in Prosthetically Treated Adults With Cleft Palate
Hearing Loss Philip
F.
Anthony, MD,
Lois S.
Anthony,
MA
\s=b\ The effect of obturator treatment of cleft palate on middle ear disease and hearing loss has not been established. This study serves as an otologic and audiologic review of a previously reported adult population with cleft palate. A substantial improvement in hearing levels subsequent to obturation was demonstrated; however, it was believed to be based on stabilization of pathologic features of the ear with age. A statistically significant correlation of hearing level with length of use of prosthesis or with type of lesion could not be demonstrated. Results are compared with those reported on the only other adult population with cleft palate. Prosthetic management of cleft palates is not shown to be detrimental, as has been generally thought.
(Arch Otolaryngol 102:151-153, 1976)
The effect, beneficial
or
deleteri-
study is a moderate range retrospective study of the same group of patients that Graham et al1 evaluated approximately ten years ago. The purpose of the study is to provide the only study of the hearing status of adult patients with cleft palates treated with prostheses. The present
METHODS Clinical Data
Thirty-six of the original 54 (67%) patients studied by Graham et al1 were examined, and audiograms were recorded. Of the original 27 male and 27 female patients, 21 male and 14 female patients were examined. All patients who were reexamined had been followed up at varying intervals by otolaryngologists and prosthodontists at the Department of Otolaryngology and Maxillofacial Surgery of the University of Iowa Hospitals.
ous, of obturator treatment of
cleft palates on middle ear disease has not been resolved.1-5 Masters et al3 have reported that as high as 78% of patients with cleft palate treated with obturators had a hearing loss of greater than 10 dB. Graham et al1 reported that only 19% of their patients had greater than a 10-dB hearing loss after they had worn obturators from one to eight years. The literature, with regard to the effect of obturator treatment of cleft palates on hearing levels, is limited. Each study has multiple criteria for use of the prosthesis and different methods of presenting data so that only through careful study can comparisons be made and conclusions be drawn from the data available.
Accepted
for publication Nov 11, 1975. From the Department of Otolaryngology, Baylor College of Medicine (Dr Anthony), and the Houston Ear, Nose and Throat Hospital Clinic (Ms Anthony), Houston. Reprint requests to 662 S Henderson, Fort Worth, TX 76104 (Dr Anthony).
Procedure An attempt
was
made to contact all
patients in the previous study. All medical charts were reviewed with special attention to preobturation audiograms and to hearing evaluations up to and including the time of the study. With the exception of the audiometric studies on three patients, examined all others. Pure-tone air and bone conduction thresholds were determined in a sound-treated room with the use of the same recently calibrated audiometer. The study was a single otologic and audiologic evaluation done during midsummer 1971. we
RESULTS
Eighty-five percent of the original patients were contacted, and 67% were examined and had audiograms. The patients ranged in age from 17 to
33 years, with a median age of 20 years. As shown in Table 1, patients with cleft lip and palate made up 26 (74%) of 35 patients, and those with cleft palate only made up 9 (26%) of 35 patients. Twenty-nine (83%) of 35 patients had open or broken-down
palates, and six (17%) of 35 had short (unrepaired) palates. Obturators were
from 11 to 16 years, with a median period of wear being 14 years. All reported patients have worn obturators continually, with only occasional interruptions for replacement or modifications. Audiograms were summarized via worn
three-frequency averaging (500,1,000, and 2,000 Hz). As can be seen in Table 2, 43 (62%) ears had a 0- to 10-dB three-frequency average, 19 (27%) had an 11- to 20-dB three-frequency average, 1 (1%) ear had a 21- to 30-dB three-frequency average, and 7 (10%)
had greater than a 30-dB three\x=req-\ frequency average. A 2 x 4 X2 analysis was conducted on these data, comparing the preobturation and the 1971 values at the four levels of hearing loss. A significant overall effect was demonstrated (X2 9.26; df 3; P < .05). As shown in Table 2, there was a general hearing improvement of 4% for the 0- to 10-dB group, an 8% increase for the 11- to 20-dB group, a 16% decrease for the 21- to 30-dB group, and a 4% increase for the greater than 30-dB group. The overall three-frequency average was 7.30 dB for the ears with better hearing levels and 15.33 dB for those with poorer hearing levels. Table 3 shows means and median hearing levels for the right and left ears for the study by Goetzinger et al6 and for the present study. From this table, the mean hearing losses for the right ear at 500,1,000, and 2,000 Hz for the present study were 13.7, 9.2, and 6.9 dB, respectively. A 2 x 3 X2 analysis comparing mean hearing levels of the right ear of the study by Goetzinger et al6 and of the present study revealed no significant difference ears
=
=
(X2 \p=m-\0.06; df=2;P> .10). Likewise, mean hearing losses of the left ear in
Downloaded From: http://archotol.jamanetwork.com/ by a Penn State Milton S Hershey Med Ctr User on 05/28/2015
Table 1.—Clinical Data
Type of
Preobturation Procedures
Lesion* PO
Patient
LP
LP
Anterior palate repair
LP
Palate broken-down
PO LP 10
PO
11
LP
12
LP
13
LP
15
PO
Palate broken-down
16
PO
Palate broken-down
17
LP
Anterior
18
LP
21
LP
22
LP
23
LP
25
LP
26
PO
30
LP
31
LP
palate repair
Anterior
palate repair
Palate broken-down
palate repair
Anterior
PO, cleft palate only; LP, t Mx, myringotomy. *
cleft
Age at
Preobturation Time of Audiogram Insert, yr L-0 R-0 L-10 11 R-10 L-20 15 R-30 L-30 12 R-25 L-10 R-20 L-20 R-10 L-40 R-30 L-25 R-30 L-10 R-10 L-30 R-30 L-5 R-15 L-10 11 R-0 L-5 R-20 L-20 R-10 L-10 R-35
1971
Audiogram =
43(62%)"
20(19%) 18 (17%)
19 1
2
< .05)
(2
9.26;
18/F
13
Left ear Mx, 1966
24/M
11
26/M
16
28/M
18'
23/F
13
Left ear
L-7 R-10 L-18 R-8 L-18 R-7 L-15 R-5 L-12 R-12 L-2 R-5 L-12 R-13 L-38 R-13 L-0 R-0 L-23 R-18 L-8 R-38 L-20 R-3 L-3 R-8 L-8 R-10 L-0 R-0 L-2 R-5 L-12 R-13 L-15 R-13 L-15 R-12
Mx, 1967
20/M
15
20/F
15
21/F
15
24/M
16
21/M
17
Right ear, modified radical mastoidectomy, 1968
22/F
13
Left ear, modified radical mastoidectomy, 1965
24/M
17
21/M
15
21/M
14
19/F
14
19/M
13
18/F Both ears, Mx & tubes, 1967
19/F
17
22/F
11
18/F
~3
13
18/M
R-0 L-3 R-3
(27%) (1%) =
3.—Comparison of Hearing Levels in Two Adult Populations With Cleft Palate Hearing Levels, dB
Ears)
63(58%)~
=
Age Present (yr)/Sex Audiogran
13
70
>30_7(6%)_7(10%) 4 test dt
2
Present
Obturatedf
14
Table
Audiogram 108 ( Ears)
(
Procedures Since
lip and palate.
Preobturation =
Patients
Years Worn
L-10 R-0 L-20 R-20 L-25 R-10 L-20 R-10 L-0 R-0 L-0 R-0
Table 2.—Audiogram Results
Decibel Level 0-10 11-20 21-30
on
3;
Anthony Anthony (N 35) &
=
Hz
Right Ear
Left Ear
Goetzinger et al1 ( 42) =
Right Ear
Left Ear
Median Median Mean Mean Median Mean Median 15.0 10.0 15.8 12.3 12.4 10.0 15.0 11.3 10.0 5.0 5.0 5.0 11.0 5.0 1,000 10.0 5.0 5.0 11.3 5.0 8.9 7.6 2,000 Mean 11.3 10.3 2 3 2 mean for right ear is 2 = 0.06; dt = 2; > .10; that for left ear, 2 = 0.03; dr = 2; >.10. Wilcoxon comparison: mean for right ear is = 0.051, and that for left ear is = 0.052.
Frequency, 500
Mean 13.7 9.2 6.9
Downloaded From: http://archotol.jamanetwork.com/ by a Penn State Milton S Hershey Med Ctr User on 05/28/2015
this
study were 15.8, 11.3, and 11.3, respectively. A 2 x 3 2 analysis of the
data of Goetzinger et al" and those of the present study on the left ear revealed no significant difference ( 2 0.03; df=2;P> .10). A Wilcox=
comparison test (matched pairs signed rank test) failed to show any significant differences (Z —0.051, right ear; —0.52, left ear). on
=
=
Since the obturators were inserted, the status of the tympanic mem¬ branes remained the same in 26 (74%) of 35 patients but changed in 9 (26%) patients, with six showing improve¬ ment and three
tion.
showing
deteriora¬
There is no demonstrable correla¬ tion of age with hearing loss, nor can time of obturator use be correlated with hearing loss. (With the use of the Pearson product moment correlation coefficients, there was a correlation between years worn and hearing level in the left ear of r +.16, and that between years worn and hearing level in the right ear of r + .05). No consistent pattern of hearing deterioration in ears originally with greater than a 30-dB average hearing loss was noted. Examinations were done on six of the original seven ears with hearing loss of greater than 30 dB. Three had less than a 15-dB threefrequency average, and three contin¬ ued to have a 30-dB or greater hearing loss. =
=
COMMENT
Many explanations have been of¬ fered for the results obtained by many authors in describing their results. No pathophysiologic notes will be offered here. It is generally well recognized that after the age of 8 years a stabilization of pathologic findings of the ear, such as tympanic membrane scarring and
hearing loss,
occurs'-3 ""; as a result of this, the patient's age no longer correlates with the amount of his hearing loss. In the present study, this is true, since all patients are older than 8 years. The expected improve¬ ment of hearing levels is seen when results of preobturation examinations are compared with those of 1971 eval¬ uations. 2 analysis comparing preobturation and 1971 values demon¬ strated a significant overall effect
(X'2
9.26;d/=3;P
Hearing Loss Philip
F.
Anthony, MD,
Lois S.
Anthony,
MA
\s=b\ The effect of obturator treatment of cleft palate on middle ear disease and hearing loss has not been established. This study serves as an otologic and audiologic review of a previously reported adult population with cleft palate. A substantial improvement in hearing levels subsequent to obturation was demonstrated; however, it was believed to be based on stabilization of pathologic features of the ear with age. A statistically significant correlation of hearing level with length of use of prosthesis or with type of lesion could not be demonstrated. Results are compared with those reported on the only other adult population with cleft palate. Prosthetic management of cleft palates is not shown to be detrimental, as has been generally thought.
(Arch Otolaryngol 102:151-153, 1976)
The effect, beneficial
or
deleteri-
study is a moderate range retrospective study of the same group of patients that Graham et al1 evaluated approximately ten years ago. The purpose of the study is to provide the only study of the hearing status of adult patients with cleft palates treated with prostheses. The present
METHODS Clinical Data
Thirty-six of the original 54 (67%) patients studied by Graham et al1 were examined, and audiograms were recorded. Of the original 27 male and 27 female patients, 21 male and 14 female patients were examined. All patients who were reexamined had been followed up at varying intervals by otolaryngologists and prosthodontists at the Department of Otolaryngology and Maxillofacial Surgery of the University of Iowa Hospitals.
ous, of obturator treatment of
cleft palates on middle ear disease has not been resolved.1-5 Masters et al3 have reported that as high as 78% of patients with cleft palate treated with obturators had a hearing loss of greater than 10 dB. Graham et al1 reported that only 19% of their patients had greater than a 10-dB hearing loss after they had worn obturators from one to eight years. The literature, with regard to the effect of obturator treatment of cleft palates on hearing levels, is limited. Each study has multiple criteria for use of the prosthesis and different methods of presenting data so that only through careful study can comparisons be made and conclusions be drawn from the data available.
Accepted
for publication Nov 11, 1975. From the Department of Otolaryngology, Baylor College of Medicine (Dr Anthony), and the Houston Ear, Nose and Throat Hospital Clinic (Ms Anthony), Houston. Reprint requests to 662 S Henderson, Fort Worth, TX 76104 (Dr Anthony).
Procedure An attempt
was
made to contact all
patients in the previous study. All medical charts were reviewed with special attention to preobturation audiograms and to hearing evaluations up to and including the time of the study. With the exception of the audiometric studies on three patients, examined all others. Pure-tone air and bone conduction thresholds were determined in a sound-treated room with the use of the same recently calibrated audiometer. The study was a single otologic and audiologic evaluation done during midsummer 1971. we
RESULTS
Eighty-five percent of the original patients were contacted, and 67% were examined and had audiograms. The patients ranged in age from 17 to
33 years, with a median age of 20 years. As shown in Table 1, patients with cleft lip and palate made up 26 (74%) of 35 patients, and those with cleft palate only made up 9 (26%) of 35 patients. Twenty-nine (83%) of 35 patients had open or broken-down
palates, and six (17%) of 35 had short (unrepaired) palates. Obturators were
from 11 to 16 years, with a median period of wear being 14 years. All reported patients have worn obturators continually, with only occasional interruptions for replacement or modifications. Audiograms were summarized via worn
three-frequency averaging (500,1,000, and 2,000 Hz). As can be seen in Table 2, 43 (62%) ears had a 0- to 10-dB three-frequency average, 19 (27%) had an 11- to 20-dB three-frequency average, 1 (1%) ear had a 21- to 30-dB three-frequency average, and 7 (10%)
had greater than a 30-dB three\x=req-\ frequency average. A 2 x 4 X2 analysis was conducted on these data, comparing the preobturation and the 1971 values at the four levels of hearing loss. A significant overall effect was demonstrated (X2 9.26; df 3; P < .05). As shown in Table 2, there was a general hearing improvement of 4% for the 0- to 10-dB group, an 8% increase for the 11- to 20-dB group, a 16% decrease for the 21- to 30-dB group, and a 4% increase for the greater than 30-dB group. The overall three-frequency average was 7.30 dB for the ears with better hearing levels and 15.33 dB for those with poorer hearing levels. Table 3 shows means and median hearing levels for the right and left ears for the study by Goetzinger et al6 and for the present study. From this table, the mean hearing losses for the right ear at 500,1,000, and 2,000 Hz for the present study were 13.7, 9.2, and 6.9 dB, respectively. A 2 x 3 X2 analysis comparing mean hearing levels of the right ear of the study by Goetzinger et al6 and of the present study revealed no significant difference ears
=
=
(X2 \p=m-\0.06; df=2;P> .10). Likewise, mean hearing losses of the left ear in
Downloaded From: http://archotol.jamanetwork.com/ by a Penn State Milton S Hershey Med Ctr User on 05/28/2015
Table 1.—Clinical Data
Type of
Preobturation Procedures
Lesion* PO
Patient
LP
LP
Anterior palate repair
LP
Palate broken-down
PO LP 10
PO
11
LP
12
LP
13
LP
15
PO
Palate broken-down
16
PO
Palate broken-down
17
LP
Anterior
18
LP
21
LP
22
LP
23
LP
25
LP
26
PO
30
LP
31
LP
palate repair
Anterior
palate repair
Palate broken-down
palate repair
Anterior
PO, cleft palate only; LP, t Mx, myringotomy. *
cleft
Age at
Preobturation Time of Audiogram Insert, yr L-0 R-0 L-10 11 R-10 L-20 15 R-30 L-30 12 R-25 L-10 R-20 L-20 R-10 L-40 R-30 L-25 R-30 L-10 R-10 L-30 R-30 L-5 R-15 L-10 11 R-0 L-5 R-20 L-20 R-10 L-10 R-35
1971
Audiogram =
43(62%)"
20(19%) 18 (17%)
19 1
2
< .05)
(2
9.26;
18/F
13
Left ear Mx, 1966
24/M
11
26/M
16
28/M
18'
23/F
13
Left ear
L-7 R-10 L-18 R-8 L-18 R-7 L-15 R-5 L-12 R-12 L-2 R-5 L-12 R-13 L-38 R-13 L-0 R-0 L-23 R-18 L-8 R-38 L-20 R-3 L-3 R-8 L-8 R-10 L-0 R-0 L-2 R-5 L-12 R-13 L-15 R-13 L-15 R-12
Mx, 1967
20/M
15
20/F
15
21/F
15
24/M
16
21/M
17
Right ear, modified radical mastoidectomy, 1968
22/F
13
Left ear, modified radical mastoidectomy, 1965
24/M
17
21/M
15
21/M
14
19/F
14
19/M
13
18/F Both ears, Mx & tubes, 1967
19/F
17
22/F
11
18/F
~3
13
18/M
R-0 L-3 R-3
(27%) (1%) =
3.—Comparison of Hearing Levels in Two Adult Populations With Cleft Palate Hearing Levels, dB
Ears)
63(58%)~
=
Age Present (yr)/Sex Audiogran
13
70
>30_7(6%)_7(10%) 4 test dt
2
Present
Obturatedf
14
Table
Audiogram 108 ( Ears)
(
Procedures Since
lip and palate.
Preobturation =
Patients
Years Worn
L-10 R-0 L-20 R-20 L-25 R-10 L-20 R-10 L-0 R-0 L-0 R-0
Table 2.—Audiogram Results
Decibel Level 0-10 11-20 21-30
on
3;
Anthony Anthony (N 35) &
=
Hz
Right Ear
Left Ear
Goetzinger et al1 ( 42) =
Right Ear
Left Ear
Median Median Mean Mean Median Mean Median 15.0 10.0 15.8 12.3 12.4 10.0 15.0 11.3 10.0 5.0 5.0 5.0 11.0 5.0 1,000 10.0 5.0 5.0 11.3 5.0 8.9 7.6 2,000 Mean 11.3 10.3 2 3 2 mean for right ear is 2 = 0.06; dt = 2; > .10; that for left ear, 2 = 0.03; dr = 2; >.10. Wilcoxon comparison: mean for right ear is = 0.051, and that for left ear is = 0.052.
Frequency, 500
Mean 13.7 9.2 6.9
Downloaded From: http://archotol.jamanetwork.com/ by a Penn State Milton S Hershey Med Ctr User on 05/28/2015
this
study were 15.8, 11.3, and 11.3, respectively. A 2 x 3 2 analysis of the
data of Goetzinger et al" and those of the present study on the left ear revealed no significant difference ( 2 0.03; df=2;P> .10). A Wilcox=
comparison test (matched pairs signed rank test) failed to show any significant differences (Z —0.051, right ear; —0.52, left ear). on
=
=
Since the obturators were inserted, the status of the tympanic mem¬ branes remained the same in 26 (74%) of 35 patients but changed in 9 (26%) patients, with six showing improve¬ ment and three
tion.
showing
deteriora¬
There is no demonstrable correla¬ tion of age with hearing loss, nor can time of obturator use be correlated with hearing loss. (With the use of the Pearson product moment correlation coefficients, there was a correlation between years worn and hearing level in the left ear of r +.16, and that between years worn and hearing level in the right ear of r + .05). No consistent pattern of hearing deterioration in ears originally with greater than a 30-dB average hearing loss was noted. Examinations were done on six of the original seven ears with hearing loss of greater than 30 dB. Three had less than a 15-dB threefrequency average, and three contin¬ ued to have a 30-dB or greater hearing loss. =
=
COMMENT
Many explanations have been of¬ fered for the results obtained by many authors in describing their results. No pathophysiologic notes will be offered here. It is generally well recognized that after the age of 8 years a stabilization of pathologic findings of the ear, such as tympanic membrane scarring and
hearing loss,
occurs'-3 ""; as a result of this, the patient's age no longer correlates with the amount of his hearing loss. In the present study, this is true, since all patients are older than 8 years. The expected improve¬ ment of hearing levels is seen when results of preobturation examinations are compared with those of 1971 eval¬ uations. 2 analysis comparing preobturation and 1971 values demon¬ strated a significant overall effect
(X'2
9.26;d/=3;P
