Children born with a cleft palate (velar or velopalate) must have an early and regular otological follow-up.
Why is this follow-up necessary?
The ear consists of several parts:
- Outer ear including auricle and external auditory canal
- Middle ear including tympanum, eardrum (containing ossicles) and mastoid.
- Internal ear, auditory organ (cochlea) but also balance.
- The middle ear functions as an amplifier and a sound transmission system. The inner ear will transform the sound (mechanical wave) into an electrical signal, transmitted by the auditory nerve to the central areas of hearing (brain).
- The middle ear is a cavity set filled with air. This aeration is effected by the Eustachian tube and is essential to balance on both sides of the eardrum allowing the good transmission of sounds from the outer ear to the inner ear.
The ventilation system is not motionless but a dynamic system.
In fact, the mucosa of the middle ear ensures permanent gas exchange, normally leading to a constant decrease in pressure in the cavities of the middle ear: it “consumes” air and the main function of the Eustachian tube is to restore balance between external pressure (atmospheric) and pressure in the middle ear.
The Eustachian tube is a cartilaginous duct extending from the back of the nasal cavity (cavum, zone of the vegetations) to the tympanic cavity. This duct opens thanks to the contraction of muscles: the tensor and the levator of the soft palate’s veil. These muscles contract normally especially during swallowing and yawning. The cleft palate occurs very early in the fetal life (6th week of pregnancy) and will therefore cause abnormalities in the cartilaginous structure, shape and orientation of the Eustachian tube. The insertion and function of the muscles of the soft palate are also modified. From birth, this malfunction will cause a lack of aeration of the middle ear and generate a negative pressure “behind” the eardrum causing the appearance of fluid: serous otitis or sero-mucosa.
This effusion is not an infection but an inflammation, most often painless and not a cause of fever.
Serous or serosal otitis has three possible consequences:
An attenuation of the transmission of sounds and therefore a decrease in hearing, which may affect acquisitions and especially language. Superinfections, ie acute otitis media.
A weakening of the eardrum
The second consequence of this decrease in pressure is an “aspiration” of the eardrum which will progressively become deformed, retracted or perforated. These complications on the eardrum of serous otitis and negative pressure generally occur after several months or years of evolution
How is surveillance done?
Regular examination of the eardrums under the microscope should be done regularly by an ENT doctor.
Hearing assessment is possible at any age using age-appropriate tests.
What are the treatments for serous otitis media?
The treatment can be medical or surgical. Children born with a cleft palate almost always initially have a thick fluid outflow that is resistant to medical treatment. Surgical treatment is therefore proposed and consists of the establishment of “trans-tympanic drains” also called “yoyos” or “diabolos”.
These drains are put in place during the general anesthesia planned for the closure of the palace. Several types of drains exist and differ in size, material and length of time installed.
We initially favor the installation of short drains, evacuated spontaneously by the eardrum after 6 to 8 months.
If the serous otitis recurs, drains are re-established and the choice of the type of drains depends on the age of the child, the thickness of the fluid, the condition of the eardrum and the informed choice of parents.
The drains have a palliative role and only the evolution of the Eustachian tube will improve the aeration of the middle ear in a lasting and definitive way. No examination can predict the duration of Eustachian tube dysfunction and only microscopic examination of the eardrums can monitor and wait for this improvement.
The aeration of the middle ear by the drains thus makes it possible to wait for this moment and to prevent more serious complications: perforations of the eardrums, retractions (deformation and depression) and cholesteatoma, epidermal (skin) tumor formed most often at from a retraction of the eardrum and causing a progressive destruction of the elements of the ear: ossicles, bones protecting the facial nerve, temporal grey matter and large vessels passing through the mastoid. These complications often require a surgical action to rebuild the ossicles, the tympanic framework and strengthen the eardrum.
The frequency of these complications has been significantly reduced since the use of drains and care to act directly on the muscles opening the Eustachian tube: tubal speech therapy, thermal cures, manosonic aerosols, tubal self-insufflation …
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