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International Journal of Otolaryngology

Volume 2012, Article ID 548698, 6 pages
doi:10.1155/2012/548698

Review Article
A Review of Hearing Loss in Cleft Palate Patients

Bilal Gani,1, 2 A. J. Kinshuck,2 and R. Sharma2

1 University of Liverpool, Cedar House, Ashton Street, Liverpool L69 3GE, UK
2 Department of Otolaryngology, Alder Hey Children’s NHS Foundation Trust, Eaton Road, West Derby, Liverpool L12 2AP, UK

Correspondence should be addressed to Bilal Gani, [email protected]

Received 14 September 2011; Accepted 24 November 2011

Academic Editor: Per Cayé-Thomasen

Copyright © 2012 Bilal Gani et al. This is an open access article distributed under the Creative Commons Attribution License,
which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.

Background. Cleft palate is associated with recurrent otitis media with effusion and hearing loss. This study analysed the way these
patients’ hearing is managed in Alder Hey Children’s Hospital. Method. A retrospective audit was carried out on cleft palate patients
in Alder Hey Children’s Hospital. Audiology assessment and treatment options were reviewed. Comparisons were made between
the use of ventilation tubes (VTs) and hearing aids (HAs). The types of cleft, types of hearing loss, and the management output
of the audiology regions were also reviewed. Results. The audiology assessments of 254 patients were examined. The incidence of
VT insertion in this group of patients was 18.9%. The hearing aid incidence rate was 10.1%. The VT-related complication rate was
25.5% and the HA related complication rate was 9.1%. Conclusion. The data demonstrates that both treatments are viable, and a
new protocol which combines the short term benefit of VT insertion with the lower complication rate of HA is required.

1. Introduction prevent the sequelae of OME including cholesteatoma for-

mation, retraction pockets, ossicular fixation, and atelectasis
Persistence of fluid in the middle ear, with an intact tympanic [8]. Studies have confirmed that early intervention with VTs
membrane, for a continuous period of three months or does provide an appreciable benefit with regards to short-
more is categorized as otitis media with effusion (OME) [1]. term hearing, between 6–12 months [9–11]. This regimen
When the fluid persists, treatment may be required to re- usually requires VTs to be inserted in the first year of life, at
duce the impact of the conductive deafness, which can have the same time as cleft palate surgery to reduce further oper-
consequences regarding the child’s language, educational and
ations [9]. However, currently the use of prophylactic VTs
social development.
is being heavily scrutinised due to the associated complica-
Certain individuals, such as those with cleft palate, are
tions; perforations, otorrhea, eardrum atrophy, vgranulation
more likely to develop OME. The association between two
tissue, and tympanosclerosis (which have been reported to be
has been well documented since Alt described the presence
as high as 80% [8]). Other studies have revealed that children
of otorrhoea in a child with cleft palate in 1879 [2]. Paradise
et al. deduced that middle ear disease probably develops in all who undergo multiple VT insertions increase their risk of
cleft palate patients [3]. However, more recent studies have conductive hearing loss in the long term [12].
confirmed this figure to be around 90% [4–6]. Maw et al. showed that 50% of OME resolves spontane-
Initially, repair of the cleft palate does slightly improve ously within 3 months and that 90% of middle ear effu-
the ventilatory function of the eustachian tube. However, sions occurring following acute suppurative otitis media
only after the adolescent growth phase, which also improves resolve spontaneously [13, 14]. In view of this and the VT
tubal function, does the incidence of OME greatly decrease complication rate, a more conservative approach to treat-
[7]. ment has ensued. Hearing aids (HAs) are now offered as
The high incidence of OME in cleft palate patients led to an alternative to VTs, and insertion of VTs should only be
the conclusion that prophylactic treatment with ventilation considered in light of careful otological and audiological
tubes (VTs) would solve the inevitable hearing loss and assessment [15].
2 International Journal of Otolaryngology

At Baby diagnosed
birth with cleft palate

Newborn hearing
screening programme

Clear responses Unclear responses

By 3 months Diagnostic auditory brainstem response

of age (ABR)

Tertiary audiology
clinic: guidelines
explained and
information issued to
parents

Normal ABR ABR 50 dBnHL or greater

Fitting of hearing
aids (HAs).
Ongoing regular
By 7 months Behavioural test review in tertiary
Discussing rehearing aids
clinic

Review 3/12. If
Free-field hearing mild or persistent hearing loss
Free field normal +/− OME
moderate + Otitis media with and OME discussion
effusion (OME). Explanation and with parents renatural
amplification, HAs, or
advice remanagement
insertion of ventilation
tubes (VTs)

From 7 6/12 review to 5 years then

months
onwards annual review

HA VT

Ongoing review in tertiary Refer to ENT

clinic

Ongoing review
in tertiary clinic

Figure 1: Audiological care pathway for children with cleft palate in the mersey region.

The audiological assessment for cleft palate patients is (i) Distribution of cleft types.
continuous until the patient is discharged from the care of (ii) The types of syndromes, sequences, and anomalies
the cleft and audiology team. It begins with the newborn found in the sample population.
screening programme and regular audiology appointments
follow, so that any hearing loss can be treated responsively. (iii) Complication rates of the treatments.
Even if the result from the tests indicates a clear response, (iv) Types of hearing losses within the sample.
careful prolonged assessment is required (Figure 1).
(v) Whether the audiology centre predisposes to the
treatment outcome (HA/VT).

2. Methods Numerous variables were collected from the available

data source for each patient (the appendix). The data was
The primary outcome of the study was to compare the obtained from both primary sources (medical records) and
hearing before and after the intervention(s) of HAs or VTs. secondary sources such as Meditech and audiology letters.
The secondary outcomes will examine a wide range of This data was captured using a purpose-designed Microsoft
outcomes including: Access database form. Chi-squared and Fisher’s exact test,
International Journal of Otolaryngology 3

used to analyse the nominal data set using SPSS. P values Table 1: Comparing treatment outcomes by way of differences in
≤ 0.05, were considered statistically significant. pre- and post-intervention hearing.
Audiological data was categorised according to the
Difference between preintervention and postintervention
average degree of hearing across the 4 frequencies of 250 Hz,
hearing versus hearing intervention
500 Hz, 1 kHz, and 2 kHz obtained through primary or sec-
Hearing intervention
ondary analysis (the verdict of the audiologist). The categor-
ies for the degree of hearing loss ranged from normal <20 dB HA VT Total
to profound >95 dB (derived from the British Association of Difference between −1 0 2 2
Audiologists). preintervention
0 2 5 7
As a result of the breadth of the data, the dataset encom- and
postintervention 1 8 12 20
passes periods where routine grommet insertion was used 2 2 9 11
hearing
and more recently a selective procedure. In the latter period,
Total 12 28 40
the decision for VT insertion and HAs was made at the dis-
cretion of the audiologist and the ENT surgeon using the
clinical triad of: (i) audiological evidence of hearing loss
>20 dB, (ii) recurrent otitis media with persistent effusion Table 2: Treatments Instituted. VT → HA = ventilation tubes first
± anatomical abnormalities, and (iii) parental preference followed by hearing aids. HA → VT = Hearing aids first followed by
regarding hearing management. ventilation tubes.
For any child to be included in the dataset, they must have Hearing interventions past and present
had a cleft palate and be under the care of the cleft team. Frequency Percent (%)
This excluded several patients with noncleft velopharyngeal
HA 16 25.4
insufficiency and or with cleft lip only. Patients who moved
to outside the catchment area, discharged from the care of VT 39 61.9
the cleft palate team, were deceased, and those who did not VT → HA 6 9.5
have aided hearing levels for HAs were excluded. HA → VT 2 3.2
Institutional ethical approval came from the Alder Hey Total 63 100.0
Hospital audit department.

3. Results 3.2. Secondary Outcomes

A retrospective audit was carried out on 254 consecutive 3.2.1. VT/HA Statistics and Complications. The VT insertion
children; under the care of the cleft palate team at Alder hey rate was 18.9% (41/217), and the HA incidence rate was
Children’s hospital. The patients attended one of 14 audio- 10.1% (22/217). The total number of children who at
logy centres in north west England, North Wales, and the Isle some point had or were still wearing HAs was 38.1%
of Man between the dates of 24/10/2009 to 08/03/2011. (24/63). A similar analysis of VTs yielded 74.6% (47/63). The
overlapping discretion was due to the 6 patients who had VTs
After the exclusion criteria, out of the 254 patients,
first, followed by HA(s) and the 2 patient who had HA(s)
217 patients remained. Of which 63 were placed in the
first, followed by VTs (Table 2).
intervention group (HA(s)/VTs), and 154 were assigned to
A large proportion of patients, 34.9% (22/63), had VTs
the watchful waiting group.
inserted at the same time as cleft surgery.
The length of follow up in the intervention group varied Of the 22.2% (14/63) patients that suffered from a
from patient to patient. This was the time that had elapsed complication 12 having VTs. Considering 47 patients had
between their last pre-intervention audiology data record VTs at the time of the complications, the VT-related
and their latest audiology data. This systematic approach complication rate is 25.5% (12/47). The main complications
yielded an average follow-up time of around 3 years. derived VT insertions were tympanosclerosis (5 patients),
perforation (5 patients), otalgia (2 patients), and retraction
pocket(s) (1 patient). In total, this equates to 13 patients, the
3.1. Primary Outcome. The primary outcome variable of overlapping discrepancy is due to one of the patients having
hearing before and after the intervention was examined both perforation and tympanosclerosis.
for each of the two intervention outcomes (Table 1). Only Similarly the HA related complication rate was 9.1%
40/63 patients were investigated, due to the timing of the (2/22). The only recorded complication was noncompliant
intervention treatment (patients who had just received a new whereby the child would constantly remove the HA device.
intervention had yet to have a postoperative assessment). A chi-square test of the current interventions and the
Even so, this provided a value P = 0.47 indicating that complications would mask those complications that were
in fact there was no significant association between hearing due to previous VTs. When the data was reorganised to
outcome and treatment, and by scrutinising the differences reflect when the complication was detected, a chi-square
between the pre- and post values it can be deduced that both value of P < 0.05 was obtained indicating that the VTs were
improve hearing outcomes. significantly associated with complications recorded.
4 International Journal of Otolaryngology

Table 3: Comparing treatment outcomes by way of differences in Table 6: Associated syndromes, associations and nonrandom
pre- and post intervention hearing. anomalies. PR: Pierre Robin sequence.

Hearing loss type versus hearing intervention Syndrome/sequence/association

Hearing Intervention Frequency Percent (%)
HA VT Total No syndrome 46 73.0
Conductive 17 39 56 PR 8 12.7
Hearing
loss type Sensorineural 2 0 2 Charge 1 1.6
Mixed 3 2 5 Crouzons 1 1.6
Total 22 41 63 Digeorge 1 1.6
Goldenhar 1 1.6
Table 4: Distribution of cleft types in the sample. UCLP: unilateral Kabuki 2 3.2
cleft lip and palate; BCLP: bilateral cleft lip and palate. Orofacial digital 1 1.6
Type of Cleft Frequency Percentage (%) Van der woude 1 1.6
Soft palate 55 25.34 Stickler and PR 1 1.6
Hard palate Total 63 100.0
and soft 61 28.11
palate Table 7: Audiology centres and type of treatment outcomes.
UCLP 61 28.11
Audiology centres versus hearing interventions
BCLP 33 15.21
Hearing intervention
Submucous 7 3.23
HA VT Total
Total 217 100
Alderhey 0 3 3
Preston 13 6 19
Table 5: Distribution of cleft types in the intervention group.
UCLP: unilateral cleft lip and palate; BCLP: bilateral cleft lip and Southport 2 3 5
palate. Chester 0 1 1
Crewe 1 3 4
Type of cleft
Audiology
Frequency Percent (%) Wirral 1 6 7
centres
Soft palate 19 30.2 St Helen 1 8 9
Hard and soft palate 15 23.8 Isle of Man 0 1 1
UCLP 17 27.0 Wrexham 2 5 7
BCLP 11 17.5 Warrington 1 5 6
Submucous cleft 1 1.6 Wigan 1 0 1
Total 63 100.0 Total 22 41 63

3.2.2. Hearing Loss Types. The predominant type of hearing 3.2.4. Syndromes/Sequences and Anomalies. A significant
loss in the intervention group was conductive, which affected proportion of cleft palate patients had associated syndromes,
88.9% (56/63) of patients, whilst 7.9% (5/63) patients in the sequences, and nonrandom associations. Just over a quarter,
study had a mixed hearing loss and a minority of 3.2% (2/63) 27% (17/63), of patients that required interventions had a
had a permanent sensorineural loss predominantly affecting syndrome/sequence/association (Table 6). The Pierre Robin
their hearing. All sensorineural hearing loss patients received sequence was the modal condition accounting for 47% (8/17)
HAs and most conductive hearing loss patients received VTs of the syndromes/sequences/associations.
(Table 3).
3.2.5. Audiology Regions and the Type of Interventions Imple-
3.2.3. Type of Orofacial Clefts. The types of clefts are mented. Since the introduction of the NICE guidelines in
shown for the whole sample of 217 patients (Table 4) and 2008, and with the majority of the patients being treated
the intervention group (Table 5). Both samples reflected a after the introduction of the guideline, it was intriguing to
similar distribution of cleft types with a submucous cleft see whether there were discrepancies between the audiology
being the most rare and unilateral cleft lip and palate, hard regions and the type of treatments implemented. Across
palate only and hard and soft palate being the most populous. the board of 63 patients, there were 11 audiology centres
The type of cleft was compared to the severity of prein- involved (Table 7). After the current type of treatment was
terventional hearing loss. This returned a value of P > 0.05 analysed against the region, a P value of 0.04 was obtained,
indicating that the type of cleft does not significantly affect which suggested that there was a significant link between the
the severity of hearing loss that the patient will experience. two.
International Journal of Otolaryngology 5

Table 8
Variable Explanation
Syndromes/sequences/associations All anomalies associated with orofacial clefts were collected.
For those who received a management intervention, this would be the last available audiological
Preintervention hearing outcome
assessment prior to the intervention.
Postintervention hearing outcome This would be the most recent audiological assessment after the intervention.
This was classified as cleft of soft palate, cleft of hard and soft palate, unilateral cleft lip and palate,
Type of cleft
bilateral cleft lip and palate and cleft lip only.
Complications The complications recorded were those that occurred during or directly after the intervention.
Regions This would be categorised according to one of the 14 centres in the locality.
Type of intervention The expanded data set is HA, VT, HA + VT, HA → VT, VT → HA, and watchful waiting.
Type of hearing loss One of sensorineural, mixed, and conductive.

4. Discussion Approximately 19.0% (12/63) patients who required an

intervention developed visible or symptomatic complica-
This study is comparable with those of Maheshwar et al., tions upon audiological assessment by way of audiograms,
Phua et al., and Shaw et al. [2, 16, 17]. Comparisons with tympanograms, and otoscopy. This is slightly higher but
these studies must be made with caution due to the different comparable to Maheshwar et al. (17.1%), but a lot lower than
clinical protocols and study designs implemented. However, some aforementioned studies [8]. VTs were also found to be
it is universally accepted that children with cleft palate have significantly linked to the complications. However, one has
a high incidence of middle ear disease, around 90%, before to bear in mind that a false negative picture may bias the
the age of 6. Up to 45% of these children will suffer from results for two reasons. Firstly, because of the sample size
recurrent ear infections [18]. used with regards to the intervention group and secondly,
Many studies have concentrated their efforts on one type because of hearing aid complications such as compliance,
of hearing management, namely, ventilation tubes. However, wax build up, or ear infections not being fully documented
a more conservative approach has begun to influence OME as they may have been treated by the General Practitioner
management due to the ability of spontaneous resolution, locally or are not recognised as a possible complication of
and this is reflected with the introduction of hearing aids in the device, leading to a false negative picture.
this study. Similarly with regards to the type of hearing loss and the
The incidence of grommet insertion was 18.9% (41/217). treatment implemented one has to factor in things such as
This is lower than previous studies, for example, Shaw et al. children accepting hearing aids and not pulling them out and
28% and Robertson et al. 26%, but it is comparative to that parents’ not wanting their children to have a visible hearing
of Maheshwar et al. 17.1% [2, 17, 19]. These discrepancies aid. This means that for a conductive or mixed hearing loss
may have arisen due to the outcomes of the different studies HAs or VTs can be used. Although for sensorineural hearing
and the attitudes and clinical protocols of the time. loss, HAs are solely used.
However, 46.8% (22/47) of the cleft palate patients Due to the uncertainty of the optimum treatment
who had or still have VT(s) underwent grommet insertions plan, there are different preferences between the audiology
during a palatal repair or revision. This encompasses a range centres. For example, in this dataset the audiology centre
from 2002–2011 that reflects the earlier view of wanting to in Preston dispenses the highest number of hearing aids
reduce the operative risk together with the present view that when compared to the Wirral and St Helen audiology centres
VTs should only be inserted at the time of cleft palate surgery which preferred VTs. This highlights the lack of uniformity in
if the child has glue ear, not as a prophylaxis. the treatment protocol.
Out of the 47 patients who had or still have VTs, 7 The primary outcome measure of hearing outcome in
patients (14.9%), all born before 2007, required VT reinser- relation to HAs and VTs indicated that there was no signifi-
tions suggesting that the ventilation tubes are in fact inef- cant link between the two variables. According to this study,
fective at preventing reinfection once shed. This study agrees in terms of audiological improvement, both types of treat-
with Merrick et al. (28%) assuming that the figures are ment are on par with each other.
relative to the change in clinical protocols [20].
The HA incidence rate was 10.1% (22/217). Interestingly,
27.2% (6/22) of patients had previous VTs before being man- 5. Conclusion
aged with HAs. This may be linked to the fact that patients
who undergo a greater number of grommet insertions have The results from this study show lower VT complication
a higher number of tympanic membrane deformities [16]. rates when compared to other similar studies. This may
This is illustrated by 28.6% (2/7) patients who underwent be linked to the greater implementation of HAs, which are
repeated grommet insertions, developing perforations of the equal to the VTs in terms of improving audiological out-
tympanic membrane. come. On the whole, HAs are also better tolerated than VTs
6 International Journal of Otolaryngology

by the majority of patients, with noncompliance being the [11] I. J. Moore, G. F. Moore, and A. J. Yonkers, “Otitis media in the
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Appendix cal review of the literature,” Clinical Otolaryngology and Allied
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See Table 8.
[15] National Collaborating Centre for Women’s and Children’s
Health: Surgical Management of Otitis Media with Effusion in
Acknowledgments Children, National Institute for Health and Clinical Excellence
(NICE), London, UK, 2008.
The authors declare that they have no conflict of interests. [16] Y. S. Phua, L. J. Salkeld, and T. M. B. de Chalain, “Middle
They would like to thank the outstanding contribution of the ear disease in children with cleft palate: protocols for manage-
ENT and Cleft Palate teams at Alder Hey Children’s Hospital. ment,” International Journal of Pediatric Otorhinolaryngology,
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