TITLE: Did we get lost in the Seventies? Adenoidectomy for middle ear
disease in cleft palate children: a systematic review.
ABSTRACT
OBJECTIVES: Cleft palate children have a higher incidence of otitis
media with effusion, more frequent recurrent acute otitis media
episodes, and worse conductive hearing losses than non-cleft children.
Nevertheless, data on adenoidectomy for middle ear disease in this
patient group is scarce, since many feared worsening of velopharyngeal
insufficiency after the procedure. This review aims at filling this
knowledge gap by collecting the available evidence on this subject, to
frame possible further areas of research and interventions.
DESIGN: A PRISMA-compliant systematic review was performed. Multiple
databases were searched with criteria designed to include all studies
focusing on the role of adenoidectomy in treating middle ear disease in
cleft palate children. After duplicate removal, abstract and full-text
selection, and quality assessment, we reviewed eligible articles for
clinical indications and outcomes.
RESULTS: Among 321 unique
citations, 3 studies were deemed eligible (2 case series and a
retrospective cohort study). The outcomes were positive in all three
articles in terms of conductive hearing loss improvement, recurrent
otitis media episodes reduction, and effusive otitis media resolution
(this last result being not statistically significant).
CONCLUSION: Despite promising results, research on adenoidectomy in
treating middle ear disease in the cleft population has stopped in the
mid-Seventies. No data is therefore available on the role of modern
conservative adenoidectomy techniques (endoscopic and/or partial) in
this context. Prospective studies are required to define the role of
adenoidectomy in cleft children, most interestingly in specific
subgroups such as patients requiring re-tympanostomy, given their known
risk of otologic sequelae.
KEY POINTS:
- Cleft palate children have a higher incidence of middle ear disease
compared to the general pediatric population
- Data on adenoidectomy for middle ear disease, diffusely available for
the general pediatric population, is scarce in cleft palate children
- The scientific literature reports only 3 studies on adenoidectomy for
middle ear disease in cleft palate children, all showing good outcomes
- Research on the role of adenoidectomy for middle ear disease in cleft
palate children has not progressed further since the identified
studies, which date back to the Seventies
- No available study on adenoidectomy for middle ear disease in cleft
palate children validated more modern techniques such as partial,
endoscopic and/or power assisted adenoidectomy in this patient group
Keywords: otitis media;
hearing loss; cleft palate; cleft lip; adenoids;
Level of evidence: II
Manuscript
OBJECTIVE
Children born with a nonsyndromic cleft palate, with or without cleft
lip (CP±L), have a higher incidence of otitis media with effusion (OME),
more frequent recurrent acute otitis media (RAOM) episodes, and worse
early age OME-related conductive hearing losses (ORCHL) than non-cleft
children[1–3]. With a wide variability among studies and age
groups, OME in CP±L children has been shown to reach incidences as high
as 90% in the first year and 97% within the first 2 years of
life[4].
There is a consensus among clinicians and studies that early ventilation
tube insertion and early surgical cleft repair allow favorable results
in this population [5]. Nevertheless, the role of repeated grommet
insertion has been shown to correlate (albeit with a possible consistent
selection bias) with a higher prevalence of chronic otitis media [5]
in a population already at a higher incidence of re-tympanostomy when
compared to non-cleft children.[6]
In the general pediatric population suffering from OME and RAOM there is
conspicuous, albeit often low-level, evidence for the role of
adenoidectomy and/or tympanostomy for OME, ORCHL, and RAOM. [7-9]
Most specifically, adenoidectomy has proved beneficial in treating OME
in the pediatric population, while its role in hearing thresholds and
RAOM episodes is less defined. [7] Analogously, the role of
tympanostomy for ORCHL is unclear and limited in time [8], while it
appears moderately beneficial in reducing RAOM episodes [9]. NICE
guidelines for example include adenoidectomy as a treatment option for
OME [10], while the Italian Pediatric Otolaryngology society
guidelines recommend adenoidectomy in carefully selected cases of OME
and RAOM, with adenoiditis or Eustachian tube obstruction [11].
Conversely, data on adenoidectomy for middle ear disease in CP±L
children is scarce at best. Many authors discouraged the use of
adenoidectomy in this population fearing worsening of velopharyngeal
insufficiency [12], though endoscopy- and/or power-assisted modern
techniques of adenoidectomy have proven safe also in this
population[13].
This review aims at filling this knowledge gap by systematically
collecting all the available evidence on the role of adenoidectomy in
CP±L in treating OME, RAOM, and ORCHL, to frame possible areas of
further research and interventions.