECTIVE

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

The incidence of secretory otitis media in cases of cleft palate

OBJECTIVE

Children with a Cleft Palate (CLP) and with or without cleft lips (non-syndromic) universally present with Secretory Otitis Media (SOM). The purpose of this study was to determine the incidence of secretory otitis media that occurs in patients with cleft palates and to confirm the existence of these manifestations by doing a Basic Audiologic Evaluation (BAE).

MATERIAL AND METHODS

A retrospective study was done on forty four male and female children who were within the 2 to 14 years age range, with non-syndromic cleft palates with or without cleft lips, with the symptoms of SOM. Otoscopy examinations were done in all the cases. X-rays of the mastoids (both sides) were done in all the cases to detect the pneumatization of the mastoid air cell system. The Basic Audiologic Evaluation (BAE) includes an evaluation by tympanometry of the middle ear function and an evaluation by pure tone audiometry to establish the type of hearing loss.

RESULTS

A majority of the patients (47.27%) were in the age group of eight-to-fourteen (8-14) years. The Basic Audiologic Evaluation (BAE) revealed that 77.27% of the children had presented with normal hearing; 13.6% had conductive hearing loss and 2.2% had presented with a mixed hearing loss. We noticed that 68.2% of the children had type A curves; 21.2% of the children had type C tympanometry curves; 7.1% had type B curves and 3.5% had Ad curves. The contralateral acoustic reflex was present in 54.5% of the children and 45.5% did not have this reflex. A majority of the patients (46%) showed sclerotic changes in their mastoid air cell systems in the X-rays of the mastoids.

CONCLUSION

The significantly higher prevalence of SOM in the children with cleft was confirmed by the study. Also, the hearing loss which was associated with SOM was evident and it demonstrated that there was a high prevalence of a mild conductive hearing loss when SOM was present. The cleft palate contributed to the occurrence of the secretory otitis media and it required proper ENT and audiological follow ups.

Pre- and post-palatoplasty Eustachian tube function in infants with cleft palate

OBJECTIVE

One past study conducted in 1986 reported Eustachian tube dilation with swallowing during the forced response test (FRT) in a very high percentage (>80%) of cleft palate patients both before and after palatoplasty. The present study was designed to determine the reproducibility of those results.

METHODS

The FRT was used to evaluate Eustachian tube function in a cohort of cleft palate children before and after palatoplasty. Pre-palatoplasty FRT data were available for 25 ears and post-palatoplasty data were available for 31 ears; 14 ears had paired pre-post palatoplasty test data. The results for the FRT tests were compared between the pre- and post-palatoplasty groups for the cross-sectional data and for the paired subset of ears.

RESULTS

The 3 passive function measures of the FRT, the opening pressure, closing pressure and passive resistance were not different before and after palatoplasty for either data set. Similarly, 2 of the 3 active function measures, active resistance and dilatory efficiency, were not different pre- and post-palatoplasty, but the percent of ears evidencing tubal dilation for the cross-sectional data was 39% and 62% (p=NS) and for the paired subset was 33% and 83% (p=0.04) at the pre- and post-palatoplasty tests.

CONCLUSION

Palatoplasty had no effect on most measures of the FRT, but may have had a positive effect on the ability to dilate the Eustachian tube during swallowing. The high frequency of ears with tubal dilation before palatoplasty reported in the 1986 study was not reproduced but that frequency after palatoplasty was similar.

Postpalatoplasty Eustachian tube function in young children with cleft palate

OBJECTIVE

To characterize Eustachian tube function using the forced response test in young children with cleft palate with or without cleft lip after palatoplasty with tympanostomy tubes inserted prepalatoplasty and compare these results with those of a 1986 study that evaluated a similar population using identical methods.

SETTING

Outpatient research clinic.

PATIENTS/PARTICIPANTS

A total of 34 children with cleft palate were tested at an average age of 18.6 ± 4.0 months. MAIN OUTCOME MEASUREs: Passive and active measures for the forced response test.

RESULTS

Of the sample, 13 ears could not be tested, and tests on 24 ears were incomplete. The forced response test showed that the passive Eustachian tube function parameters were similar to those of normal adults and children. The percentage of ears that showed tubal dilation with swallowing was 60%. The active resistance and dilatory efficiency were similar to those of a normal adult population.

CONCLUSIONS

A 1986 study of Eustachian tube function in postpalatoplasty subjects with cleft palate (37 ears) aged 15 to 26 months documented Eustachian tube dilation with swallowing in 84% of the ears. In the present study, which focused on a similar population, the frequency of tubal dilation was 60%. Nonetheless, both frequencies are significantly greater than the dilation frequency of 27% reported for 56 ears of subjects with cleft palate tested between 3 months and 18 years with tympanostomy tubes inserted for persistent otitis media with effusion. This suggests that dilation during the forced response test may be a prognostic marker for those children with cleft palate who will resolve their ear disease at an early age.

Profile of patients with cleft palate fitted with hearing AIDS

Cleft palates cause alterations in palate and lip structures, and it may also cause hearing loss because of recurrent otitis media. The appropriate treatment is controversial. It may include the prescription of antibiotics and insertion of a ventilation tube, or even otorhinolaryngological and audiological assistance, and hearing rehabilitation, with the use of an individual sound amplifier aid (ISAA).

Aim

To characterize the profile of individuals with cleft palate and hearing loss, users of ISAA are assisted by the center of otorhinolaryngology and speech therapy of a hospital specialized in craniofacial anomalies and hearing impairment. Retrospective Study.

Materials and Methods

Retrospective analysis of 131 charts of patients with corrected cleft palate and hearing loss, fitted with ISAA by the center abovementioned.

Results

The sample (n=131) was characterized by a prevalence of females (53%), unilateral incisive transforaminal cleft (27%), presence of associated anomalies (51%), history of alterations of the middle ear (56%) and surgery intervention (56%).

Conclusion

The general profile of the individuals with cleft palate and hearing loss, fitted with ISAA, was characterized by the predominance of cleft lip and palate, positive history of middle ear alterations, surgery intervention and bilateral sensorineural hearing loss.

Tensor veli palatini preservation, transection, and transection with tensor tenopexy during cleft palate repair and its effects on eustachian tube function

BACKGROUND

During cleft palate repair, levator sling palatoplasty with tensor veli palatini tendon transection significantly improves speech results. However, the procedure may pose a risk to eustachian tube function. This study assesses the impact of three types of palatoplasty techniques on eustachian tube function: no tensor transection, tensor transection alone, and a new addition to the palatoplasty technique, tensor tenopexy.

METHODS

A retrospective review was conducted of all patients undergoing cleft palate repair at two institutions between 1997 and 2001. Three cleft palate repair groups were studied: no tensor transection (n = 64), tensor transection alone (n = 31), and tensor tenopexy (n = 52). The percentages of patients requiring myringotomy tubes at each year of age were compared among the three groups.

RESULTS

By 7 years of age, there was a significantly decreased need for myringotomy tubes in patients who underwent no tensor transection compared with patients who underwent tensor transection alone (38 percent versus 61 percent, respectively; p = 0.05), as well as for patients who underwent tensor tenopexy compared with patients who underwent tensor veli palatini tendon transection (23 percent versus 61 percent, respectively; p < 0.001). Also, by the age of 7, there was a trend toward a decreased need for myringotomy tubes in patients who underwent tensor tenopexy compared with patients who underwent no tensor transection (23 percent versus 38 percent, respectively; p = 0.11).

CONCLUSIONS

No tensor transection and tensor tenopexy significantly decrease the need for myringotomy tubes compared with tensor transection alone. There is a small decrease in the need for myringotomy tubes when comparing tensor tenopexy with no tensor transection.

Repaired Cleft Palate and Ventilation Tubes and Their Associations with Cholesteatoma in Children and Adults

Objective:

To determine the influence of ventilation tubes (VTs) on the formation of cholesteatoma and hearing in operated cleft palate patients with chronic ear problems.

Design:

Retrospective 72-month follow-up of 116 operated cleft palate patients.

Patients and Interventions:

Demographic data, clinical examination, and hearing were evaluated. The patients were divided according to age and type of cleft and subdivided in a subgroup with (VT+) or without ventilation tube (VT−).

Main Outcome Measures:

The effect of ventilation tubes (VT) on the incidence of cholesteatoma formation and degree of hearing loss in operated cleft palate patients with chronic ear problems.

Results:

The overall incidence of cholesteatoma was 15.5% (VT+, 14.0%; VT−, 16.7%; not significant). Bilateral hearing loss of >20 dB remained in 14.0% of the VT+ patients and in 22.7% of the VT− patients (p < .05). Submucous cleft palate (SM CP) adults (n  =  15) developed high rates of cholesteatoma and hearing loss of >20 dB (both 26.7%).

Conclusions:

Tube insertion had no influence on the development of cholesteatoma. Adults with submucous cleft palate especially require periodic otologic evaluation because they have Eustachian tube–related otologic disease and hearing loss at a higher rate than expected.

The high prevalence of otitis media with effusion in children with cleft lip and palate as compared to children without clefts

OBJECTIVES

Children with cleft lip and palate universally present with otitis media with effusion. This prevalence has not been systematically studied. The purpose of the present study was to examine and compare the prevalence of otitis media with effusion, hearing sensitivity, and audiometry method utilised for assessment in children with and without clefts.

METHODS

Two groups of children (children with unilateral cleft lip and palate, N=22, and children without clefts, N=20) were followed prospectively and longitudinally from 1 to 5 years of age. Data were collected at four points (1, 1.5, 3, and 5 years of age). Assessments at each of the four points included: (1) otomicroscopy, (2) tympanometry, and (3) hearing assessment.

RESULTS

Overall the children with unilateral cleft lip and palate demonstrated a significantly higher prevalence of otitis media with effusion (121 ears, 74.7%) than children without clefts (31 ears, 19.4%) (p<0.001). This higher prevalence was also significant at 1, 1.5, 3, and 5 years of age (p<0.001). Of those ears with otitis media with effusion, 83.1% of the ears exhibited a hearing loss (PTA >20 dB), with this loss more prevalent in the cleft group (89.7% UCLP and 70.0% non-cleft). The hearing loss was significantly more pronounced in the cleft (group 35.71 dB HL UCLP and 26.41 dB HL non-cleft group). Children with unilateral cleft lip and palate utilised a lower age-appropriate audiometry testing method than age-matched children with no cleft at 1, 1.5, and 3 years of age.

CONCLUSIONS

Children with unilateral cleft lip and palate present with a significantly higher prevalence of otitis media with effusion than children without cleft. Also, the hearing loss associated with otitis media with effusion is demonstrated in this study. Furthermore, the method of audiometry has been examined and children with unilateral cleft lip and palate had to be assessed with a lower level of method than children without cleft.

Middle ear disease in children with cleft palate: protocols for management

OBJECTIVE

There is wide international variation in the protocols used for middle ear disease management in cleft palate patients. Ventilation tube (grommet) insertion may occur routinely at the time of palatoplasty or selectively on a separate occasion if symptomatic middle ear disease develops. The audiological and otologic outcomes of cleft palate patients were studied in a single institution over a timeframe in which both protocols were utilised.

METHODS

This was a retrospective study of 234 cleft palate patients who underwent palatoplasty from 1990 to 2005 at Middlemore Hospital, Auckland, New Zealand. Data on hearing loss, middle ear disease, and tympanic membrane abnormalities was collected from clinical notes. Audiological data was obtained from pure tone audiogram reports.

RESULTS

Forty-five patients had routine grommets inserted concurrent with palatoplasty and 189 patients were managed conservatively with selective grommet insertion if indicated. Grommets were subsequently required in 79 (41.8%) of these 189 patients. There was no difference in the incidence of persistent conductive hearing loss, but recurrent middle ear disease, tympanic membrane abnormalities, and the total number of grommet insertions were significantly higher in the routine grommet group. Poorer outcomes were noted in patients who had undergone a greater number of grommet insertions.

CONCLUSION

No significant deterioration in audiological outcomes and better otologic outcomes were found in cleft palate patients undergoing selective grommet insertion compared to routine grommet insertion. It is recommended that ventilation tube placement occur in patients selected on the basis of symptomatic infection or significant hearing loss.

The Management of Otitis Media with Early Routine Insertion of Grommets in Children with Cleft Palate—A Systematic Review

Objective:

To determine whether early routine grommet insertion in children with cleft palate has a beneficial effect on hearing and speech and language development compared with conservative management.

Design:

Systematic review of randomized controlled trials, controlled clinical trials, case series, and prospective and historical cohort studies.

Main Outcome Measures:

The main outcome measure was the effect of early routine grommet placement on the degree of conductive hearing loss. Secondary outcome measures included differences in hearing level, possible side effects, speech and language development, and quality of life.

Results:

We identified 368 citations for review. From a review of the titles, 34 potentially relevant papers were selected. Of these, 18 studies met our inclusion criteria, including eight case series, six historical cohort studies, three prospective cohort studies, and one randomized trial. Most studies were either small or of poor quality or both. The results of the studies were contradictory, with some studies suggesting early placement of grommets was beneficial and others reporting there was no benefit.

Conclusions:

There is currently insufficient evidence on which to base the clinical practice of early routine grommet placement in children with cleft palate.

The effect of early insertion of grommets on the development of speech in children with cleft palates

The aim of this study was to find out whether simultaneous primary palatoplasty and myringotomy was advantageous in the management of otitis media with effusion in children with cleft lip and palate and whether this combined operation resulted in improvement in the early development of speech. Assessments of hearing and speech were made in 50 consecutive patients with cleft lip and palate who had the combined operation (the cleft group). The results were compared with those of an age- and sex-matched control group. The incidence of otitis media with effusion in the cleft group was 24%, compared with 14% in the control group. Assessment of speech using the cleft audit protocol for speech showed that 90% of patients with clefts had speech-intelligibility ratings that were either normal or showed only minor defects, compared with 98% of controls. Among patients with clefts, there was no evidence of cleft-type characteristics of speech in 58%.

Long-Term Clinical, Audiologic, and Radiologic Outcomes in Palate Cleft Children Treated with Early Tympanostomy for Otitis Media with Effusion: A Controlled Prospective Study

OBJECTIVES

The role of tympanostomy in the treatment of otitis media with effusion (OME) in children with palate cleft with regard to the otologic and audiologic outcome is controversial. Little is known about the development of the mastoid air cell system (MACS) in these children.

STUDY DESIGN

Controlled, prospective.

METHODS

All children born in the hospital district area of the Central Hospital of Central Finland during the years 1983 to 1993 with palate cleft were reviewed at the age of 6 months. A total of 39 patients were followed up for 6 years after primary tympanostomy. Otologic and audiologic data were collected, and the MACS size was planimetrically measured. The control group consisted of age-matched children without palate cleft suffering from OME and were identically reviewed.

RESULTS

The otologic outcome was similar in the study group, 64.1%, and among the controls, 60.6% were healed. There were no serious otologic complications in the study group. The audiologic outcome was also similar, with a mean pure-tone average (0.5-2 kHz) of 10.5 dB and 10.9 dB for the corresponding groups. The initial size and growth of the MACS did not significantly differ between the groups.

CONCLUSIONS

The prognosis of children with palate cleft treated with early tympanostomy is favorable and does not differ from children without palate cleft. Active treatment ensures normal hearing during the critical years of language, speech, and cognitive development and maintains the development of an aerated mastoid. We believe that early tympanostomy is the treatment of choice of OME in palate cleft children.

Conservative management of otitis media in cleft palate

AIMS

Eustachian tube dysfunction affects nearly all children with cleft palate but its management is controversial. Some units perform routine prophylactic grommet insertion at the time of palate repair, whilst others are more conservative, inserting grommets only when signs and symptoms of otitis media with effusion are present. This study aims to present outcome data from one cleft team practising a conservative approach.

DESIGN

This is a retrospective study in which consecutive palate repairs over 10 years are analysed and compared with previously published data. The spectrum of clefting and severity (LAHSHAL), otological and speech outcomes were recorded. Patients were excluded if incomplete data was available, and if sensorineural deafness or syndromic clefting was present.

RESULTS

Data is presented for 72 of 109 consecutive patients and the 37 excluded patients are discussed. Following a conservative approach to otitis media with effusion, 29% of cases required grommets. The use of grommets seemed to be more common in those with more severe clefting. Despite this, the group receiving grommets had better speech results than those who did not, although this improvement was not statistically significant.

CONCLUSIONS

There is no evidence of poor overall otological outcome in this series. The data demonstrates that those receiving grommets had better results despite more severe clefting.

Incidence and outcome of middle ear disease in cleft lip and/or cleft palate

OBJECTIVE

Otitis media with effusion is known to be very common among children with cleft palate, however, less is known regarding the natural history and outcome in this group. The purpose of the present study was to examine the incidence, natural history, treatment, and outcome of middle ear disease in children with clefts.

METHODS

A questionnaire was sent to the parents of all children registered on the cleft lip and palate database at our institution. The medical records of all respondents were also reviewed. Statistical analysis of the results was performed using Fisher's exact test in contingency tables and binary logistic regression analyses, where appropriate.

RESULTS

397 fully completed questionnaires were returned. Ear disease was much more common in children with cleft palate, or cleft lip and palate, than in children with cleft lip. Among children with cleft palate, ear problems (infections and/or hearing loss) were most prevalent in the 4-6-year-old age group. However, ear problems persisted at a substantial level for many years after this; only after the age of 12 years did problems appear to settle. The incidence of below normal current hearing and of surgery for chronic otitis media was significantly related to history of ear infections (P=0.000 and 0.000, respectively), and to increased number of ventilation tube insertions (P=0.000 and 0.000, respectively).

CONCLUSIONS

Middle ear disease is common in children with cleft palate, and, unlike the case for children without clefts, has a prolonged recovery, and a substantial incidence of late sequelae. The higher incidence of below normal hearing and surgery for chronic otitis media in children undergoing a greater number of ventilation tube insertions, although most likely reflecting an increased underlying severity of otitis media in these children, also underlines the lack of long-term benefits of ventilation tubes in this group.

Audiologic and tympanometric findings in children with cleft lip and palate

OBJECTIVE

To evaluate the otologic and audiologic status of 50 children with repaired cleft lip, cleft palate, or both in Hacettepe University, Ankara, Turkey.

DESIGN

Audiometric and tympanometric evaluation of 100 ears in 50 children were performed. Hearing levels < or = 15 dB and middle ear pressures between -50 to +50 decaPascals were considered to be normal. Results were examined according to cleft type and laterality. The least and most affected frequencies were calculated. A simple evaluation of speech characteristics including nasal resonance, nasal air escape, and errors of articulation was also performed.

RESULTS

Sixty-three of the 100 ears had normal hearing status, whereas 40 had normal middle ear pressures. No evidence was found to suggest that individual cleft type and laterality of the ear had any effect on hearing loss or middle ear disease. Two-thirds of the patients had normal or acceptable degree of language skills.

CONCLUSION

The final hearing status of patients with cleft palate is a result of a combination of surgical correction, developmental factors, and treatment of middle ear disease. Early and aggressive ventilation tube placement is the standard of cleft care in many countries. Our long-term hearing outcome is relatively good in a population not treated with routine insertion of ventilation tubes. The majority of patients also have satisfactory speech. Patients with cleft palate should have close follow-up for middle ear disease, but further research is warranted to determine the aggressive usage of ventilation tubes.

Use of hearing aids in the management of children with cleft palate

OBJECTIVE

The incidence of otitis media with effusion in children with cleft palate is high. There are numerous reports looking at early insertion of ventilation tubes (VT) with associated complications. We believe that this is the first paper that discusses the use of hearing aids (HA) as the first line of management.

METHODS

Children with cleft palate are managed in a special multidisciplinary clinic in our hospital. Detailed records of these children are maintained. We studied the otological management of 70 children with repaired cleft palate.

RESULTS

12 of the 70 (17.1%) had VT inserted, 17 (24.3%) were provided with HA, 14 (20%) had both grommets and HA and 27 (38.6%) had neither. Of the 31 (44.3%) children who had HA, 16 (51.6%) had good compliance with the HA. The hearing, speech and language developments in these children have been good. Twelve of the 70 patients (17.1%) have had one or more otological complications. These were significantly higher in children treated with VT.

CONCLUSION

We have successfully treated 62.9% of our patients with non-surgical intervention, and show a low incidence of long term complications.

The inhibitory effect of topical N-acetylcysteine application on myringosclerosis in perforated rat tympanic membrane

OBJECTIVE

Myringosclerosis often occurs in patients in whom ventilation tube insertion and tympanoplasty procedures are performed. Recent studies have revealed a relationship between the development of myringosclerosis and oxygen-derived free radicals, and some investigations have demonstrated that free radical scavengers prevent the development of myringosclerosis. N-acetylcysteine is a well-known anti-oxidant and anti-inflammatory agent. In this study, we aimed to investigate the preventive effect of N-acetylcysteine on myringosclerosis in myringotomized rat tympanic membranes.

METHODS

Twenty Sprague-Dawley rats were bilaterally myringotomized and divided into four groups. Group 1 received no treatment, group 2 was treated with topical saline solution in Spongostan, group 3 received topical 0.6 mg N-acetylcysteine in Spongostan and group 4 received 1.2 mg N-acetylcysteine in Spongostan daily for 12 days. Tympanic membranes were examined by otomicroscopy on day 12. Then, the membranes were harvested and evaluated histologically by light microscopy.

RESULTS

The tympanic membranes of groups 1 and 2 (saline and non-treated) showed extensive occurrence of myringosclerosis, whereas groups 3 and 4 (treated with N-acetylcysteine) showed lesser occurrence of myringosclerosis in otomicroscopic evaluation (P<0.01). Under light microscopic examination, lamina propria of pars tensa was found thicker in groups 3 and 4 when compared with groups 1 and 2. There was no significant difference between groups 3 and 4 (P: 0.30).

CONCLUSIONS

Topically applied N-acetylcysteine was found to be effective in the prevention of sclerotic lesions in myringotomized rat tympanic membranes.

Parental perceptions of grommet insertion in children with cleft palate

Otitis media with effusion is almost universal in children with cleft palate and can delay speech, language and educational development by causing hearing loss. Grommet insertion at the time of cleft palate repair is common. There is debate about whether the benefits of grommets outweigh the risk of complications. A postal questionnaire was used to investigate parental perceptions of middle-ear ventilation via grommet insertion in children attending the multidisciplinary cleft palate clinic. These children's case notes were reviewed. Many children had speech and language delay, but parents thought this improved after grommet insertion. Overall parents were pleased with the results. This confirms that grommets have an important part to play in the management of children with cleft palate.

Current indications for tympanostomy tubes

Current indications for TT placement are (1) persistent SOM that has not responded to a 6 to 12-week course of medical treatment. This includes full and prophylactic doses of antimicrobials (and corticosteroids, as indicated); (2) recurrent AOM (at least three episodes in 6 months or four episodes in 12 months) that does not respond to, or recurs after, antimicrobial prophylaxis; (3) complications of AOM such as meningitis, facial nerve paralysis, coalescent mastoiditis, or brain abscess; and (4) complications of eustachian tube dysfunction such as tympanic membrane retraction with hearing loss, ossicular erosion, and/or retraction pocket formation. It must be emphasized that TT placement in children does not "cure" the condition that led to the surgical intervention. Rather, the TT maintains aeration of the middle ear until the child grows and his eustachian tube function normalizes. These recommendations for TT placement are to be regarded as guidelines, not as absolute requirements. They must be applied individually to each patient and his/her unique situation. Certain factors may influence timing of TT placement and lead to modification of the guidelines as they apply to each child.

Pathogenesis of tympanosclerosis

In spite of the wealth of information on the clinical, histologic, and pathologic aspects of tympanosclerosis, the pathogenesis of tympanosclerosis is still unclear. In an attempt to understand the pathogenesis, 319 human temporal bones from 196 individuals with otitis media were studied. The extent and nature of tympanosclerosis and the characteristics of the otitis media associated with it were studied. Forty-five temporal bones from 35 individuals with otitis media were found to have tympanosclerosis, giving an incidence of 14.1%. It was seen most commonly in individuals over 40 years of age (86.7%). The male-to-female ratio was 1.6:1. The most common site of occurrence was the tympanic membrane (88.9%). Tympanosclerosis was seen more often in the anterior and posterior inferior quadrants of the tympanic membrane and that, too, in a central position. Tympanosclerosis was seen more commonly in temporal bones with irreversible inflammatory changes, and in this group, late plaques were more commonly seen than early or intermediate plaques. Audiometric charts failed to show any direct relationship between extent of tympanosclerosis and the severity of hearing loss. The only audiometric finding of any consequence was a mixed hearing loss in the presence of middle ear tympanosclerosis.

A conservative approach to the management of otitis media with effusion in cleft palate children

Otitis media with effusion (OME) is almost universal in children born with a cleft palate. Early placement of a ventilation tube to alleviate hearing problems is common. A retrospective study has been carried out to assess whether the practice of tube placement only for definite clinical indications is successful in terms of subsequent hearing levels and speech and language development. This was assessed by a case note review, analysis of speech therapy data and by means of a special follow-up clinic. There was no difference in speech development between those treated with tube insertion for OME and those untreated. Audiological thresholds were worse in the treated group. A similar number in each group required regular speech therapy. More abnormal otological findings were present at follow up in those who had tubes inserted, some of these were directly attributable to the presence of tubes. A conservative management of OME in cleft palate children, with tube insertion for only definite clinical indications, is an appropriate management, and will lead to fewer otological complications of tube insertion.

Alterations in tympanic membrane appearance and middle ear function in 11-year-old children with complete unilateral cleft lip and palate compared with healthy age-matched subjects

Forty-four 11-year-old children born with a complete unilateral cleft lip and palate were examined to determine the frequency and the extent of changes in the tympanic membrane and the middle ear function and compared with 16 healthy children of the same age. The incidence of hearing impairment, abnormal middle ear pressure, retraction of the pars flaccida and abnormal tympanic membrane appearance were 24, 44, 23 and 67% respectively among the patients while the same parameters in the control group were 0, 12.5, 6 and 12%. Previous grommet insertion in the patient group was statistically correlated to both tympanic membrane abnormality and abnormal middle ear pressure but, remarkably, no association was found between grommet insertion and hearing impairment. The poor middle ear function in the children with cleft lip and palate was probably a result of reduced Eustachian tube function.

Serous otitis media and paranasopharyngeal extension of nasopharyngeal carcinoma

Two hundred thirty-two patients with nasopharyngeal carcinoma were evaluated for serous otitis media (SOM) at diagnosis. The diagnosis of SOM required the detection of effusion behind the tympanic membrane in association of air-bone gap of 10 dB or more in pure tone audiogram. These patients were also evaluated by computed tomography for the degree of tumor extension. By stepwise logistic regression analysis, the degree of paranasopharyngeal extension of tumor, erosion of petrous temporal bone, and the obliteration of pharyngeal recess were significantly related to the development of SOM, but sex and age were not. The findings of computed tomography may influence the plan of management for SOM in patients with nasopharyngeal carcinoma at diagnosis.