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:
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.