Ear Problems in Children with Cleft Palates by Ken Pearman, Consultant Ear, Nose & Throat Surgeon First

printed in CLAPA News issue 12, 2000 Ear Problems in Children with Cleft Palates Children born with a cleft palate are often prone to glue ear. Why? Ken Pearman, F.R.C.S., Consultant Ear, Nose & Throat Surgeon at the Childrens Hospital in Birmingham, explains. Many children born with cleft palate or cleft lip and palate have much more than their fair share of ear trouble. The ear consists of three main parts, the external, middle and inner ears (see diagram).

The outer ear is a channel to conduct sound down to the eardrum, causing it to vibrate. The vibrations are transmitted through the middle ear by a system of levers (three little bones called ossicles) to the inner ear where they are turned into nerve impulses which are transmitted to the brain via the auditory nerve. For the system to work properly, the middle ear must be full of air, which gets there from the back of the nose via a tube (the eustachian tube). Eustachian tubes are normally closed but are opened by the palate muscles on swallowing allowing air to enter the middle-ear cavities. Children born with a cleft palate can occasionally suffer from abnormalities in any part of the ear but the vast majority of problems arise from the middle ear. Middle ear conditions are very common in childhood anyway because the eustachian tubes are not very efficient in early life. In children with cleft palates, the palatal muscles are abnormal and even the most expert palate repair cannot guarantee normal tube function. This is the reason why children with clefts are more prone to middle ear problems with perhaps 80% of them being affected at least temporarily. If the eustachian tubes do not function properly, the ears become underventilated and tend to fill with liquid leading to some degree of hearing loss and proneness to earaches. It happens to many people temporarily during colds. When persistent over a period of months or years, the problem is usually called glue ear. It is a condition which usually cures itself eventually, although it may persist for some years in deft children and, despite our best efforts, occasionally leads to more serious long-term ear problems. Curiously, glue ear seems to give some children no difficulties whatever, while others, with apparently identical ears, can be severely troubled by hearing loss and earaches. Earaches are easily recognised but the adverse effects of hearing loss are not always so obvious and may be overlooked by parents. Most children with glue ear have a mild hearing loss which is

not as easy to notice as severe deafness. One of the main uses of our ears is to enable us to communicate with each other through speech. If the hearing mechanism is impaired, the ability to understand and use spoken language is diminished. If one analyses speech, it consists of louder, mostly low-note, vowel sounds, chopped up into recognisable words by softer, mostly high-pitched, consonant sounds. A minor hearing loss stops the sufferer hearing the softer consonant sounds while the louder ones still come through. This corrupts the incoming information. A way of demonstrating this is to try to work out the meaning of the well-known phrase below with only the vowels to go on: _O_ _ A_E _ _E_ _UEE_

The answer is below*. It is much easier to work out with the consonants in place. Minor hearing loss also brings difficulty in coping in background noise. We all switch off sometimes, but spare a thought for the youngster with hearing loss at the back of a noisy classroom who may not be able to make out what the teacher is saying. Assessment of the ears involves asking parents about factors such as earache, hearing difficulties and speech, examining the ears and testing the hearing. Treatment decisions are not made on test results alone; parents' opinions are very important since they are with the child all the time and have an overall view which a doctor cannot obtain in a brief outpatient visit. Assessment of abnormalities of speech in smaller children is not always easy. There is wide variation in normal speech development and the speech problems of some cleft palate children are complex. The treatment options available for middle ear problems are "seeing how things go', medication, grommets and hearing aids. Most childhood ear disease cures itself by the age of seven or eight. It may linger longer in children with deft palates but many are affected mildly, intermittently or for only a short time. Waiting for nature to take its course can therefore be the best option for some children. Various medications are used in glue ear. Antibiotics are helpful for the treatment of ear infections. Decongestants and nasal sprays are sometimes prescribed in an attempt to dear middle ears. If under-ventilation of the middle ears due to poor eustachian tube function is the cause of the problem, an alternative Ventilation system ought to help. This is the purpose of grommets, which are tiny flanged tubes which are placed in the eardrum. Their insertion in children requires a short operation under general anaesthetic. The eardrum is punctured, any liquid in the middle ear is sucked out and the grommet is placed in the puncture, which would otherwise dose very quickly. Grommets are not permanent and tend to be pushed out by the eardrum after six months or so. When they come out, the drum heals and the eustachian tube must take over the task of ventilating the ear again. If it is not up to the job, the ear may refill with liquid and the cycle of ear trouble can recur. This may lead to more grommets being fitted. Usually, while the grommet is in place, the ear hears well and is earache-free. Parents often notice a dramatic improvement in symptoms following grommeting. As with all medical treatments, however, there can be problems. The most common is infection, which causes a runny ear which usually responds to antibiotics or drops. Hearing aids are very effective at improving hearing and, for various reasons are the best treatment for some children. They are less popular than grommets because, unlike grommets, they require maintenance, cannot be worn for twenty-four hours a day, do not stop earaches and are visible. Since ear problems are so prevalent in children with cleft palates, an ENT surgeon is an integral member of many cleft palate teams. The recent CSAG report recommends regular ear and hearing checks throughout childhood. In this way, we hope to identify and treat problems early, minimise long-term difficulties and build up expertise so that we can offer the best possible advice in the future

*G_D

S_V_

TH_

Q___ N.