Presentations

Abstract

Introduction: Individuals with cleft palate frequently experience difficulties in speech and language development, often exacerbated by hearing loss. Hearing loss is a well-described complication of chronic otitis media (COM), an infection of the middle ear that occurs in 96%-100% of cleft palate patients. The standard treatment for COM is bilateral myringotomy with tympanostomy tube placement (BMTT). While BMTTs have been shown to significantly improve hearing and decrease COM recurrence, the relationship between BMTTs and speech outcomes in individuals with cleft palate is not well described. Additionally, most tympanostomy tubes will fall out spontaneously within 4-18 months, resulting in many individuals with cleft palate receiving multiple sets of tympanostomy tubes if COM or hearing issues persist. While the BMTT procedure is generally regarded as safe, complications such as persistent otorrhea, scarring and perforation of the eardrum, and tympanosclerosis may develop. Currently, there is little research comparing the speech outcomes of individuals with cleft palate who have undergone one BMTT to those who have undergone multiple BMTTs. This study aims to explore whether there is a strong association between BMTTs and speech outcomes in patients with cleft palate.

Methods: 100 patient charts were reviewed from CHKD's Cleft and Craniofacial Center. Cleft palate severity was graded using the Veau Classification System: Class I (soft palate only), Class II (hard and soft palate, complete to left/right alveolus, incomplete to left/right alveolus), Class III (unilateral cleft lip/palate), and Class IV (bilateral cleft palate). Only patients with craniofacial anomalies that conformed to the Veau classification were included in the analysis. Speech assessment variables, including nasal air emission, facial grimace, nasality, resonance, and articulation, were evaluated and scored using the Pittsburgh Weighted Speech Score (PWSS), which quantifies velopharyngeal insufficiency (VPI) with a numerical score. A PWSS ≥ 7 indicates VPI. Additional variables considered in the analysis included patient gender, number of BMTT's, patient age at BMTT placement, cleft palate surgery history (date, repair method, age of patient at time of surgery), speech therapy compliance, and post-operative complications. To analyze whether there was a significant difference in speech outcomes between patients who receive one set of ear tubes when compared to those who received multiple sets, Chi-squared analyses were performed. To determine whether there was a proportional relationship between the number of ear tubes a patient receives and their speech score, linear regression was performed.

Results: 65 patients could be classified using the Veau classification system (Class I: n = 7; Class II, n = 10; Class III, n = 33; Class IV, n = 15). 35 patients with craniofacial abnormalities that did not fit the Veau classification (craniosynostosis, cleft lip only, Pai syndrome) were excluded from analysis. For Veau Class I: 6 patients (85.7%) underwent BMTT placement, with a mean age at placement of 20.3 months and a median PWSS of 4 (range: 0-9). For Veau Class II: 9 patients (90%) underwent BMTT placement, with a mean age at placement of 9 months and a median PWSS of 6 (range: 0-13). For Veau Class III: 28 patients (84.8%) underwent BMTT placement, with a mean age at placement of 19.3 months and a median PWSS of 6 (range: 0-15). For Veau Class IV: 12 patients (80%) underwent BMTT placement, with a mean age at placement of 20.8 months and a median PWSS of 2 (range: 0-15). There was a significant difference in speech outcomes between patients who received one set of ear tubes when compared to those who received multiple sets for Veau Class III (p = 0.0276) and Veau Class IV (p = 0.0488); however, no significant difference was found for Veau Class I (p = 0.2525) and Veau Class II (p = 0.1714). Among Veau classifications, only Veau Class I showed a significant proportional relationship between the number of BMTTs and speech outcomes (p = 0.0158); no significant proportional relationships were observed for Veau Class II (p = 0.7219), Veau Class III (p = 0.9955), and Veau Class IV (p = 0.2683).

Conclusion: Our findings suggest that individuals with cleft palate who receive multiple sets of tympanostomy tubes are more likely to exhibit velopharyngeal insufficiency, as indicated by the PWSS, when compared to those who receive a single set of tubes. Additionally, the data indicate that the number of BMTTs does not have a significant proportional effect on speech outcomes for most Veau classifications.