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Case Study Analysis: Master of Clinical Audiology

Craniofacial Foundation University of Santo Tomas


of the Philippines (CFFP)

Case Study Analysis of Population-based Practice:


Audiological Practice for Patients with
Cleft Palate/ Craniofacial Anomalies

In Partial Fulfillment of the Requirements for


Master of Clinical Audiology Program
Assessment Strategies II

Submitted by:
Kathleen Dy, CSP-PASP
Darla Florendo, CSP-PASP
Dennis Gascon, CSP-PASP

November 2019
Case Study Analysis: Master of Clinical Audiology
Craniofacial Foundation University of Santo Tomas
of the Philippines (CFFP)

Acknowledgment

We would like to acknowledge the cooperation of Craniofacial Foundation of the


Philippines (CFFP) for their participation in this case study analysis. We would also
like to acknowledge the following persons for their valuable time in helping us gather
the necessary information for this analysis:

Chino Mandap, CSP-PASP


Erika Encila, UST SLP Intern
Czarina Justiniani, UST SLP Intern

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Case Study Analysis: Master of Clinical Audiology
Craniofacial Foundation University of Santo Tomas
of the Philippines (CFFP)

I. Introduction

Craniofacial anomalies are malformations that affect a child’s cranial and facial
bones (Center for Disease and Prevention, 2018). Typically acquired from birth and
more commonly seen among patients with syndromic conditions, craniofacial anomalies
bring about a multitude of possible concerns for a developing child. An epidemiologic
study conducted in 2003 to 2006 revealed that the most common craniofacial anomaly
in the Philippines was observed to be all forms of orofacial clefts, with an estimated
incidence of 1 in 1136 livebirths (Philippine Oral Cleft Registry, 2006). Considered to be
a local health burden, approximately 4,500 children are estimated to be born every year
with an orofacial cleft in the Philippines (Operation Smile, 2015).

Oral clefts can either be a cleft lip, a cleft palate, or a combination of both. Locally,
a combination type seems to be the most prevalent (WHO, 2006). Children with a cleft
palate will often have concerns feeding, speaking clearly, and are more likely to develop
ear infections that can lead to long-term hearing loss if left untreated (Center for Disease
and Prevention, 2018).

Given this, the Craniofacial Foundation of the Philippines was chosen as a study
site. As this foundation primarily caters to patients with craniofacial anomalies who are
considered to be at high risk for hearing loss, an existing protocol for the prevention,
identification, and management of hearing loss is therefore vital for this population.

Upon analysis of the current program and management of CFFP, there is


currently no hearing management protocol in their program. A hearing management
protocol recommendation was constructed in this study.

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Case Study Analysis: Master of Clinical Audiology
Craniofacial Foundation University of Santo Tomas
of the Philippines (CFFP)

II. Brief Description of Practice

The Craniofacial Foundation of the Philippines is a non-profit and non-


government organization established in 1989. Founded by the first female plastic
surgeon of the Philippines, Dr. Teresita Tongson, a center catering to indigent patients
with craniofacial malformations and other neurodevelopmental conditions was founded.
Currently, it is now under the management of Mrs. Yolanda Abad together with her
husband, Mr. Archie Abad.

Patient Demographics
According to the informants: (1) staff nurse, and (2) the supervising speech-
language pathologist, majority of CFFP’s patients are those with cleft lip and palate,
comprising of about 80% of the patient load. The remaining patients are further
subdivided into neurodevelopmental conditions (10%), other syndromic conditions
such as Down Syndrome (5%) and patients with isolated dental concerns (5%). For
the purpose of this case analysis, focus will be placed on one population alone, and
that is patients with craniofacial anomalies – the primary patients catered by the
center.

The Health Care Team and Health Services


In its initial years, the health care team was comprised of volunteer maxillofacial
surgeons, plastic surgeons, dentists, nurses, pediatricians, and anesthesiologists.
However, with further expansion in the subsequent years, this core interdisciplinary
team has since expanded. Current services and programs include the following:

Provision of Free Surgical Services, After-care and Follow-Up


Particularly for patients requiring reconstructive and maxillofacial operations, free
surgery for indigents in need are provided. Surgeries are done at the center-
based clinic located in Sta. Mesa, Manila under trained oral and maxillo-facial
surgeons and plastic surgeons.

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Case Study Analysis: Master of Clinical Audiology
Craniofacial Foundation University of Santo Tomas
of the Philippines (CFFP)

Assessment and Treatment of Patients with Communicative Disorders


In partnership with the University of Santo Tomas – Speech- Language Pathology
(UST-SLP) Department, CFFP provides means for the provision of assessment
and management of patients with speech and language concerns. Supervised by
a certified speech-language pathologist, two (2) interns are tasked to rotate in the
foundation each month for the continuity of management.

Service delivery
Since the foundation’s inception, CFFP has been closely working with other non-
government organizations such as Smile Train to provide services in far flung
areas in the Philippines. Through these outreach missions, access to the following
health services are made possible:

(1) Medical Missions: Through medical missions, free surgical operations and
dental services are provided. Made possible through the funding of
sponsors and partnerships with affiliated non-government organizations –
equipment, medications and aftercare kits are given to identified patients.

(2) Rehabilitative Services: Through the help of volunteer speech-language


pathologists, Speech Camp programs are organized to help assess and
manage the communicative concerns of patients after surgery. Duration of
speech camp programs typically last for a week, where activities are
prepared specifically for improving articulation. Seminars for parents are
also held within this time frame to carry over the disseminated home
programs for the children.

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Case Study Analysis: Master of Clinical Audiology
Craniofacial Foundation University of Santo Tomas
of the Philippines (CFFP)

Referral System and Current Practice Algorithm


CFFP’s current practice is primarily focused on the surgical and rehabilitative
aspects of care for patients with craniofacial anomalies, and their algorithm can be
divided into 4 phases:

Phase 1: Referral System


Referrals are usually received from tertiary hospitals and other institutions
affiliated with CFFP. These institutions include Our Lady of Lourdes Hospital in
Sta. Mesa, Manila, and the University of Santo Tomas – Speech- Language
Pathology Laboratory located in España, Manila.

Phase 2: Identification/ Initial Assessment


Once a patient arrives at the center-based clinic either through a referral or a
walk-in evaluation, the staff nurse assesses the patients through a screening
process comprised of the following procedures:

Procedure Description
Interview Assessment of indigence certificate, obtaining
basic demographic details and pertinent case
history
Physical Examination Obtaining height and weight of the patient
Visual Inspection Done for patients with craniofacial anomalies –
assessing oral and facial structures; identifying
location and size of cleft
Table 1. List of procedures done during Initial Assessment

Phase 3: Treatment/ Management


Once a patient is identified eligible for services, scheduling of appropriate
evaluations from specialists will be done. Should a patient have dental concerns
to be managed, an in-house evaluation from a volunteer orthodontist will be
scheduled. If the patient was noted have communicative concerns, then a clinic
evaluation from a speech-language pathology intern supervised by a certified

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Case Study Analysis: Master of Clinical Audiology
Craniofacial Foundation University of Santo Tomas
of the Philippines (CFFP)

speech-language pathologist will be arranged. Should the patient be identified


eligible for reconstructive and maxillo-facial surgery, then an evaluation from a
volunteer maxillo-facial or plastic surgeon will take place. Operations are done
within the clinic’s operating room. For patients who live far, lodging within the
center are also available to allow patients more time for recovery.

Phase 4: After-Care, Follow-Up and Discharge


After surgery, counselling and provision of an after-care kits are done by the
volunteer nurses. Counselling is focused on how to properly clean the sutured
areas. After care kits consist of items used for oral hygiene such as cotton swabs,
anti-bacterial oral solution, and a pamphlet for reminders. Follow-up after surgery
typically occurs at 1-2 months. Once the structures have completely stabilized
post-surgery at approximately 3 months, then the patient is immediately referred
for speech and language therapy.

III. Description of Practice Area

CFFP is located in Sta. Mesa, Manila. The foundation is housed in a


building consisting of three floors with the following rooms:

Figure 1. Craniofacial Foundation of the Philippines

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Case Study Analysis: Master of Clinical Audiology
Craniofacial Foundation University of Santo Tomas
of the Philippines (CFFP)

Some rooms on the third floor, when not used by patients, are used by the speech
language pathology student interns as a therapy room.

IV. Analysis of the Practice and Related Activities

Audiological Services
Upon interview, no existing protocols for the provision of audiological services
are currently in place at the foundation. Supported by statements from the center’s head
nurse and supervising speech-language pathologist, the foundation’s primary focus is
on the overall treatment and management of the cases being referred – hence, surgical
and rehabilitative services – with little resources allocated for prevention. Although
efforts in prevention of hearing loss among this population form part of the discussion
by speech-language pathologists during parent seminars, the supervising speech-
language pathologist feels that this may be inadequate, and consistent audiologic
monitoring is essential to ensure normal hearing acuity.

When probed about hearing screening measures, it was reported that an


otoscopy evaluation is done during initial assessment, however, this procedure is done
infrequently. Factors that contribute to this include (1) lack of available otoscope in the
center, and (2) the nurses’ limited knowledge in performing and interpreting otoscopy
results. When volunteering physicians and speech-language pathologists are present in
the center, they will be asked to perform the procedure. Speech-language pathology
interns also routinely perform the Ling-6 sound check during initial assessments,
however, the nurses, caregivers and other health care members are not trained on this
hearing screening measure.

Given the lack of volunteer professionals within this health care area (i.e. ENTs
and Audiologists) and lack of available equipment (i.e. otoscopes, audiometers),
patients who are identified or suspected of having audiological concerns are usually

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Case Study Analysis: Master of Clinical Audiology
Craniofacial Foundation University of Santo Tomas
of the Philippines (CFFP)

referred out to affiliated institutions. Unfortunately, most of patients referred out for
formal audiologic testing are lost to follow up.

Clinical Practice Guideline


There is currently one Clinical Practice Guideline for Audiology with regards to
the addressing and managing audiological concerns among patients with craniofacial
anomalies. This was done by the BC Children’s Hospital which is entitled Audiology
Clinical Practice Guideline: Cleft Palate/Craniofacial and Syndromic Patients last 2012.
This Clinical Practice Guideline was patterned with several studies but was mainly
guided by the practice guideline made by The American Cleft Palate-Craniofacial
Association done last 2009.

Their recommendation is that children in this population are provided with the following
audiological services:

1. Undergo newborn hearing screening


This is done for early detection of hearing impairment upon birth. Infants
who were identified with hearing loss through the newborn hearing screening had
earlier referral, diagnosis and management than those who were not screened
according to a study by Sood and Kaushal in 2009.

2. Infant diagnostic assessment via ABR by 3 months


“ABR provides information concerning the functional integrity of the
brainstem nuclei” (Sharma et.al, 2016). ABR diagnostic assessment provides a
more accurate results in determining the estimated thresholds of the patient at
this age. It is also the gold standard in determining ear and frequency specific of
children under 6 months. According to the BC hospital this is necessary to inform
surgical decisions and identify mild unusual configurations common with this
population (2012).

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Case Study Analysis: Master of Clinical Audiology
Craniofacial Foundation University of Santo Tomas
of the Philippines (CFFP)

3. Management for infants diagnosed with HL


Children who were identified with hearing loss should be already given
audiological management based on the recommendations by ENTs and
Audiologists. It may be in the form of provision of hearing amplification devices.
In a study by Apuzzo and Yoshinaga-Itano (1995), children who were given
intervention and management within the first 2 months of age had significantly
higher language quotients than those who were managed later.

4. Audiological assessment at the 9th month


The audiological assessment for cleft palate patients will be continuous
until the patient is discharged from the care of the cleft and audiology team. It
begins with the newborn screening program and regular audiology appointments
to gather accurate and more reliable behavioral and objective tests, so that any
hearing loss or ear problem detected can be treated responsively. Even those
with unremarkable tests, constant monitoring throughout early childhood is
warranted due to higher risks associated with Cleft palate (Gani, 2012).

5. Cleft palate repair at age 9 - 12 months


Cleft palate usually is repaired through surgery called palatoplasty, usually
when the baby is 9–12 months old. The goals are to close the fistula or opening
between the nose and the mouth; prevent food from leaking out the nose and
create a palate that will work in speech production. (Kellogg, 2019)

6. Post Tube assessment (if with tube intervention)


Compared to healthy children, children with Cleft Lip and/or Palate (CLP)
are more at risk to OME. Thus, necessary assessment is deemed to be significant
in preventing further complications brought about CLP. Previous studies show
that OME occurs at least once before the first birthday in 90% of the infants with
CLP, and almost 97% within the first 2 years of life (Kuo, 2017).

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Case Study Analysis: Master of Clinical Audiology
Craniofacial Foundation University of Santo Tomas
of the Philippines (CFFP)

7. Annual audiological assessment, monitoring, or amplification:

Children who have higher risk in developing middle ear infections are
highly encouraged to have their annual hearing tests for monitoring and prevent
further complications such as hearing loss.

According to the Audiology Clinical Practice Guideline: Cleft Palate/Craniofacial


and Syndromic Patients last 2012, attached are the following practice algorithms
recommended:

Figure 2. Abbreviated Care Path (BC Children’s Hospital, 2012)

This is the summarized algorithm of the BC hospital wherein different


protocols are recommended based on the degree of the risk of hearing loss on the

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Case Study Analysis: Master of Clinical Audiology
Craniofacial Foundation University of Santo Tomas
of the Philippines (CFFP)

patient. They also listed different syndromes and conditions which also require hearing
assessment.

Specific to patients with cleft palate who are at higher risk for conductive hearing
loss, the recommended practice algorithm is as follows:

Figure 3. Care Path for Patients with Cleft Palate (BC Children’s Hospital, 2012)

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Case Study Analysis: Master of Clinical Audiology
Craniofacial Foundation University of Santo Tomas
of the Philippines (CFFP)

The American Cleft Palate-Craniofacial Association (2009) suggested that


acoustic-immittance (tympanometry) should be part of the assessment for middle ear
status. BC Children’s Hospital (2012) also suggested the use of high probe
tympanometry for children under 6 months of age and the assessment of acoustic
reflexes ipsilaterally should be done using broad band noise stimuli. Children with aided
permanent hearing loss should also receive audiologic assessment every 6 months
through age 4, then annually at 5, 6, 7, 8, and 10 years of age.

Given that children in this population mostly will have middle ear problems, most
specifically Otitis Media with Effusion (OME), the primary intervention for this is
grommets or tympanostomy tubes which is surgically placed in the eardrums of the
patient to equalize the pressure in the middle ear according to ASHA (2012).

Recommendations
Based on the analysis, the current practice of CFFP can be summarized as:

Figure 4. Summary of Current CFFP Practice

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Case Study Analysis: Master of Clinical Audiology
Craniofacial Foundation University of Santo Tomas
of the Philippines (CFFP)

Taking into consideration the reviewed literature, our recommended practice


algorithm for the provision of audiological services is seen below:

Figure 5. Recommended Protocol

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Case Study Analysis: Master of Clinical Audiology
Craniofacial Foundation University of Santo Tomas
of the Philippines (CFFP)

The following are our additional recommendations and plan of action with regards
to children with cleft/ cleft palate and craniofacial anomalies:

1. Early Identification and Management


Early identification of middle ear diseases in children with cleft lip and/or
palate will give the best prognosis in the overall development of the child. This
will jumpstart the medical management of the child by having him/her seek
treatment from an ENT to resolve the issue which prevents any further
complications such as hearing loss.

2. After Care and Monitoring


Once discharged after undergoing palatoplasty, the patients will be
referred to Speech Therapy services when the patient is deemed ready by the
rehabilitation team. They will also be referred to UST- HSL for annual audiological
monitoring and be given amplification if the need arises.

3. Skills Education and Increasing Knowledge on Ear and Hearing Care


Nurses will be trained on how to properly perform and interpret an
otoscopic evaluation. Caregivers and healthcare members will also be given
training on relevant information about proper ear and hearing care for this
population. In addition to their current after care program, flyers and brochures
will be given to the parents that give information about (1) newborn hearing
screening, (2) proper ear and hearing care, (3) hearing assessment and (4)
home program for the speech and language development of the child (for
sample brochures, see attached appendices). The home program includes
different speech and language techniques and developmental milestones that
will help with the family of the patient. Calling cards will be given with the contact
details of CFFP and University of Santo Tomas- Hearing Sciences Laboratory
(UST-HSL) to them if ever they would have some questions and concerns
regarding their child’s hearing.

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Case Study Analysis: Master of Clinical Audiology
Craniofacial Foundation University of Santo Tomas
of the Philippines (CFFP)

References

American Cleft Palate-Craniofacial Association. Parameters for Evaluation and


Treatment of Patients with Cleft Lip/Palate or Other Craniofacial Anomalies. Official
Publication of the American Cleft Palate-Craniofacial Association. Revised Edition
November 2009.

American Speech-Language-Hearing Association. Cleft Lip and Palate. (n.d.).


Retrieved November 28, 2019, from
https://www.asha.org/PRPSpecificTopic.aspx?folderid=8589942918§ion=Treatment.

Apuzzo, M., & Yoshinaga-Itano, C. (1995). Early identification of infants with significant
hearing loss and the Minnesota Child Development Inventory. Seminars in Hearing,
16(2), 124–139.

BC Children's Hospital. (2012). Audiology Clinical Practice Guideline: Cleft


Palate/Craniofacial and Syndromic Patients. American Speech-Hearing Association.

Center for Disease Control and Prevention (2018). Facts about Cleft Lip and Palate.
National Center on Birth Defects and Developmental Disabilities.

Global strategies to reduce the health-care burden of craniofacial anomalies: report of


WHO meetings on International Collaborative Research on Craniofacial Anomalies
(2006). Geneva, Switzerland.

David-Padilla, C. (2006). Profile of Oral Cleft Cases Reported in the Philippine Oral
Cleft Registry from May 2003 to December 2006. University of the Philippines, Manila.

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Case Study Analysis: Master of Clinical Audiology
Craniofacial Foundation University of Santo Tomas
of the Philippines (CFFP)

Operation Smile, Inc. (2015). Cleft Registry. Retrieved from


http://www.operationsmile.org.ph/index.php/what-we-do/cleft-registry/

Sharma, M., Bist, S. S., & Kumar, S. (2016). Age-Related Maturation of Wave V
Latency of Auditory Brainstem Response in Children. Journal of Audiology and
Otology, 20(2), 97–101. doi: 10.7874/jao.2016.20.2.97

Sood, M., & Kaushal, R. K. (2009). Importance of newborn hearing screening. Indian J
OtolaryngolyHead Neck Surgery, 61(2), 157–159. doi: doi: 10.1007/s12070-009-0058-
9

Kellogg BC, ed. Cleft Palate With Cleft Lip (for Parents) - Nemours KidsHealth.
KidsHealth. https://kidshealth.org/en/parents/cleft-palate-cleft-lip.html. Published June
2019. Accessed November 28, 2019.

Gani, B., Kinshuck, A.J., Sharma, R. (2012). A Review of Hearing Loss in Cleft Palate
Patients Retrieved from https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3299272/

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Case Study Analysis: Master of Clinical Audiology
Craniofacial Foundation University of Santo Tomas
of the Philippines (CFFP)

APPENDIX I
Peer Evaluation and Grading

Florendo, Darla D.

Case Study Analysis of Population Based Practice: Patients with Cleft Palate and
Other Craniofacial Anomalies

For our case study, we decided to have the Craniofacial Foundation of the
Philippines (CFFP), a non-government and non-profit organization as our study site.
Last November 8, 2019, I went to CFFP located at Sta. Mesa, Manila to pass a letter
of request in behalf of my groupmates, Kathleen and Dennis. After obtaining
permission, Kathleen and Dennis conducted and interview on November 13 and 20. I
transcribed the recordings and identified themes for the completion of the paper. We
then divided our tasks equally for the research and paper writing. We all finalized our
case study together on a timely manner and made sure to consult each other
throughout the writing process.

PEER RATING:

Dy, Kathleen (100%)


Gascon, Dennis (100%)

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Case Study Analysis: Master of Clinical Audiology
Craniofacial Foundation University of Santo Tomas
of the Philippines (CFFP)

Dy, Kathleen

Case Study Analysis of Population Based Practice: Patients with Cleft Palate and
Other Craniofacial Anomalies

For our case study, we decided to have the Craniofacial Foundation of the
Philippines (CFFP), a non-government and non-profit organization as our study site.
Last November 13 and 15, 2019, I went to CFFP located at Sta. Mesa, along with
Dennis Gascon, to interview the administrators, owners, and clinical supervisors
regarding their current protocols and practice. We then divided our tasks equally for
the research and paper writing. We all finalized our case study together on a timely
manner and made sure to consult each other throughout the writing process.

PEER RATING:

Gascon, Dennis (100%)


Florendo, Darla D. (100%)

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Case Study Analysis: Master of Clinical Audiology
Craniofacial Foundation University of Santo Tomas
of the Philippines (CFFP)

Gascon, Dennis

Case Study Analysis of Population Based Practice: Patients with Cleft Palate and
Other Craniofacial Anomalies

For our case study, we decided to have the Craniofacial Foundation of the
Philippines (CFFP), a non-government and non-profit organization as our study site.
Last November 13 and 15, 2019, I went to CFFP located at Sta. Mesa, along with
Kathleen Dy, to interview the administrators, owners, and clinical supervisors
regarding their current protocols and practice. We then divided our tasks equally for
the research and paper writing. We all finalized our case study together on a timely
manner and made sure to consult each other throughout the writing process.

PEER RATING:
Dy, Kathleen (100%)
Florendo, Darla D. (100%)

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Case Study Analysis: Master of Clinical Audiology
Craniofacial Foundation University of Santo Tomas
of the Philippines (CFFP)

APPENDIX II
Current Brochures of Craniofacial Foundation of the Philippines (CFFP)

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Case Study Analysis: Master of Clinical Audiology
Craniofacial Foundation University of Santo Tomas
of the Philippines (CFFP)

APPENDIX III
Proposed Additional Brochure (Hearing Assessment)

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Case Study Analysis: Master of Clinical Audiology
Craniofacial Foundation University of Santo Tomas
of the Philippines (CFFP)

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Case Study Analysis: Master of Clinical Audiology
Craniofacial Foundation University of Santo Tomas
of the Philippines (CFFP)

APPENDIX IV
Proposed Additional Brochures
(Home Program, Proper Ear and Hearing Care)

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Case Study Analysis: Master of Clinical Audiology
Craniofacial Foundation University of Santo Tomas
of the Philippines (CFFP)

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Case Study Analysis: Master of Clinical Audiology
Craniofacial Foundation University of Santo Tomas
of the Philippines (CFFP)

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