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Late ear sequelae in cleft palate patients
Internationd Journal of Pediatric Otorhinolaryngology, 15 (1988) 149-156 Elsevier
149
POR 00509
ordon‘, Francoise Jean-
all
orton 2
r Nose and Throat Department, Middlemore Hospital, Auckland (New Zealand) ’ Department of Otolaiyngology, Greenlane Hospital, Auckland (New Zealand) (Received 30 December 1987) (Accepted 7 February 1988)
Key wor&: Cleft palate; Otitis media with effusion
et This retrospective study looks at the incidence and nature of ear disease in 50 adolescent patients who had cleft palates repaired in in had a history of grommet insertion. We found that hearing (81%) and middle-ear pressures (86%), although a half had tympanic membrane abnormalities. Grommet insertion did no hearing in this study but was stron did not influence the degree of ea clefts had a history of repeated grommet insertion. almost universal in cleft palate infants and may educational development. At the time of palata to improve hearing in these infants.
The association between cleft-palate and hearing-loss was first reporte 1878. Since then it has been shown that nearly all infants with unrepaired clefts have Gtitis media with effusion (QME) [12,14]. It has also been shown with aud brainstem recording that OME in such infants does result in a hearing loss improves following grommet insertion [S]. Following cleft repair t E has been shown to decline with age [ll]. Eustachian tube thought to be the cause of middle ear effusions in both the cleft-palate and normal Correspondence: A.S.D. Gordon, C/o Department of Otorhinolaryngology, 55905, U.S.A. 0165-5876/88/$03.50
0 1988 Elsevier Science Publishers
T-.4ayoClinic, Rochester, MN
.V. (Biomedical Division)
150
population, but the exact nature of this dysfunction is not fully resolved. There are some abnormalities in the cleft-palate population which may predispose to middle ear effusions such as altered base of skull anatomy, abnormal positioning of the tensor and levator palati muscles, a more ~llapsible Eust~~~~ tube, and refiux of oropharyngeal secretions into the nasopharynx [2,3,7,10,13].However, recent studies have also suggested that active Eustachian tube function in many cleft-palate children is quite good, even before repair [4]. This is a retrospective study of a group of patients who had palatal repair performed as infants between 1970 and 1976. The study examines the incidence and nature of ear disease in this group of patients 9 years or more after palatal repair.
At Middlemore hospital infants with cleft palates and cleft lips have repair of the lip and ~te~or palate ~rforrn~ at 5 months and repair of the secondary palate at 9 months of age. The pterygoid hamulus was routinely infractured in these cases. After repair, patients are followed regularly at the Plastic Surgical Clinic where they are seen by a plastic surgeon, an otol~ngolo~st, a speech therapist and an orthodontist. Between 1970 and 1976 grommets were not routinely inserted in these patients whereas our present practice is to routinely insert grommets at the time of palatal repair. Many patients were from outside the Auckland area and their otologic care after palatal repair was perform elsewhere. The patients were reviewed during 1986 in the Ear Nose and Throat Department after attendance at the Plastic Surgical Clinic. They were questioned about any history of ear symptoms or hearing loss. A note of previous ear surgery was made and a microscopic examination of the tympanic membranes was performed. Results of pure-tone audiometry and impedance tympanometry were also recorded. The Plastic Surgical records -were reviewed for details of cleft type and surgery. There TABLE I Caution
of clefts (So patients
Ctcfrpalatetype
Numberof patients
IncompIetecleft of 2O palate In~mplete cleft of 1O&2Opalate Subnwuuscleft
20
Total MicUinecompletecleft of 2O palate Unilateralcompletedeft of lo&Z0 palate Bilatarcllcompletecleft of l”&20 palate Total
5
Partialclefts of 2O palate
2 G s 12 6 G
Completeclefts of 2” palate
were 50 patients in 17 years (mean 12 tional Confederation for Plastic arty-nine of the 50 p
significance of observed differences.
Otopathology
Fifty-five (55%) of the 100 ty Twenty-five patients (SOears) had had appearances included tympanoscleros
ranes were
normal in
tions (one discharging) cholesteatoma (Table II). Twenty-three patients had complete clefts of the set had had partial clefts of the 2” palate (Table I). Abou had bad grommets inserted (48% of complete a cantly more (39%) of the co n once when compared wit partial clefts (22%) palate (P > 0.025). Table IV shows that, exclu ng the 7 ears with grommets still in situ, those ears that had had grommets inse d had a higher proportion of abno membranes (31/43) than those that had no grommets (7/SO). highly significant (P < 0.001). About one third (M/50) of intuba tympanosclerosis compared wit 2%(1/SO) of non-intubated ears. Almost all (16/17,
TABLE II Qmpanic membrane appearance (100 ears)
Otoscopicfindings Normal
Tympanosclerosis Scarring/retraction Grommet in situ Perforation Otitis media with effusion (OME) Cholesteatoma Total
% of ears
55 17 15 7 4 2 0 loo
152 TABLE III Grommef inserlionaccording lo clef1
Numberof grommet 1 insertions >l No grommets Total
type
Partial cleft
Complete cleft
16 (30%) 12 (22%) 26 (48%) 54 (100%)
4 (9%) 18 (39%) 24 (52%). 46 (100%)
Total
’
20 30 ‘50 100
TABLE IV Tympanic membrane appearance in relation to grommet insertions Qvnpanicmembrane appearance
amnmet insertion No grommet insertion Total
Total
Normal
S)rmpanoscleraris
Scarring/ retraction
OME
Per&
Grommet
12 (22%)
16 (95%)
11 (73%)
2
2
7
50
43 (78%) 55 (100%)
1 (5%) 17 (100%)
4 (27%) lS(lOO%)
0 2
2 4
7
50 100
94%) of tympanosclerotic membranes had beea intubated. Of the 4 ears with
perforations, two had had grommets inserted and two had not. Audiometry Most (78/98)
ears in this study had normal average pure tone thresholds, irrespective of whether grommets had been inserted or not, the proportion being
TABLE V Audiometryaccording to grommet insertionand cleft type Grommets Yes Pure-tone audiogram
Crefrrype No
Normal
Total
(Z%) 20
(i%)
Total
(li%)
78 (K) 8 (17%)
98 (1:;)
a Two em not tested; * P = 0.05.
Partial
78 (:%)
Abnormal Total
Complete
(li%)
(Z%)
(K) 20 (::I) B (li%)
98 ,
153 TABLE VI Tympanometry results Tymputaometry Type A
Grommets inserted No grommets inserted Total
No Tympanogram Total
Perf
Grommet
8 (23%)
35 (100%)
2
7
3 (7%)
42 (100%)
2
-
6
77
4
7
12
Type WC
27 (77%) 39 (93%)
66
11
Not dome 6
71% (34/48) and 88% (44/50) respectively ( s difference is not significant (P > 0.05). reover, 83% (38/46) (40/52) of the partial fts had normal hea marginally significant (P= 0.05). Of the air-bone pap equal to or greater than 10 nly 77 of the 89 intact ear A tympanograms, with 41% (27/66) of these ears having had gromm (Table VI). The difference between the grommet inseL:ion was not significant (
TABLE VII Tympanometty according to cleft type (ears) No Tympanogram
Tympanometry Tjye A
Complete cleft Partial cleft Total
Type B/C
Total
Per& /Grommet
Not done
28 (82%)
6 (18%)
34 (100%)
4
8
38 (88%) 66
5 (12%) 11
43 (100%) 77
7 11
4 12
TABLE VIII Otoscopic findings and audiology results Tympanic membrane appearance
Normal audiogram Type A tympanogram
Normal
Tympanosclerosis
Scarring/retraction
93% (51/S)
76% (13/17)
67% (10/H)
94% (44/47)
87% (13/15)
85%(11/13)
154
Type A tympanograms did not vary significantly with the type of cleft palate (Table VII). Of the 55 ears with normal otoscopic appearances, 93% @l/55) had normal average pure-tone thresholds and 94% (44/47) had Type A tympanograms, showing a good correlation between otoscopy and audiology. Seventy-six per cent (13/17) of ears with tympanosclerosis had normal hearing and 87% (13/15) had Type A tympanograms. Only 67% (10/15) of ears with scarred or retracted drums had normal pure tone thresholds whereas 85% (11/13) had Type A tympanograms (Table VIII). Dhcumion
This retrospective study of 50 adolescents who had palatal clefts repaired in lute incidence of tympanic membrane or middle ear abnormalce of hearing impairment. This agrees fairly well with figures of 50% quoted for otoscopic abnormality and 30-50% for hearing loss in other studies of long-term outcome in cleft palate patients [l,lI,16]. The type of cleft was not an important determinant in respect of late hearing loss or middle ear disease in our study, There was no difference in the incidence of grommet insertion between partial and complete clefts of the 2’ palate. However, significantly more of those with complete clefts had had repeated grommet insertions compared with those with partial clefts. This may indicate a greater degree of persistent Eustachian tube dysfunction in those with repaired complete clefts. All patients in this study regularly attend the Plastic Surgical Clinic and following such a visit they were asked to attend the E.N.T. Clinic. We have therefore avoided selecting only those patients with ear disease, thus providing a good estimate of the true prevalence of late ear disease in the cleft palate population. The aim of grommet insertion in cleft palate infants is to improve hearing at an important cognitive and language learning time and also to try and prevent long-term ear disease. Speech, language and education were not assessed in these patients but there is some evidence that prolonged middle ear effusions especially in the first year of life may result in some subsequent disability [8,9,15]. Although the ears that had had grommets inserted had a slightly lower incidence of normal hearing, and Type A tympanograms, compared with those who had not, the difference was not significant and in any case the two groups are not strictly comparable. The criteria for grommet insertion were not known in many of the patients, although it is reasonable to assume that those with grommets inserted may have had. worn ear disease than those without. The slightly poorer long-term outcome of those with grommets may reflect this. Nearly all patients with tympanosclerosis had had grommets inserted. However, with tymlxunxclerotic drums still had a high incidence of normal hearing and normal middle ear pressures (87%). No patients in this study had cholesteatoma, only two had OME and two had discharging ears. This agrees with Moller’s finding that cleft palate children have a relatively low incidence of
155
long-term serious ear disease [ll]. The low incidence of discharge in this study may also reflect old, and by this age adequate Eustx many children [6,11]. We recommend routine insertion of grommets at the time of lip or and thereafter only as necessary. Since the incidence of high in cleft palate infants we feel that this practice important time of language and c ive development. Although grommet insertion results in an increased incidence o mpanic membrane scarring and otorrhoea, we do not feel that infants with persistent middle ear effusion shoul grommets because the long-term hearing is generally goo
Hospital for his assistance.
1 Bennett, M., The older cleft palate patient (a clinical otologic-audiologic study), Laryngoscope, 82 (1972) 1217-1225. 2 Bluestone, C.D., Paradise, J.L., Beery, Q.C. and Wittel, R., Certain effects of cleft palate repair on Eustachian tube function, Cleft Palate J., 9 (1972) 183-193. nol. 3 Dickson, D.R., Anatomy of the normal and cleft palate Eustachian tube, Ann. Otol. Laryngol., 85 (1976) 25-29. 4 Doyle, W.J., Reilly, J.S., Jardim, L. and Rovnak, S., Effect of palatoplasty on the function of the Eustachian tube in children with cleft palate, Cleft Palate J., 23 (1986) 63-68. 5 Fria, T.J., Paradise, J.L., Sabo, D.L. and Elster, B.A., Conductive hearing loss in infants and young children with cleft palate, J. Ped., 111 (1987) 84-87. 6 Gopalakrishna, A., Goleria, K.S. and Raje, A., Middle ear function in cleft palate, &it. J. Plastic Surg., 37 (1984) 558-565. 7 Holborow. C., Eustachian tubal function: changes throughout childhood and neuro-muscular control, J. Laryngol. Otol., 89 (1975) 47-55. 8 Hubbard, T.W., Paradise, J.L., McWilliams, B.J., Elster, B.A. and Taylor, F.H., Consequences of unremitting middle-ear disease in early life. Otologic, audiologic and developmental findings in children with cleft palate, N. Engl. J. Med., 312 (1985) 1529-1534. 9 Klein, J.O., Otitis media with effusion and development of speech and language, Ann. Otol. Rhino1 Laryngol., 94, Suppl. 120 (1985) 53-54. 10 Kriens, O., Anatomy of the velopharyngeal area in cleft palate, Clin. Plastic Surg., 2 (1975) 261-283. 11 Moller, P., Long-term otologic features of cleft palate patients, Arch Otolaryngol., 101 (1975) 605-607. 12 Paradise, J.L., Bluestone, C.D. and Felder, J-L.The universality of otitis media in SOinfants with cleft palate, Pediatrics, 44 (1969) 35-42. 13 Rood, S.R. and Stool, SE., Current concepts of the etiology, diagnosis, and management of cleft palate related otopathologic disease, Otol. Clin. N. Am., 14 (1981) 865-884.
14 Stool, SE. and Randall, P., Unexpected ear disease in infants with cleft palate, Cleft Palate J., 4 (1967) 99-103. 15 T&e, D.W., Klein, J.O. and Rosner, B.A., The Greater Boston Otitis Media Study Group. Otitis media with effusion during the fiist three years of life and development of speech ilnd language, Pediatrics, 74 (1984) 282-287. 16 Yules, RB., Current concepts of treatment of ear disease in cleft palate children and adults, Cleft Palate J., 12 (1975) 315-322.
149
POR 00509
ordon‘, Francoise Jean-
all
orton 2
r Nose and Throat Department, Middlemore Hospital, Auckland (New Zealand) ’ Department of Otolaiyngology, Greenlane Hospital, Auckland (New Zealand) (Received 30 December 1987) (Accepted 7 February 1988)
Key wor&: Cleft palate; Otitis media with effusion
et This retrospective study looks at the incidence and nature of ear disease in 50 adolescent patients who had cleft palates repaired in in had a history of grommet insertion. We found that hearing (81%) and middle-ear pressures (86%), although a half had tympanic membrane abnormalities. Grommet insertion did no hearing in this study but was stron did not influence the degree of ea clefts had a history of repeated grommet insertion. almost universal in cleft palate infants and may educational development. At the time of palata to improve hearing in these infants.
The association between cleft-palate and hearing-loss was first reporte 1878. Since then it has been shown that nearly all infants with unrepaired clefts have Gtitis media with effusion (QME) [12,14]. It has also been shown with aud brainstem recording that OME in such infants does result in a hearing loss improves following grommet insertion [S]. Following cleft repair t E has been shown to decline with age [ll]. Eustachian tube thought to be the cause of middle ear effusions in both the cleft-palate and normal Correspondence: A.S.D. Gordon, C/o Department of Otorhinolaryngology, 55905, U.S.A. 0165-5876/88/$03.50
0 1988 Elsevier Science Publishers
T-.4ayoClinic, Rochester, MN
.V. (Biomedical Division)
150
population, but the exact nature of this dysfunction is not fully resolved. There are some abnormalities in the cleft-palate population which may predispose to middle ear effusions such as altered base of skull anatomy, abnormal positioning of the tensor and levator palati muscles, a more ~llapsible Eust~~~~ tube, and refiux of oropharyngeal secretions into the nasopharynx [2,3,7,10,13].However, recent studies have also suggested that active Eustachian tube function in many cleft-palate children is quite good, even before repair [4]. This is a retrospective study of a group of patients who had palatal repair performed as infants between 1970 and 1976. The study examines the incidence and nature of ear disease in this group of patients 9 years or more after palatal repair.
At Middlemore hospital infants with cleft palates and cleft lips have repair of the lip and ~te~or palate ~rforrn~ at 5 months and repair of the secondary palate at 9 months of age. The pterygoid hamulus was routinely infractured in these cases. After repair, patients are followed regularly at the Plastic Surgical Clinic where they are seen by a plastic surgeon, an otol~ngolo~st, a speech therapist and an orthodontist. Between 1970 and 1976 grommets were not routinely inserted in these patients whereas our present practice is to routinely insert grommets at the time of palatal repair. Many patients were from outside the Auckland area and their otologic care after palatal repair was perform elsewhere. The patients were reviewed during 1986 in the Ear Nose and Throat Department after attendance at the Plastic Surgical Clinic. They were questioned about any history of ear symptoms or hearing loss. A note of previous ear surgery was made and a microscopic examination of the tympanic membranes was performed. Results of pure-tone audiometry and impedance tympanometry were also recorded. The Plastic Surgical records -were reviewed for details of cleft type and surgery. There TABLE I Caution
of clefts (So patients
Ctcfrpalatetype
Numberof patients
IncompIetecleft of 2O palate In~mplete cleft of 1O&2Opalate Subnwuuscleft
20
Total MicUinecompletecleft of 2O palate Unilateralcompletedeft of lo&Z0 palate Bilatarcllcompletecleft of l”&20 palate Total
5
Partialclefts of 2O palate
2 G s 12 6 G
Completeclefts of 2” palate
were 50 patients in 17 years (mean 12 tional Confederation for Plastic arty-nine of the 50 p
significance of observed differences.
Otopathology
Fifty-five (55%) of the 100 ty Twenty-five patients (SOears) had had appearances included tympanoscleros
ranes were
normal in
tions (one discharging) cholesteatoma (Table II). Twenty-three patients had complete clefts of the set had had partial clefts of the 2” palate (Table I). Abou had bad grommets inserted (48% of complete a cantly more (39%) of the co n once when compared wit partial clefts (22%) palate (P > 0.025). Table IV shows that, exclu ng the 7 ears with grommets still in situ, those ears that had had grommets inse d had a higher proportion of abno membranes (31/43) than those that had no grommets (7/SO). highly significant (P < 0.001). About one third (M/50) of intuba tympanosclerosis compared wit 2%(1/SO) of non-intubated ears. Almost all (16/17,
TABLE II Qmpanic membrane appearance (100 ears)
Otoscopicfindings Normal
Tympanosclerosis Scarring/retraction Grommet in situ Perforation Otitis media with effusion (OME) Cholesteatoma Total
% of ears
55 17 15 7 4 2 0 loo
152 TABLE III Grommef inserlionaccording lo clef1
Numberof grommet 1 insertions >l No grommets Total
type
Partial cleft
Complete cleft
16 (30%) 12 (22%) 26 (48%) 54 (100%)
4 (9%) 18 (39%) 24 (52%). 46 (100%)
Total
’
20 30 ‘50 100
TABLE IV Tympanic membrane appearance in relation to grommet insertions Qvnpanicmembrane appearance
amnmet insertion No grommet insertion Total
Total
Normal
S)rmpanoscleraris
Scarring/ retraction
OME
Per&
Grommet
12 (22%)
16 (95%)
11 (73%)
2
2
7
50
43 (78%) 55 (100%)
1 (5%) 17 (100%)
4 (27%) lS(lOO%)
0 2
2 4
7
50 100
94%) of tympanosclerotic membranes had beea intubated. Of the 4 ears with
perforations, two had had grommets inserted and two had not. Audiometry Most (78/98)
ears in this study had normal average pure tone thresholds, irrespective of whether grommets had been inserted or not, the proportion being
TABLE V Audiometryaccording to grommet insertionand cleft type Grommets Yes Pure-tone audiogram
Crefrrype No
Normal
Total
(Z%) 20
(i%)
Total
(li%)
78 (K) 8 (17%)
98 (1:;)
a Two em not tested; * P = 0.05.
Partial
78 (:%)
Abnormal Total
Complete
(li%)
(Z%)
(K) 20 (::I) B (li%)
98 ,
153 TABLE VI Tympanometry results Tymputaometry Type A
Grommets inserted No grommets inserted Total
No Tympanogram Total
Perf
Grommet
8 (23%)
35 (100%)
2
7
3 (7%)
42 (100%)
2
-
6
77
4
7
12
Type WC
27 (77%) 39 (93%)
66
11
Not dome 6
71% (34/48) and 88% (44/50) respectively ( s difference is not significant (P > 0.05). reover, 83% (38/46) (40/52) of the partial fts had normal hea marginally significant (P= 0.05). Of the air-bone pap equal to or greater than 10 nly 77 of the 89 intact ear A tympanograms, with 41% (27/66) of these ears having had gromm (Table VI). The difference between the grommet inseL:ion was not significant (
TABLE VII Tympanometty according to cleft type (ears) No Tympanogram
Tympanometry Tjye A
Complete cleft Partial cleft Total
Type B/C
Total
Per& /Grommet
Not done
28 (82%)
6 (18%)
34 (100%)
4
8
38 (88%) 66
5 (12%) 11
43 (100%) 77
7 11
4 12
TABLE VIII Otoscopic findings and audiology results Tympanic membrane appearance
Normal audiogram Type A tympanogram
Normal
Tympanosclerosis
Scarring/retraction
93% (51/S)
76% (13/17)
67% (10/H)
94% (44/47)
87% (13/15)
85%(11/13)
154
Type A tympanograms did not vary significantly with the type of cleft palate (Table VII). Of the 55 ears with normal otoscopic appearances, 93% @l/55) had normal average pure-tone thresholds and 94% (44/47) had Type A tympanograms, showing a good correlation between otoscopy and audiology. Seventy-six per cent (13/17) of ears with tympanosclerosis had normal hearing and 87% (13/15) had Type A tympanograms. Only 67% (10/15) of ears with scarred or retracted drums had normal pure tone thresholds whereas 85% (11/13) had Type A tympanograms (Table VIII). Dhcumion
This retrospective study of 50 adolescents who had palatal clefts repaired in lute incidence of tympanic membrane or middle ear abnormalce of hearing impairment. This agrees fairly well with figures of 50% quoted for otoscopic abnormality and 30-50% for hearing loss in other studies of long-term outcome in cleft palate patients [l,lI,16]. The type of cleft was not an important determinant in respect of late hearing loss or middle ear disease in our study, There was no difference in the incidence of grommet insertion between partial and complete clefts of the 2’ palate. However, significantly more of those with complete clefts had had repeated grommet insertions compared with those with partial clefts. This may indicate a greater degree of persistent Eustachian tube dysfunction in those with repaired complete clefts. All patients in this study regularly attend the Plastic Surgical Clinic and following such a visit they were asked to attend the E.N.T. Clinic. We have therefore avoided selecting only those patients with ear disease, thus providing a good estimate of the true prevalence of late ear disease in the cleft palate population. The aim of grommet insertion in cleft palate infants is to improve hearing at an important cognitive and language learning time and also to try and prevent long-term ear disease. Speech, language and education were not assessed in these patients but there is some evidence that prolonged middle ear effusions especially in the first year of life may result in some subsequent disability [8,9,15]. Although the ears that had had grommets inserted had a slightly lower incidence of normal hearing, and Type A tympanograms, compared with those who had not, the difference was not significant and in any case the two groups are not strictly comparable. The criteria for grommet insertion were not known in many of the patients, although it is reasonable to assume that those with grommets inserted may have had. worn ear disease than those without. The slightly poorer long-term outcome of those with grommets may reflect this. Nearly all patients with tympanosclerosis had had grommets inserted. However, with tymlxunxclerotic drums still had a high incidence of normal hearing and normal middle ear pressures (87%). No patients in this study had cholesteatoma, only two had OME and two had discharging ears. This agrees with Moller’s finding that cleft palate children have a relatively low incidence of
155
long-term serious ear disease [ll]. The low incidence of discharge in this study may also reflect old, and by this age adequate Eustx many children [6,11]. We recommend routine insertion of grommets at the time of lip or and thereafter only as necessary. Since the incidence of high in cleft palate infants we feel that this practice important time of language and c ive development. Although grommet insertion results in an increased incidence o mpanic membrane scarring and otorrhoea, we do not feel that infants with persistent middle ear effusion shoul grommets because the long-term hearing is generally goo
Hospital for his assistance.
1 Bennett, M., The older cleft palate patient (a clinical otologic-audiologic study), Laryngoscope, 82 (1972) 1217-1225. 2 Bluestone, C.D., Paradise, J.L., Beery, Q.C. and Wittel, R., Certain effects of cleft palate repair on Eustachian tube function, Cleft Palate J., 9 (1972) 183-193. nol. 3 Dickson, D.R., Anatomy of the normal and cleft palate Eustachian tube, Ann. Otol. Laryngol., 85 (1976) 25-29. 4 Doyle, W.J., Reilly, J.S., Jardim, L. and Rovnak, S., Effect of palatoplasty on the function of the Eustachian tube in children with cleft palate, Cleft Palate J., 23 (1986) 63-68. 5 Fria, T.J., Paradise, J.L., Sabo, D.L. and Elster, B.A., Conductive hearing loss in infants and young children with cleft palate, J. Ped., 111 (1987) 84-87. 6 Gopalakrishna, A., Goleria, K.S. and Raje, A., Middle ear function in cleft palate, &it. J. Plastic Surg., 37 (1984) 558-565. 7 Holborow. C., Eustachian tubal function: changes throughout childhood and neuro-muscular control, J. Laryngol. Otol., 89 (1975) 47-55. 8 Hubbard, T.W., Paradise, J.L., McWilliams, B.J., Elster, B.A. and Taylor, F.H., Consequences of unremitting middle-ear disease in early life. Otologic, audiologic and developmental findings in children with cleft palate, N. Engl. J. Med., 312 (1985) 1529-1534. 9 Klein, J.O., Otitis media with effusion and development of speech and language, Ann. Otol. Rhino1 Laryngol., 94, Suppl. 120 (1985) 53-54. 10 Kriens, O., Anatomy of the velopharyngeal area in cleft palate, Clin. Plastic Surg., 2 (1975) 261-283. 11 Moller, P., Long-term otologic features of cleft palate patients, Arch Otolaryngol., 101 (1975) 605-607. 12 Paradise, J.L., Bluestone, C.D. and Felder, J-L.The universality of otitis media in SOinfants with cleft palate, Pediatrics, 44 (1969) 35-42. 13 Rood, S.R. and Stool, SE., Current concepts of the etiology, diagnosis, and management of cleft palate related otopathologic disease, Otol. Clin. N. Am., 14 (1981) 865-884.
14 Stool, SE. and Randall, P., Unexpected ear disease in infants with cleft palate, Cleft Palate J., 4 (1967) 99-103. 15 T&e, D.W., Klein, J.O. and Rosner, B.A., The Greater Boston Otitis Media Study Group. Otitis media with effusion during the fiist three years of life and development of speech ilnd language, Pediatrics, 74 (1984) 282-287. 16 Yules, RB., Current concepts of treatment of ear disease in cleft palate children and adults, Cleft Palate J., 12 (1975) 315-322.