Abstract
Chronic middle ear effusion is generally present in children with cleft palate (CP) associated with or without cleft lips. The aim of our study was to assessment of how common middle ear effusion is in patients with cleft palates and to evaluate the presence of these symptoms by performing a Basic Audiological Evaluation (BAE). A retrospective randomized study was conducted on 50 children (29 male and 21 female) aged 2 to 16 years who had CPs (associated with or without cleft lips) with symptoms of middle ear effusion. The study was conducted from March 2021 to February 2022. Data review included the results of otoscopic findings and BAE. The Fundamentals of BAE comprise the testing of middle ear function with tympanometry and a pure tone audiometry to determine the kind and degree of hearing impairment. Regarding the BAE, we found that 70% of the children with normal hearing, 24% with conductive type of hearing loss, and 6% with mixed type of hearing loss. The tympanometric results revealed that 66% of the children with type A tympanogram, 24% with type C tympanogram, and 10% with type B tympanogram. The contralateral stapedial reflex was present in 60% of the patients while in 40% of cases not present. The results confirmed the great prevalence of chronic middle ear effusion in children with CPs. Furthermore, the hearing impairment associated with middle ear effusion was visible, demonstrating that middle ear effusion was linked with the prevalence of moderate conductive type of hearing loss. The OME in cases of CP necessitates early prediction and in turn early treatment.
Keywords: Effusion, Cleft, Palate
Background
In many communities around the world, the overall incidence rate of cleft palate (CP) is roughly 1:750-1:2000 new-born. In these patients, chronic middle ear effusion is known as a common cause for conductive type of hearing impairment due to reduction of middle ear ventilation through the Eustachian tube [1].
The ventilation of middle ear depends on the activity of the tensor veli-palatini and levator veli-palatini muscles. The main action of these muscles is opening of the Eustachian tube by active contraction [2].
Flynn et al. showed a high prevalence of chronic middle ear effusion in children with CPs at one, one and half, three and five years of age in comparison with children without CP. This explains the high prevalence of chronic middle ear effusion in patients with CP due to abnormal insertion of tensor veli and levator palatini muscles in case of CP, as the palate does not fuse during this time of fetal development. The lateral insertion of theses muscles compromises the proper function for opening of Eustachian tube and the ventilation of middle ear is not properly occur. Improper ventilation of middle ear will lead to occurrence of negative pressure and this in turn leads to retraction of tympanic membrane and increase in the secretory activity of middle ear mucus glands. However, OME can also result from an acute middle ear infection [3].
OME can lead to persistent or recurrent conductive hearing loss of variable severity, affecting one or both ears [4].
Early treatment of chronic middle ear effusion by insertion of ventilation tubes is essential as hearing impairment at early childhood is thought to impair the language development, behaviors, and social relationships; and in turn, this can affect the life quality of these individuals [5].
Aim of the Work
The aim of this work was to evaluate how common chronic middle ear effusion is present in patients with CPs and to validate the presence of middle ear effusion by performing the Basic Audiological assessment (BAE).
Methods
This is a retrospective cohort study included 50 children (29 male and 21 female) aged 2 to 16 years with cleft palate (associated with or without cleft lip). The study was conducted from March 2021 to February 2022. All patients with CPs (associated with or without cleft lip) were included in this work. Patients with cleft lips only were excluded. Complete otorhinolaryngological examination including otoscopy of both ears and BAE were performed in all cases. The BAE involves tympanometry for evaluation of function of middle ear and a pure tone audiometry (PTA) to determine the type and degree of hearing impairment. The children under five years of age were assessed by tympanogram alone, and the patients older than five years were assessed by tympanometry and PTA. PTA is the primary audiological test used to identify threshold values of hearing, thereby allowing to determine type, degree and configuration of hearing impairment. Tympanometry is the test used for examining the function of middle ear, the tympanic membrane mobility and ossicles due to pressure fluctuations in the external auditory canal. The results of Tympanometry should be considered in conjunction with those of PTA.
Results
50 male and female patients with age from 2 to 16 years with cleft palate associated with or without cleft lips, with symptoms of chronic middle ear effusion formed the sample size in our work during one year period for this study.
In the group of 50 children (100%), 29 males (58%) and 21 females (42%), 25 patients (50%) were in the age from 8 to 16 years, 15 patients (30%) were in the age from 5 to 7 years and 10 patients (20%) were in the age from 2 to 4 years (Table 1).
Table 1.
Shows the age groups and male to female percentage
| Age and gender | Number of male patients | Number of female patients | Total number |
Percentage |
|---|---|---|---|---|
| 2–4 y | 6 | 4 | 10 | 20% |
| 5–7 y | 10 | 5 | 15 | 30% |
| 8–16 y | 13 | 12 | 25 | 50% |
| Total | 29 | 21 | 50 | 100% |
In our BAE course, the evaluation showed that 35 of the patients showed normal results (70%), 7 patients (14%) show very mild type of conductive hearing loss, 5 patients (10%) show mild type of hearing loss and 3 patients (6%) show a moderate combined hearing impairment (Table 2).
Table 2.
Shows the BAE results
| Total | Normal results | Very mild Conductive | Mild Conductive | Moderate Combined |
|---|---|---|---|---|
| 50 | 35 | 7 | 5 | 3 |
| 100% | 70% | 14% | 10% | 6% |
The results of tympanometry and stapedial reflex were analysed by every ear (right side and left side), for 100 ears of all number. We found that 66% of ears had type A tympanogram; 24% of the ears with type C tympanogram, and 10% with type B tympanogram (Table 3).
Table 3.
Types of tympanometry
| Total | Type A | Type B | Type C |
|---|---|---|---|
| 100% | 66% | 10% | 24% |
| 50 | 33 | 5 | 12 |
The stapedial reflex (contralateral) was present in 60% of the ears and 40% don’t have that reflex.
Discussion
The aim of this work was to assess the prevalence of chronic middle ear effusion in patients with CPs with the use of BAE. The majority of 25 patients (50%) were in the group age 8–16 years, with a ratio of 13 male (52%) to 12 female (48%). Analysis of statistical results was done to verify the incidence between the age and gender. Chu and Mcpherson [6] reviewed 180 audiograms of children from Chinese with cleft plate and pointed out 13.4% of the patients had conductive type of hearing impairment and about 23.7% of the cases showed changes in tympanogram. The patient’s age, sex, and type of cleft palate were found not to be related to the hearing test results. Also in our work, age and gender show insignificant correlations. In another chart analysis study that was conducted by Goudy et al. [7], for 101 patients with CPs between 8 and 25 years, they found a higher degree of conductive type of hearing loss incident. Of the patients with conductive type of hearing impairment, 75% had a slight hearing impairment, 21% with a moderate hearing loss and only 4% with a severe mixed type of hearing impairment. Our study found that 35 children presented normal hearing results (70%), 7 children (14%) were very mild conductive hearing loss, mild hearing loss in 5 children (10%), and that 3 children (6%) with moderate degree mixed type of hearing loss. In this study, there is no any type of severe hearing impairment. The results regarding the tympanogram and stapedial reflex were analyzed by every ear (right side and left side), 100 in total number of ears. We found that 66% of children with type A tympanogram; 24% of children with type C tympanogram and 10% with type B tympanogram. The stapedial reflex (contralateral) was present in 60% of patients and 40% show no stapedial reflex. If diagnosis is later with no good treatment of middle ear effusion this can cause complications, recurrent attacks of acute otitis media, more hearing loss and this effect on the language and cognitive development of the child [8]. Various research on this were associated with high frequency of Eustachian tube dysfunction in patients with CP and association of middle ear effusion in these patients because of some anatomical or functional problems. Regarding the involvement of hearing in children with CP may have, we emphasize the importance of audiological with follow up examinations. Very important to emphasize that even mild or very mild hearing loss can cause significant impairments for the children in terms of learning, development of language, and school performance. Correct treatments can help prevent the occurrence of hearing loss in children with CPs that can affect oral and mouth development, leading to learning difficulties, school performance and social life.
Conclusion
There is significantly high incidence of middle ear effusion in child patients with CPs that confirmed by our study. According to the results of our work, we conclude that CP was contributed to the occurrence of middle ear effusion. The middle ear effusion was linked with the prevalence of conductive type of hearing impairment. The cases of middle ear effusion with CP necessitate early prediction and in turn early intervention.
Acknowledgements
Not applicable.
List of Abbreviations
- OME
Otitis Media with Effusion
- CP
Cleft palate
- BAE
Basic Audiologic Evaluation
- PTA
Pure Tone Audiometry
Author’s contributions
“MA analyzed and interpreted the patient data. HM and EH performed the cases and share in data collection. AF was a major contributor in writing the manuscript. All authors read and approved the final manuscript.”
Funding
Not applicable.
Data Availability
The datasets generated and/or analysed during the current study are not publicly available due [REASON WHY DATA ARE NOT PUBLIC] but are available from the corresponding author on reasonable request.
Declarations
Ethics approval and consent to participate
An approval of Al-Azhar University, Faculty of medicine ethical committee was obtained before the start of this study. The aim of the study was explained and informed. Consents were taken from all participants included. Privacy of the data was assured.
Consent for Publication
Not applicable.
Competing Interests
The authors declare that they have no competing interests.
Footnotes
Publisher’s Note
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References
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Associated Data
This section collects any data citations, data availability statements, or supplementary materials included in this article.
Data Availability Statement
The datasets generated and/or analysed during the current study are not publicly available due [REASON WHY DATA ARE NOT PUBLIC] but are available from the corresponding author on reasonable request.