Morphology of the Auditory Tube and Palatal Muscles in a Case of Bilateral Cleft Palate

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.

Three-dimensional Anatomy of the Velopharyngeal Muscles in the Cleft Palate

OBJECTIVE

We have used micro-computed tomography (CT) to elucidate the relationship between the muscle fibers in specimens with cleft palate. These findings could be useful for muscle reconstruction in cleft palate repair and to better understand cleft palate speech.

DESIGN

Cadaveric anatomical study.

PARTICIPANTS

This study included three specimens with cleft palate.

INTERVENTION

The specimens were stained with phosphomolybdic acid and scanned by Micro-CT.

MAIN OUTCOME MEASURE(S)

The anatomy of the muscles.

RESULTS

Using 2D projection images and 3D reconstruction models, subtle anatomical structures could be observed in the muscles. The attachment of the levator veli palatini (LVP) was not at the posterior edge of the hard palate or palatine aponeurosis (PA), but at the anterior 21.71-44.2% of the cleft edge. The palatopharyngeal (PP) was composed of two bundles: inferior and superior heads, which clasped the LVP. The uvularis was unevenly distributed, and located on both sides of the cleft edge, originating at the edge. The palatoglossus, superior constrictor of pharynx and anatomical structure around the pterygoid hamulus, were normal. The PA, PP and LVP were attached to the cleft edge from front to back, in that order. The position of the uvularis was not fixed.

CONCLUSIONS

With the help of Micro-CT technology, detailed anatomical features and the relationship between muscles could be visualized. In the specimen with cleft palate, muscles in the soft palate were associated with the pharyngeal muscles, which formed the 3D "velopharyngeal muscles complex." These findings provide anatomical evidence for muscle reconstruction in cleft palate repair.

Maloclusões e disfunção da tuba auditiva em crianças: uma revisão integrativa

RESUMO Esta revisão integrativa da literatura objetivou analisar as evidências científicas disponíveis sobre a relação entre as maloclusões e a disfunção da tuba auditiva. Através dos descritores "malocclusion","eustachian tube", "otitis media", fez-se uma busca na Biblioteca Virtual em Saúde / Bireme, incluindo artigos publicados em inglês, português e espanhol, sem limite de data de publicação. Os artigos repetidos nas bases de dados, relatos de caso e os que não se apresentaram em formato de artigo científico, tais como resenhas, teses, editoriais, dissertações e cartas foram excluídos. Após análise foram selecionados 09 artigos que preenchiam os critérios de inclusão estabelecidos, sendo que a maioria foi conduzido no continente Europeu e apenas um estudo foi realizado no Brasil. Foi possível verificar uma escassez de artigos sobre a relação entre as maloclusões e a disfunção da tuba auditiva. Não houve um consenso entre os estudos disponíveis sobre a relação entre as desordens da orelha média e as maloclusões, no entanto os estudos de intervenção mostraram que a expansão rápida da maxila tem efeito positivo no funcionamento da tuba auditiva. Em meio a escassez de artigos, verifica-se a necessidade de mais estudos sobre essa temática para que a Odontologia e a Fonoaudiologia, juntamente com as demais áreas da saúde, possam contribuir na escolha de tratamentos que possibilitem uma melhora na qualidade de vida desta população.

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

Objective

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

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

Materials and methods

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

Results

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

Conclusion

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

Clinical relevance

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

ABR thresholds in infants born with CLP and OME and infants with OME

OBJECTIVES

The aim of this study was to investigate and compare auditory brainstem response (ABR) thresholds related to otitis media with effusion (OME) in infants with and without cleft palate and/or lip (CP±L).

METHODS

Forty-seven infants with CP±L and 67 infants with OME participated in the study. Hearing thresholds of ears of infants with OME were compared between groups and within the group with CP±L.

RESULTS

Infants with CP±L and OME presented with similar hearing thresholds as infants with OME and not CP±L. Within the cleft group, infants with isolated cleft palate and OME demonstrated significantly higher hearing thresholds than infants with unilateral cleft lip and palate and OME.

CONCLUSION

A high prevalence of infants with CP±L present with OME early in life. Hearing thresholds of these infants are similar to infants without CP±L, but with OME. The ear status and hearing thresholds of infants with CP±L needs to be monitored to be able to provide the best access to hearing in order to fully allow speech and language development.

Can peripheral hearing justify the speech disorders in children with operated cleft palate?

Introduction Any impairment in the hearing ability of a child with cleft lip and palate may cause difficulties in receptive and expressive language. Purpose Check the association between velopharyngeal dysfunction (VPD), compensatory articulation (CA), and peripheral hearing loss in children with cleft palate surgery. Methods Retrospective study with 60 children (group 1: presence of VPD and CA; group 2: absence of VPD, presence of CA; group 3: presence of VDP, absence of CA; group 4: absence of VPD and CA), age 4 to 5 years old, with cleft palate surgery, through the analysis of the hearing, VP, and speech evaluations. Results Group 4 presented 80% normal hearing; group 1 had 60% hearing loss. The conductive hearing loss type was the most frequent. The glottal stop was the most frequent in group 1 and the middorsum palatal plosive in group 2. There was no significant association (p = 0.05) between hearing loss and the presence of compensatory articulations (groups 2 and 4), nor between hearing loss and the presence of VPD (groups 3 and 4; p = 0.12). Statistical significance (p = 0.025) was found when the group with VPD was associated with the group with CA, that is, group 1 with the control group (group 4). Conclusion Significant association between peripheral hearing loss, compensatory articulations, and VPD was verified for the children in group 1, which not only presented compensatory articulations but also VPD.

A longitudinal study of hearing and middle ear status of individuals with cleft palate with and without additional malformations/syndromes

Objective : To describe and compare the middle ear status and hearing sensitivity in adolescence with isolated cleft palate plus additional malformations and/or syndromes with those with only an isolated cleft palate. Design : Retrospective and longitudinal. Two groups of individuals with isolated cleft palate were compared. Participants : A cohort of individuals born over 4 years in the western region of Sweden. The cohort was divided into one group with isolated cleft palate (n = 31; ICP) and one group with isolated cleft palate plus additional malformations and/or syndromes (n = 37; ICP+). Methods : Middle ear status and hearing thresholds were collected from the medical records at 7, 10, 13, and 16 years of age, examined, and compared within and between groups over time. Results : The ICP+ group demonstrated a significantly higher prevalence of abnormal middle ear status and elevated hearing thresholds as compared with the ICP group. As the individuals aged, the prevalence of abnormal middle ear status decreased. The hearing levels in both groups decreased in the low to middle frequencies as individuals aged; however, the hearing in the high frequencies did not. Conclusions : Individuals with cleft palate need to be followed routinely for middle ear status and hearing thresholds to ensure optimal audiological rehabilitation, with particular attention to those with additional malformations and/or syndromes.

A relação entre disfunção temporomandibular e disfunção tubária em pacientes com fissura palatina

OBJETIVO: investigar, em indivíduos com fissura palatina, a existência de disfunções temporomandibulares, tendo como fator predisponente a disfunção tubária. MÉTODO: foram avaliados 10 indivíduos (20 articulações temporomandibulares), operados de fissura de palato, que estavam em tratamento no Centro Clínico de Fonoaudiologia da PUC Minas, com idade variando entre 8 e 18 anos, de ambos os sexos, e que apresentavam história de otite média na primeira infância. Esses foram submetidos à meatoscopia, imitanciometria, pesquisa da função tubária, exame de palpação da musculatura orofacial e exames de imagem (radiografias transcraniana em seis posições e Ap de Town). RESULTADOS: foi observado que a maioria da amostra apresentava disfunção da tuba auditiva, correspondendo a 80% do total. Em relação à articulação temporomandibular nove indivíduos (90%) não apresentaram disfunção, em apenas um indivíduo (10%) foi verificado presença de desordem temporomandibular. CONCLUSÃO: ao analisar a relação entre a disfunção tubária e disfunção temporomandibular, não foram observados resultados significantes de acordo com o Teste Exato de Fisher, evidenciando que a articulação temporomandibular dos fissurados de palato, não sofre alterações provenientes do funcionamento ineficiente da tuba auditiva.

Auditory complaints and audiologic assessment in children with surgically repaired cleft lip and palate

Introduction: At the initial consultation, the speech–language pathologist and audiologist may consider possible diagnostic hypotheses based on the child's history and the parents' complaint.

Aim: To investigate the association of hearing complaints with the findings obtained in the conventional audiologic assessment in children with cleft lip and palate. Retrospective study.

Methods: We analyzed medical charts of 1000 patients with cleft lip and palate who underwent surgical repair between 1988 and 1995 at a mean age of 6 years 8 months. We excluded charts with records of inconsistent audiological responses and charts with missing data for any of the audiologic evaluations considered. Thus, the sample consisted of 393 records.

Results: Two hundred thirty-nine patients presented hearing loss in one or both ears, but only 3.8% reported hearing complaints. The most frequent were otorrhea followed by otalgia. There was no statistical significance between the complaint and gender (p = 0.26) nor between the complaint and hearing loss (p = 0.83).

Conclusion: This study showed no association between the hearing complaint and the conventional audiologic assessment.

Morphology of the levator veli palatini muscle using magnetic resonance imaging

Background : No studies have reported the circumference and diameter of the levator veli palatini muscle at multiple points along its length and from both views (frontal and lateral). The purpose of this study was to provide quantitative data regarding the levator muscle morphology along the length of the muscle using magnetic resonance imaging and advanced three-dimensional computer technology. Methods : Ten Caucasian male subjects participated in the study. Subjects were scanned using a Siemens 3 T Trio. Levator muscle measures were obtained using a two-dimensional image plane. A three-dimensional model was used to measure the circumference and muscle diameter (in two directions) at six points along the length of the levator muscle. Results : Levator muscle length ranged from 41.67 mm to 52.85 mm across all subjects. Mean extravelar muscle length was 30.55 mm (SD, 2.8 mm) and 30.01 mm (SD, 2.9 mm) for right and left muscles. The mean circumference at the origin was 18.90 mm (SD, 2.6 mm). At the second point, the muscle circumference mean increased slightly (mean, 22.40 mm; SD, 4.9 mm). The means for the remainder of the measures (points 3, 4, 5, and 6) were consistent, showing little to no change. Conclusion : Circumference and diameter values were similar to those reported in previous literature. The muscle did diverge at the point where the muscle bundle entered the velum, as it has been previously described. Instead, the muscle diverges near the midline insertion becoming sparser (smaller superior-to-inferior diameter).

Application of the International Classification of Functioning, Disability, and Health–Children and Youth Version (ICF-CY) to Cleft Lip and Palate

Objective

In recent health policy discussions, the World Health Organization has urged member states to implement the International Classification of Functioning, Disability, and Health: Children and Youth Version in their clinical practice and research. The purpose of this study was to identify codes from the International Classification of Functioning, Disability, and Health: Children and Youth Version relevant for use among children with cleft lip and/or palate, thereby highlighting the potential value of these codes for interprofessional cleft palate-craniofacial teams.

Design

The scope of recent published research in the area of cleft lip and/or palate was reviewed and compared with meaningful terms identified from the International Classification of Functioning, Disability, and Health: Children and Youth Version. In a five-step procedure, a consensus-based list of terms was developed that was linked separately to International Classification of Functioning, Disability, and Health: Children and Youth Version categories and codes. This provided a first draft of a core set for use in the cleft lip and/or palate field.

Conclusions

Adopting International Classification of Functioning, Disability, and Health: Children and Youth Version domains in cleft lip and/or palate may aid experts in identifying appropriate starting points for assessment, counseling, and therapy. When used as a clinical tool, it encourages health care professionals to go beyond treatment and outcome perspectives that are focused solely on the child and to include the children's environment and their familial/societal context. In order to establish improved, evidence-based interdisciplinary treatments for children with cleft lip and/or palate, more studies are needed that seek to identify all the influencing conditions of activities, children's participation, and barriers/facilitators in their environments.

Avaliação audiológica pré-cirurgia otológica de indivíduos com fissura labiopalatina operada

OBJETIVO: descrever as características audiológicas de indivíduos com fissura labiopalatina operada (FLP) e indicação de cirurgia otológica, comparando os grupos quanto ao tipo e grau da perda auditiva, bem como a curva timpanométrica. MÉTODOS: análise de 150 prontuários, ambos os gêneros, idade igual ou superior a 4 anos, FLP e indicação de cirurgia otológica, divididos em 3 grupos: I - Tubo de ventilação (TV), II - Timpanoplastia e III - Timpanomastoidectomia, analisando aspectos quanto a entrevista audiológica, audiometria tonal limiar e imitanciometria. RESULTADOS: o grupo I apresentou porcentagem maior de cirurgia bilateral (86%), o que não ocorreu nos demais grupos. Na entrevista audiológica, 83% apresentou algum tipo de queixa auditiva, sendo a mais frequente a perda auditiva (64%) com p<0,05 entre os grupos I e II; I e III. O tipo de perda auditiva de maior ocorrência foi condutivo bilateral (56%) seguido de unilateral (35%), com p<0,05 entre os grupos I e II; I e III. A perda de grau leve unilateral foi a de maior ocorrência (41%), seguida de grau leve a moderada bilateral (20%), com p<0,05 entre os três grupos. A curva timpanométrica mais frequente foi a do tipo B bilateral (39%) com p<0,05 entre os três grupos. CONCLUSÃO: a maioria dos indivíduos apresentou algum tipo de queixa na entrevista audiológica e alterações na audiometria tonal limiar e imitanciometria. A maioria dessas alterações foi compatível com problemas de orelha média, com perda auditiva do tipo condutiva, de grau leve e bilateral, independentemente da indicação cirúrgica.

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.

Séquelles otologiques dans les fentes palatovélaires. Analyse et prise en charge

As early as in 1878, medical teams managing children born with a velopalatine cleft had noted the prevalence of middle-ear pathologies largely related to anatomic and inflammatory Eustachian tube dysfunction. The aim of this study was to describe otologic sequels related to a velopalatine cleft and to suggest an adapted management. These sequels are evolving presentations of chronic serous otitis; they worsen the functional prognosis (hypoacousia) and more rarely the vital prognosis (cerebral or infectious complications of cholesteatoma). We must stress the importance of prevention: during the initial management, by Eustachian tube rehabilitation, and by ENT (Ear, Noseand Throat) follow-up allowing to prevent these sequels and to bring hearing to normal as soon as possible, so as to support cognitive development, language skills, and sociofamilial integration of the children.

Update on eustachian tube dysfunction and the patulous eustachian tube

PURPOSE OF REVIEW

The purpose of this review is to summarize the recent knowledge on eustachian tube dysfunction and the patulous eustachian tube.

RECENT FINDINGS

A clinically useful test for eustachian tube function is still lacking. Narrowing of the isthmus alone was demonstrated to be an insufficient cause of otitis media. Inflammatory mediators identified within the eustachian tube and middle ear cells were causally linked with otitis media with effusion. Increasing evidence was found that allergic disease and reflux may be two of the most important contributors of tubal inflammation causing otitis media with effusion. The adenoid size and proximity to the torus tubaris may also be important in considering which patients with persistent otitis media with effusion may benefit from adenoidectomy. Computed tomography scan has documented loss of soft tissue within the cartilaginous eustachian tube in patients with patulous eustachian tubes. An endoscopic approach to seal the tubal lumen has been found to be effective in relieving patulous symptoms.

SUMMARY

These studies suggest that allergic rhinitis and gastroesophageal reflux should be investigated in patients with eustachian tube dysfunction. Adenoidectomy should also be considered in patients who have adenoids that obstruct the torus tubaris. Patients with a patulous eustachian tube may benefit from an endoscopic closure. Further research is needed to identify a clinically useful test for eustachian tube dysfunction.