International Journal of Medical and Health Sciences

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1 International Journal of Medical and Health Sciences Journal Home Page: ISSN: Original article Assessment of Eustachian tube function before and after cleft palate repair S V Dhanasekaran 1*, Mithun Eldhose Joyce, 2 Govind Krishnan 3, Abilash K C 4, Komathi Raja 5 1 Professor and Head, 2 Senior Resident, 3,4,5 Post Graduates, Department of ENT, VMKVMCH, Salem. ABSTRACT Background: The incidence of hearing loss is higher in children with cleft lip and/or cleft palate. The etiologic basis for middle ear pathology and hearing loss in patients with Cleft palate is considered to be Eustachian tube dysfunction due to functional obstruction. Aim: To assess the Eustachian tube function before and after cleft palate repair. Methodology: A longitudinal study was conducted in the department of Otorhinolaryngology, at Kirupananda Variyar Medical College during the period of October 2012 to October A total of 50 patients with cleft palate were examined. Tympanometric analysis was done to study subjects before and after cleft palate repair. The patients underwent for cleft palate repair. The parametric variables measured before and after palatoplasty were analysed using paired t test and for all non parametric variables Man-Whitney U test was applied for analysis. Results: The compliance of middle ear, middle ear pressure and middle ear reflex showed a statistic ally significant improvement in both the ears after the surgical correction for cleft palate. After the cleft palate repair the tympanogram showed that the type A graph among the patients were increased and type B and C graph were decreased and this difference was found to be statistically significant (p<.05). Conclusion: An overall hearing profile for the children with cleft lip and palate should be conducted before 5 years and early intervention is recommended as hearing loss in childhood could affect speech and language development as well as scholastic performance. KEYWORDS: Eustachian tube, cleft palate, tympanometry. INTRODUCTION Cleft lip and palate is one of the most common congenital anomaly. It occurs during the first 12 weeks of gestation. It has a birth prevalence rate ranging from 1/1000 to 2.69/ 1000 amongst different parts of the world1].basic pathophysiology which contributes to deafness in these children is eustachian tube dysfunction leading to impaired middle ear ventilation. The incidence of hearing loss is known to be higher in children with cleft lip and/or cleft palate. There is great concern towards the production of normal speech and the prevention of facial deformity and so considerable attention is paid towards the development of a competent velopharyngeal sphincter and normal facial development in these children. Unfortunately, attention is often not paid to the complication of hearing loss in these children. The occurrence of recurrent acute otitis media or otitis media with effusion has been reported to be higher in children with cleft palate[2,3]. The etiologic basis for middle ear pathology and hearing loss in patients with Cleft palate is considered to be Eustachian tube dysfunction due to functional obstruction, secondary to failure of the palatal muscles to assist in opening the Eustachian tube. Persistence of fluid in the middle ear, with an intact tympanic membrane, for a continuous period of three months or more is categorized as otitis media with effusion (OME)[4]. Certain individuals, such as those with cleft palate, are more likely to develop OME. The association between two has been well documented since Alt described the presence of otorrhoea in a child with cleft palate in 1879[5]. Paradise et al. deduced thatmiddle ear disease probably develops in all cleft palate patients[6]. However, more recent studies have confirmed this figure to be around 90%[7-9]. Furthermore, the retrospetive nature of most of these works introduces reservations on the observations made. Finally, Int J Med Health Sci. Oct 2015,Vol-4;Issue-4 462

2 the definition of hearing impairment in relation to thresholds and frequencies varied so much between studies that any meaningful comparison was impossible[10]. The aim of the study was to assess the Eustachian tube function before and after cleft palate repair. MATERIALS AND METHODS A longitudinal study was conducted in the department of Otorhinolaryngology, at Kirupananda Variyar Medical College during the period of October 2012 to October A total of 50 patients with cleft palate were subjected to detailed clinical examination with regard to patient s age sex and present illness. Patients with sensory neural hearing loss, ottitis media due to infective causes, Chronic suppurative otitis media (CSOM) with tympanic membrane perforation and children with cleft lip alone were excluded from the study. Tympanometric analysis was done to study subjects before and after cleft palate repair. It is an audiological examination used to test the condition of the middle ear and the mobility of the tympanic membrane by creating variations of air pressure in the ear canal. It is an assessment tool used routinely in the measurement of acoustic energy, either by facilitation (admittance) of or opposition (impedance) to the passage of sound energy. This is influenced by the amount of sound energy that is absorbed and reflected by the tympanic membrane (TM). When it is more compliant, the TM absorbs more energy and therefore allows greater admittance of the system. On the other hand, the more rigid the TM, the more energy will be reflected, creating greater system impedance. Tympanometry is a measure of the variation of the acoustic impedance of the tympanic ossicular system caused by pressure variations introduced into the external auditory canal and indicates the condition of the middle ear (ME). The results are produced in the form of curves in a graph. The classification of these curue are: a) Type A - Suggestive of normal middle ear function b) Type AS - Suggestive of a less compliant middle ear system c) Type Ad - Suggestive of highly compliant middle ear system d) Type B (low and high) low - Suggestive of middle ear dysfunction, high - Suggestive of grommet or perforation e) Type C - Suggestive of Eustachian tube dysfunction The patients underwent Pinto s Modification of Wardill- Kilner two-layer palatoplasty without radical dissection of soft palate musculature for cleft palate repair. All data were entered and analysed in SPSS version 16. For all the parametric variables measured before and after palatoplasty were analysed using paired t test and for all non parametric variables which are measured before and after palatoplasty were analysed by Man-Whitney U test. RESULTS The age and sex wise distribution of the study population. It is seen from the table that majority of the study population were in the age group of 1 3 years and only 2 patients were more than 12 years of age. Males were comparatively more than the females and it was in the ratio of 2:1(Table 1). Table 1: Age and sex wise distribution of the study population Gender Total Age group Male Female 1 3 years 28 (84.8%) 8 (47%) 36 (72%) 4 6 years 2 (6%) 4 (23.5%) 6 (12%) 7 9 years 1 (3%) 3 (17.6%) 4 (8%) years 1 (3%) 1 (5.8%) 2 (4%) >12 years 1 (3%) 1 (5.8%) 2 (4%) Total 33 (100%) 17 (100%) 50 (100%) Among the study population 68.5% (35) of them had cleft palate alone and 31.4%(15) of them had both cleft palate and cleft lip. The compliance of the right middle ear before and after the. The normal compliance is ml. There was a significant improvement in the compliance of the patients after the and this difference was found to be statistically significant (<.005) in both the ears. In the right ear for 32% of patients before and 20% after the compliance was not able to be measured as they had a B type tympanogram and similarly in the left ear it was 37% before and 23% after ( Table 2). Int J Med Health Sci. Oct 2015,Vol-4;Issue-4 463

3 Table 2 : Compliance of the right and left middle ear before and after among the study population Compliance Right ear P value Left ear (ML) (5.7%) 0 7(14.2%) 1(2.8%) (14.2%) 10(20%) 6(11.4%) 14(28.5%) (11.4%) 4(8.5%) 5(8.5%) 4(8.5%) (8.5%) 7(14.2%) 4(8.5%) 6(11.4%) (14.2%) 7(14.2%) 4(8.5%) 3(5.7%) (5.7%) 5(8.5%) 4(8.5%) 1(2.8%) >0.7 4(8.5%) 7(14.2%) (2.8%) 9(17.1%) Not able to measure 16 (31.4%) 10 (20%) 19(37.1%) 12(22.8%) P value derived by applying student s paired T test. The tympanogram of the right and left ear before and after. Among the tympanogram Type A is the normal curve and Type B and C are abnormal. It is inferred from the table that after the operation the type A graph among the patients were increased and type B and C graph were decreased and this difference was found to be statistically significant (p<.05) (Table 3). The middle ear pressure of the right and left ear before and after operation. The normal P value middle ear pressure value ranges between +50 to It is inferred from the table that there was a statistical significant (p<.005) improvement in the middle ear pressure before and after operation in both the ears (Table 4). The middle ear reflex of the right and left ear before and after operation. A statistical significant (p<.005) improvement was seen after cleft palate repair in the middle ear reflex of both the ears (Table 5). Table 3 : Tympanogram of the right and left ear before and after among the study population Tympanogram Right ear P Value Left ear P value A type graph 14(28.5%) 27(54.2%) (25.7%) 29(57.1%) B type graph 16(31.4%) 10(20%) 19(37.1%) 11(22.8%) C type graph 20(40%) 13(25.7%) 18(37.1%) 10(20%) P value derived by applying Mann-whitney U test Table 4 : Middle ear pressure of the right and left ear before and after among the study population Middle ear Right ear P value Left ear pressure P value (5.7%) 4(8.5%) 3(5.7%) 4(8.5%) (2.8%) (2.8%) (22.8%) 14(28.5%) 9(17.1%) 13(25.7%) (5.7%) 13(25.7%) 6(11.4%) 11(22.8%) (11.4%) 4(8.5%) 3(5.7%) 6(11.4%) (8.5%) 3(5.7%) 4(8.5%) 3(5.7%) > (11.4%) 2(2.8%) 6(11.4%) 2(2.8%) Not able to measure 15(31.4%) 10(20%) 18(37.1%) 11(22.8%) P value derived by applying student s paired T test. Int J Med Health Sci. Oct 2015,Vol-4;Issue

4 Table 5 : Middle ear reflexes of the right and left ear before and after among the study population Middle ear Right ear P Value Left ear P value reflex Before After Before After Present 10 (20%) 26 (51.4%) 11 (22.8%) 28 (57.1%) Absent 40 (80%) 24 (48.5%) (77.1%) 22 (42.8%) P value derived by applying Mann-whitney U test DISCUSSION Cleft lip and palate are variations of a type of congenital deformity caused by abnormal facial development during gestation. Cleft palate is a condition in which two plates of skull that forms the hard palate (roof of mouth) are not completely formed. Cleft palate can occur as complete (hard palate and soft palate) or incomplete (a hole in the roof of mouth). The basic defect is failure of fusion of the lateral palatine processes, the nasal septum and/or the median palatine processes. The review of literature showed a prevalence of otitis media with effusion in 84.8% cases of cleft palate[11].holborow suggested that the tensor palatine muscle is ineffective in its role of opening the nasopharyngeal end of the Eustachian tube. This results in inadequate ventilation of the middle ear and otitis media with effusion results[12]. Roentgenographic study conducted by Bluestone et al[13], supported this hypothesis. Shprintzen conducted fiber-optic nasopharyngoscopy in patients of cleft palate[14]. He suggested hypoplasia of cartilage at pharyngeal end of eustachian tube, small size of opening, and inability to maintain patency during deglutition as the causes of eustachian tube dysfunction. In the present study the tympanogram results showed an increase of B type and C type graphs pre-operatively indicating a diagnosis of Otitis media in the majority of cases and postoperatively majority of the patients had type A curve and our results are almost in par with study done by Paradise J L et al[7], in which he found 80 (72.72%) cases having B type curve and 12 (10.91%) cases having C type curve as compared to 18 (16.36%) cases having A type curve, and similar type of results were also found by studies done by RS Dhillon,[15] Timmermans etal[16] and Grobellar etal[17] where they inferred a statistically significant improvement in the tympanogram postoperatively. The compliance of middle ear in the present study was significantly improved after the correction of the cleft palate and the similar type of results are also seen in the study done by Paradise J L etal[7] and Mann EA etal[18]. In our study the middle ear reflex which was absent before the cleft palate repair had significantly improved after the cleft palate surgey. The lack of suitable anchorage for the muscle being cited as the anatomical fault thereby resulting in inadequate ventilation of the middle ear and Otitis media with effusion results. Palatoplasty provides suitable and effective anchorage for tensor veli palitini and overcome the inferior stunting of the levator veli palitini. This hypothesis has been supported by the study of Bluestone C D[19]. Few authors had reported higher incidence of recovery of Eustachian tube function following cleft palate repair[20,21]. CONCLUSION In our study the middle ear functions of the patients were improved after the cleft palate repair. An overall hearing profile for the children with cleft lip and palate should be conducted as early as possible. Early intervention for middle ear effusion is recommended as, hearing loss in childhood could affect speech and language development as well as scholastic performance. Palatoplasty definitely has a role to play in the middle ear function according to our study REFERENCES 1. Mc leod NM, Urioste ML, Saeed NR. Birth prevalence of cleft lip and palate in Sucre, Bolivia. Cleft palate Craniofac J 2004;41: Mossey P, Little J. Addressing the challenges of cleft lip and palate research in India. Indian J Plast Surg. 2009;42(suppl): IPDTOC Working Group. Prevalence at birth of cleft lip with or without cleft palate: data from the International Perinatal Database of Typical Oral Clefts (IPDTOC). Cleft Palate Craniofac J Jan;48(1): Bluestone CD, Wittel RA, Paradise JL.Roentgenographic evaluation of Eustachian tube function in infants with cleft and normal palates. Cleft Palate J. 1972;9: R. Clarke and P.Bull, Eds., Diseases of the Ear, Nose and ThroatIn: P Bull editor.middle ear diseases. 10th edition. UK, Blackwell, Oxford;2007.pp A. A. Maheshwar, M. A. P. Milling, M. Kumar, M. I. Clayton, and A. Thomas,Use of hearing aids in the management of children with cleft palate International Journal of Pediatric Otorhinolaryngology.2002;6: J. L. Paradise, C. D. Bluestone, and H. Felder, The universality of otitis media in 50 infants with cleft palate, Pediatrics. 1969;44: H. R. Grant, R. E. Quiney, D. M. Mercer, and S. Lodge, Cleft palate and glue ear, Archives of Disease in Childhood.1988;63: Int J Med Health Sci. Oct 2015,Vol-4;Issue-4 465

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