When a child is conceived, there are possible occurrences during fetal development that can result in the child being born with defects or anomalies. One anomaly that can be present in a newborn child is clefting of the palate. When the child is formed in the womb, their facial features fuse together from the outside to the midline causing the palate to be the last structure of the oral cavity to form (CDC, 2017). Cleft palate occurs when there is a disruption in this fusion of the palate resulting in an opening in the tissue and bone in the roof of the mouth (CDC, 2017). When a child is born with cleft palate, the deformity may cause the child to experience chronic otitis media, receive multiple surgical procedures to help repair the chronic otitis media, and experience hearing loss and speech-language difficulties. In addition to the surgeries and therapy that coincide with cleft palate, the child may have a future of surgeries and therapy for their otitis media, hearing delays, and speech-language delays. Overall, cleft palate is an anomaly that presents possible lifelong difficulties that the child must overcome.
Cleft palate not only causes malformations of the child’s palate, but it can also cause malformations of the eustachian tube and the muscles that control it. The eustachian tube is a bony and cartilaginous structure that opens into the back of the nose with the functions of regulating pressure in the middle ear, protecting the middle ear from secretions from the back of the nose, and draining the middle ear secretions into the back of the nose (Riley Children’s Health, 2012). When the eustachian tube cannot perform its required functions, there can be swelling, inflammation, and mucus which causes the accumulation of fluids in the middle ear (Mayo Clinic, 2018). The muscles that control the eustachian tube, the tensor palatini and levator palatini, can have abnormal connections due to cleft palate causing the act of opening of the eustachian tube to be difficult, or in worst cases, impossible (Frisina, Pasanisi, Bacciu, & Cerasoli, 1998). When the eustachian tube cannot be opened efficiently, it will not have the proper ventilation required to prevent pressure and buildup within the middle ear. When the child has one or both of these malformations, it can result in the child developing chronic otitis media. Chronic otitis media, more commonly known as middle ear infection, occurs when fluid collects behind the tympanic membrane causing pain, infection, speech and language delays, and the inability to hear clearly (Jones, et al., 2018). Not only does the child have to endure the difficulties, pain, and surgeries that correlate with cleft palate, but the difficulties, pain, and surgeries of chronic otitis media as well.
When a child has chronic otitis media, there is potential for the child to suffer from hearing loss and speech and language delays. The build-up behind the tympanic membrane that causes otitis media can result in the child having a conductive hearing loss. A conductive hearing loss is a hearing loss that affects the outer or middle ear rather than the cochlea and auditory nerve (McCormick, 2017). The buildup in the child’s middle ear makes it more difficult for the tympanic membrane and the ossicles to work together in order to move the sound from the outer ear to the central auditory nerve. When vibrations travel down the external auditory canal and reach the tympanic membrane, it then faces the difficulty of traveling through the ossicles, the cochlea, and to the central auditory nerve due to the fluid-filled middle ear (McCormick, 2017). Hearing loss due to otitis media is often temporary and can be aided back to normal limits by antibiotics and pressure equalization tubes. If the hearing loss cannot be resolved, the child’s physician may recommend hearing aids to help the child have a greater quality of life (McCormick, 2017).
The presence of chronic otitis media may also cause the child to present speech and language delays. The time period where a child suffers from otitis media due to the cleft palate is detrimental to the development of speech and language. Parents whose children present hearing loss due to chronic otitis media should take into the account that hearing and speech-language development are closely intertwined (Francisco-Howe, 2017). When a child is beginning to acquire speech and language, they must be able to hear what is happening in the world around them. Since the fluid in the ear blocks the auditory information from traveling at its greatest potential, it makes speech that is being said around the child less intelligible or “muffled” (Francisco-Howe, 2017). If the child has early intervention for their hearing loss, it is possible to prevent the child from speech-language delays. It is not uncommon for these children to receive surgeries, or in some cases, hearing aids to improve hearing and promote speech and language acquisition.
There are numerous types of surgical procedures that can be done to help a child who is suffering from chronic otitis media due to the malformations of the eustachian tube caused by cleft palate. The most commonly used surgical procedure is the placement of pressure equalization tubes. PE tubes are minuscule hollow cylinders that are surgically inserted into the child’s tympanic membrane in order to create an airway that provides drainage and ventilation into the middle ear (Mayo Clinic, 2018). This surgical procedure has the ability to reduce the risk of ear infections, improve language acquisition, improve speech and hearing abilities, and alleviate behavioral problems due to the pain chronic otitis media causes. These tubes, however, are not long term. The general amount of time that pressure equalization tubes stay in the child’s tympanic membrane ranges from six to eighteen months before naturally falling out, that is, if they do not fall out prematurely (Mayo Clinic, 2018). When the tubes fall out, they are designed to fall outward into the canal allowing the tympanic membrane to repair itself (Mayo clinic, 2018). It is not abnormal for children who have this surgery to undergo it multiple times due to premature removal. Though this surgery is common, it has the ability to damage the tympanic membrane causing scarring, which also contributes to conductive hearing loss.
Though the insertion of pressure equalization tubes is used to help drain the fluid buildup behind the tympanic membrane, there is another option that is significantly less invasive. This procedure is called a tympanocentesis. Tympanocentesis is the removal of fluid from behind the tympanic membrane by inserting a needle attached to a tube into the tympanic membrane to manually drain the fluid (Kim, Romito, & Pope, 2018). This procedure may be used in special situations where the child is not responding well to antibiotics. Additionally, it can also be used as a form of delivery of antibiotics directly into the middle ear (Kim et al., 2018).
The insertion and removal of pressure equalization tubes or the manual draining of the middle ear fluid is a continuous cycle that can result in significant scarring or weakening of the tympanic membrane, called tympanosclerosis (McCormick, 2017). Due to the weakening and scarring caused by the surgical insertion of pressure equalization tubes, tympanoplasties can be done to repair the tympanic membrane. A tympanoplasty is a surgical operation that can be performed for the reconstruction of the tympanic membrane and/or the small bones of the middle ear, also known as the ossicles (Panetti, Cavaliere, Marino, Lemma, & Panetti, 2017). The main goal of a tympanoplasty is to treat middle-ear diseases and restore sound conduction mechanisms that may have been damaged due to the usage of pressure equalization tubes (Guo, Sun, & Wang, 2018). After this surgery, it is not common for individuals to have reduced occurrences of chronic otitis media, reduced tinnitus, improved air conduction hearing (Guo et al., 2018). Overall, it is possible for children with chronic otitis media due to cleft palate to improve their quality of life if they undergo these surgical procedures.
Alongside the numerous surgeries that can be performed, the family physician might also refer the child to an audiologist. An audiologist is a health care professional who is trained to evaluate hearing loss and related disorders, including balance disorders, tinnitus, and to rehabilitate individuals with hearing loss and related disorders (Gan, Overton, Benton, & Daniel, 2017). An audiologist can determine if the child needs hearing aids to combat the conductive hearing loss caused by the malformations of the eustachian tube, fluid behind the ear, and the damage that surgeries may cause (Gan et al., 2017). For some parents, the thought of surgery on a child can be overwhelming so the use of hearing aids is an effective alternative. Hearing aids can also be used as a form of pre-surgical treatment (Gan et al., 2017). While the use of hearing aids is useful if the child wears them, it is only a form of treatment, not a cure.
In conclusion, the occurrence of a cleft palate as a birth defect can determine that a child will be on a long and overwhelming path of surgeries and therapies. Chronic otitis media is simply one of the complications that a child will have to face when born with this anomaly. Due to the malformations in the eustachian tube caused by the cleft palate, the child is prone to have chronic otitis media. Otitis media may cause the child to have speech and language delays, conductive hearing loss, and can require them to undergo multiple surgeries at such a sensitive age. Overall, early recognition and early intervention for this diagnosis are extremely crucial. If parents and pediatricians can determine the child’s chronic otitis media at an early stage and the child receives the correct treatment, therapies, and surgeries needed, the child is promised to live a long and fulfilling life despite their birth defect.