Hearing-related problems in children with cleft palate: A single-center cross-sectional study in the sub-Himalayan population

Vishal Mago; Arush Pasricha; Hiteswar Sarma; Praveen A Jayaprakash; Madhubari Vathulya; Debarati Chattopadhyay

doi:10.4103/jclpca.jclpca_12_22

ORIGINAL ARTICLE

Year : 2023 | Volume : 10 | Issue : 1 | Page : 5-8

Hearing-related problems in children with cleft palate: A single-center cross-sectional study in the sub-Himalayan population

Vishal Mago¹, Arush Pasricha¹, Hiteswar Sarma², Praveen A Jayaprakash¹, Madhubari Vathulya¹, Debarati Chattopadhyay¹
¹ Department of Burns and Plastic Surgery, AIIMS, Rishikesh, Uttarakhand, India
² Guwahati Comprehensive Cleft Care Center, Mission Smile, Kolkata, West Bengal, India

Date of Submission	27-May-2022
Date of Acceptance	03-Aug-2022
Date of Web Publication	14-Mar-2023

Correspondence Address:
Dr. Arush Pasricha
720, Hostel 85, AIIMS, Rishikesh - 249 203, Uttarakhand
India

Source of Support: None, Conflict of Interest: None

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DOI: 10.4103/jclpca.jclpca_12_22

Abstract

Purpose: Cleft palate is known to cause recurrent otitis media with hearing loss. Various studies have stated the incidence of middle ear disease in patients with cleft palate is around 90%. The anomalous position of the Eustachian tubes in patients with cleft palate leads to otitis media with effusion. If left uncorrected this leads to complications such as cholesteatoma, retraction pockets, and atelectasis leading to permanent hearing loss. In this study, we evaluated the children presenting to our institute with cleft palate for hearing-related issues. Materials and Methods: The study was conducted in our institute from January 2017 to September 2020. It was a cross-sectional study, where 45 children with cleft palate were compared with 36 children with cleft lip who were considered the control group. Hearing of all children was assessed using tympanometry, otoscopy, and brainstem evoked response audiometry (BERA). Results: About 93.3% of children in the cleft palate group had an abnormal tympanic membrane on otoscopy, whereas in the control group only 11.1% of children had an abnormal tympanic membrane on otoscopy. About 97.8% of children in the cleft palate group had a hearing threshold greater than 25 decibels, whereas only 13.9% of children in the control group had a hearing threshold of above 25 decibels. More children in the cleft palate group had an abnormal tympanogram (42.2% had a type B tympanogram and 46.7% had a type C tympanogram) compared to the control group (5.6% had a type B tympanogram and 2.8% had a type C tympanogram). Conclusion: Our study adds to the evidence that there is a high incidence of hearing impairment in children with cleft palate. Hence, we advocate that early identification by screening measures such as otoscopy, tympanometry, auditory brainstem response, and pure tone audiometry during the first visit itself in these children so that early treatment can be initiated.

Keywords: Cleft lip, cleft palate, hearing impairment

How to cite this article:
Mago V, Pasricha A, Sarma H, Jayaprakash PA, Vathulya M, Chattopadhyay D. Hearing-related problems in children with cleft palate: A single-center cross-sectional study in the sub-Himalayan population. J Cleft Lip Palate Craniofac Anomal 2023;10:5-8

How to cite this URL:
Mago V, Pasricha A, Sarma H, Jayaprakash PA, Vathulya M, Chattopadhyay D. Hearing-related problems in children with cleft palate: A single-center cross-sectional study in the sub-Himalayan population. J Cleft Lip Palate Craniofac Anomal [serial online] 2023 [cited 2023 Jun 5];10:5-8. Available from: https://www.jclpca.org/text.asp?2023/10/1/5/371638

Introduction

Cleft palate is known to cause recurrent otitis media with hearing loss.^[1] Various studies have stated that the incidence of middle ear disease in patients with cleft palate is around 90% with up to 90% of children experiencing at least one episode of otitis media with effusion before reaching the age of 1 year.^[2],[3] The anomalous position of the Eustachian tube ^{More Details}s in patients with cleft palate leads to otitis media with effusion. If left uncorrected this leads to disastrous consequences such as the formation of cholesteatoma, retraction pockets, atelectasis, and ossicular fixation which might cause permanent hearing loss.^[3] Hearing problems add to the difficulties in the development of speech, language, and learning to which children with cleft palate are already prone to. Studies have shown that early intervention with grommets/ventilation tubes in these patients provides appreciable benefit in terms of hearing by effectively treating otitis media with effusion.^[4],[5] However, prophylactic use of grommets/ventilation tubes is known to cause complications like perforation, otorrhea, atrophy of the tympanic membrane, granulation tissue and tympanosclerosis.^[6] Hence, it is important to evaluate these children for otitis media with effusion or its sequelae during the first visit itself so that at-risk patients can be identified and proper intervention can be done as early as possible. In this regard, we conducted a study by screening patients with cleft palate for hearing anomalies.

Materials and Methods

This study was conducted in a tertiary care center in Uttarakhand, India, between March 2017 and September 2020. It was a cross-sectional study approved by the institutional ethics committee. The study was conducted on the sub-Himalayan population which included people residing in the southernmost Himalayan mountains, Shivalik Hills which oversee the Indo-Gangetic planes. All children with primary cleft palate <5 years of age were included in the study. Children with syndromes or with secondary deformities were excluded from the study. At the first visit, the demographic data of the child such as name, age, and sex were documented. History of hearing-related complaints was elicited from parents. ENT consultation was done during the first visit itself and hearing was assessed by otoscopy, tympanometry, and pure tone audiometry (PTA)/BERA (for analysis of hearing thresholds). Children with only cleft lip were considered controls and were evaluated using the same parameters.

Data collected were tabulated and analyzed. Forty-five patients with cleft palate were compared with 36 patients with cleft lip who were considered the control group. Statistical analysis was done using SPSS version 20 (IBM Corp., Armonk, NY, USA). Demographic data such as age and sex were represented as mean ± standard deviation. The Chi-square test was used to compare the hearing parameters in both groups.

Results

There were 45 patients with cleft palate (cases) and 36 patients with cleft lip (controls). The mean age of patients in the cleft palate group was 24.8 ± 17.08 months and the mean age of patients in the control group was 26.5 ± 22.5 months. There were 26 females (57.8%) and 19 males (42.2%) in the cleft palate group, whereas there were 16 females (44.4%) and 20 males (55.6%) in the control group. The difference was not statistically significant (P = 0.233).

The better ear was chosen for all the analyses. More children in the cleft palate group had an abnormal tympanogram (42.2% had a type B tympanogram and 46.7% had a type C tympanogram) compared to the control group (5.6% had a type B tympanogram and 2.8% had a type C tympanogram) [Table 1]. The difference was statistically significant (P < 0.05). Even when compared across different age groups (i.e., 0–12 months, 13–36 months, and 36–60 months) more children had an abnormal tympanogram in the cleft palate group compared to the control groups. The difference was statistically significant (P < 0.05).

Table 1: Comparison of tympanogram patterns of cleft palate cases and controls

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About 93.3% of children in the cleft palate group had an abnormal tympanic membrane on otoscopy, whereas in the control group only 11.1% of children had an abnormal tympanic membrane on otoscopy [Table 2]. The difference was statistically significant (P < 0.05). In all different age group categories, more children in the cleft palate group had an abnormal appearing tympanic membrane in otoscopy compared to children in the control group. The difference was statistically significant (P < 0.05).

Table 2: Appearance of the tympanic membrane in otoscopy of cleft palate cases and controls

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Hearing threshold above 25 decibels was considered abnormal. About 97.8% of children in the cleft palate group had a hearing threshold greater than 25 decibels, whereas only 13.9% of children in the control group had a hearing threshold of above 25 decibels [Table 3]. All the children with increased hearing threshold belonged to the mild-to-moderate hearing loss category according to the WHO classification, and none of the children in either group had severe hearing loss. When compared across different age groups, the children in the cleft palate group had significantly higher hearing thresholds in all age group categories compared to the control groups (P < 0.05). About 4.5% of children in the group <12 months in the cleft palate group had a normal hearing threshold, whereas no child >12 months old had normal hearing in the cleft palate group.

Table 3: Hearing thresholds of cleft palate cases and controls

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Discussion

Cleft palate is a relatively common anomaly with reported incidences of up to 1 in 700 live births.^[7] Although cleft palate is not a major cause of mortality in developed countries, it does lead to considerable morbidity to children who are affected and imposes a considerable financial risk for families. Individuals with cleft palate may experience problems with speech, hearing, feeding, and social integration. These deformities can be corrected to varying degrees by surgical modalities and adjuvant treatment like speech therapy etc., It is an established fact that Eustachian tube dysfunction is the causative factor which leads to middle ear pathology. In these patients, the tensor veli palatini is ineffective in opening the pharyngeal end of the Eustachian tube. This leads to inadequate aeration of the middle ear causing decreased middle ear pressure and middle ear effusion. Studies using fiber optic nasopharyngoscopy in cleft palate patients have demonstrated hypoplastic Eustachian tube cartilage in these patients.^[8]

Studies have reported the incidence rates of middle ear disease of up to 97% of children with cleft palate within the first 24 months of life, with this being a major complication in these children.^[8] Our results resonate with these data with up to 97.8% of children with cleft palate having abnormal hearing thresholds, 88.9% of children having abnormal tympanograms, and up to 93.3% of children having abnormal findings on otoscopy.

There are various methods to assess hearing in children with cleft palate such as tympanometry, PTA, otoscopy, newborn hearing screens, sphenopalatine angle measurements, mastoid air cell system analyses, wideband reflectance, and auditory brainstem response (ABR). Studies have shown that tympanometry and otoscopy have good diagnostic efficacy in detecting hearing anomalies in children with cleft palate.^[9],[10] There are also studies that say impedance audiometry alone has limitations in diagnosing the presence of serous otitis media in this group of patients. We hence used a combination of otoscopy, tympanogram, and ABR for a comprehensive analysis of hearing in all these patients during their first visit.

A good number of parents were unaware of the children having hearing-related problems in our study (56.7%). There is not much data available about parental awareness of hearing loss in children with cleft palate. A study by D'Mello et al. reported that a “majority” of parents were unaware of children having hearing-related issues in a camp for hearing analysis in cleft palate patients.^[11] A recent study by Lucy McAndrew suggested that up to one-third to half of parents of children with cleft palate are unaware of their children having hearing problems. This goes on to add to the fact that parental concern is not always a reliable indicator of children with cleft palate having a hearing impairment. Hence, all children with cleft palate should be assessed for hearing during their initial visit.

There are conflicting reports regarding the effect of palatal repair on hearing outcomes. Certain studies have quoted that the incidence of otitis media with effusion only marginally reduces with cleft palate repair.^[8] On the other hand, there are also studies which have reported that palate repair had worsened the hearing outcomes in patients with cleft palate.^[12] Combining palatoplasty with the early use of grommets reduced the incidence of otitis media with effusion and therefore improved conductive hearing at the crucial period of development of speech.^[13] The results of our study and the evidence in the available literature suggest that middle ear dysfunction and cleft palate coexist. Studies have proven that the repair of cleft palate alone is not sufficient to correct the middle ear pathology. It is, therefore, appropriate to direct our attention toward controlling the otologic sequelae of cleft palate. Since otitis media with effusion and mastoiditis are preponderant types of middle ear anomalies, they should be managed by the traditional approaches. Studies have shown that early intervention by the use of simple techniques such as grommet/ventilation tube insertions can improve hearing in these patients as well as prevent further complications.^[5] They must be placed early (before 3 years) as studies have shown late placements leads to deterioration in prognosis.^[14] Grommet insertion is a relatively simple surgery which can be combined with cleft palate repair in the same sitting.

Proper early diagnosis is necessary to facilitate this. Better coordination between the plastic surgeon and ENT surgeon is required in this regard so that screening for ear pathology can be done during the first visit of the child itself hence facilitating early diagnosis and appropriate management.

Conclusion

Children with cleft palate are already prone to speech abnormalities. The presence of hearing impairment will further affect the development of speech in these children. Our study of screening children with cleft palate for middle ear pathology is the first of its kind in the sub-Himalayan population. Our study adds to the evidence that there is a high incidence of hearing impairment in children with cleft palate. Hence, we advocate that early identification by screening measures such as otoscopy, tympanometry, ABR, and PTA during the first visit itself in these children so that early treatment can be initiated.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.

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