• sharp pains in the ear with no fever
• wakeful nights
• irritability

Problems with balance may show up in a child's general clumsiness or inability to master riding a bike.

Hearing Assessment

If hearing loss is suspected, the child should have hearing tests performed by an Audiologist (Also see Section 15 on Audiology).

It is important to remember that hearing can be tested at any age.

Management of Otitis Media with Effusion

If fluid is recognised in the very young child it should be drained and small tubes inserted into the eardrum to allow ventilation of the middle ear and to prevent or minimise any damage to the developing language centres.

In the past if the condition was recognized before the palate was closed and there was no pain, it was recommended that treatment be delayed until three months after the palate closure. It was believed that after the palate was closed the fluid would resolve in some children. However this is now not thought to be correct and the major risk to the developing language centres is too great to allow the possibility of natural resolution of their middle ear problem.

The risks associated with insertion of ventilation tubes are much less than the risks of creating a permanent language impairment.

In the older child, if persistent fluid is noted at the beginning of summer and the child is old enough to learn to swim, then this is encouraged, as it is believed swimming improves the eustachian tube function.

In all other children, if fluid is present for longer than three months or if the child is having considerable hearing impairment or suffering earache or balance disturbance, then the fluid needs to be drained. This is performed usually under general anaesthetic, when the eardrum is inspected with an operating microscope and a very small, carefully placed incision is made into the In all other children, if fluid is present for longer than three months or if the child is having considerable hearing impairment or suffering then the drum. Through this incision the middle ear is inspected and the presence of fluid is confirmed.

Some fluid is removed by gentle suction and a small tube or grommet is inserted through the incision and left in place. This tube helps to ventilate the middle ear, and to alter the imbalance between the secretion and absorption of the fluid. Once this occurs, hearing should return to normal. Even though there is a small hole in the eardrum, hearing is not affected by the tube or the hole. Three to four weeks after the tube insertion, another audiogram is performed to determine if the tube is functioning and if hearing has returned to normal.

The tube usually stays in place for between six and twelve months. After this time the body slowly causes the tube to come out. If the local doctor notices that the tube is out of the ear drum, the ENT surgeon can usually remove it from the ear canal with very little discomfort to the child. Sometimes the parents may see the tube in wax in the outer part of the ear canal. As the tube comes out, the eardrum heals by itself in almost every case. If it doesn't heal and the child is of an age when there is little likelihood of further ear infection, the ENT surgeon may need to perform a small procedure to close the perforation. This is very uncommon and is not usually performed before 8 years of age.

Most ENT surgeons recommend that no water be allowed in the ear while the tube is in place. This is very important if the child's head is likely to be put under water as in swimming or in the bath. If water fills the ear canal, it is likely to pass through the tube into the middle ear where the very delicate membrane is unable to protect itself and hence infection can occur. Water can be kept out by using:

• a cottonwool or lambswool plug covered in vaseline
• a swimming cap
• Blu-Tack or silicone 'ear putty' rolled into a round ball and placed in the outer part of the ear to act as a plug or
• custom-fitted plugs, usually of silicone rubber, made by some ENT surgeons or by companies that make hearing aids

In a small proportion of children, fluid returns and this may require reinsertion of the ventilating tube. More rarely, the persistent fluid or recurrence of infections leads to permanent eardrum damage. This may require special surgery to repair the defect. The operation to correct the middle ear defect is termed a TYMPANOPLASTY.

Since the advent of ventilation tubes more serious middle ear problems have been avoided in most children.

It is more likely that serious middle ear damage and/or permanent hearing problems will occur if the fluid is not treated or left to resolve spontaneously.

Nose and Sinus

A child with a cleft lip and palate does not have a greater incidence of upper respiratory tract infections, sinus infection or allergy than the non-cleft population.

A child with a unilateral cleft lip and palate almost always has some deformity of the nasal septum. The nasal septum is a central partition of cartilage, bone and mucous membranes in the nose, separating it into right and left cavities. The main part of the septal deformity is towards the side of the cleft.

In the young infant the nasal septal deformity is noted before the cleft is repaired. After repair, there is usually little trouble with the airway until the child becomes older (4-8 years). The septum appears to grow across and above the closed palate.

14.3 Nasal septal deformity

This deformity usually only occurs in children who have had a complete cleft lip and palate, and does not occur with any greater frequency in a child with a pure cleft palate or with a cleft lip alone.

The correction of a septal deformity is usually delayed until teenage years, but it may need to be performed earlier if there are troublesome symptoms of nasal obstruction (blocked nose).

The usual indications for repair are:

• obstruction leading to mouth breathing
• persistence of one-sided discharge
• as a prelude to cosmetic rhinoplasty
• in association with sinus surgery.

The repair of the nasal septum is termed a SEPTOPLASTY.

Often the nasal obstruction is aggravated by a thickness of the outer side of the nostril, called the lateral alar region. This thickness is not usually corrected early as the tissue may be required for later cosmetic surgery to the nose.

Sinus Surgery

With advances in surgery and investigations diseases of the sinuses and nose have been better understood. Patients with symptoms of sinusitis eg. headaches, chronic nasal discharge, persistent cough, are able to be investigated and treated with much greater accuracy. Surgery to the sinuses is much less invasive and traumatic. The surgery aims to return the nasal sinuses to normal function. This surgery is termed FUNCTIONAL ENDOSCOPIC SINUS SURGERY OR F.E.S.S.

Adenoids

Adenoids are a mass of lymphoid tissue situated at the back of the nose and above the soft palate. The adenoids can only be seen with special instruments. The adenoids can enlarge, causing obstruction behind the nose, and this usually presents as snoring or persistent mouth breathing. Removal of adenoids in a patient with a cleft palate is rarely, if ever, indicated. The palate often closes onto the adenoid pad in speech and not onto the back wall of the pharynx. Removal of the adenoids in these patients interferes with this closure and may lead to hypernasal speech ('cleft palate speech') even if the palate has been closed with an excellent result.

Adenoid size, palatal thickness, length and palatal movement patterns can be assessed by a lateral airway x-ray or VIDEOFLOUROSCOPY (soft palate study).

The nasal cavity and adenoid area can also be visualised with fibreoptic equipment. This procedure is termed NASENDOSCOPY.

Tonsils

The pharyngeal tonsils are situated on the lateral or side wall of the pharynx and lie between two folds of tissue that contain the muscles extending from the soft palate to the tongue and pharynx. The tonsils are usually visible as small bulges on the outer side of the pharynx, extending just above the back of the tongue.

Children with cleft lip and palate do not get recurrent tonsillitis with any greater frequency than the rest of the population. Sometimes the frequency and severity of the attacks of tonsillitis may lead to decision to remove the tonsils (tonsillectomy). This operation should only be performed after consulting the ENT surgeon on the cleft palate team or the plastic surgeon looking after the child.

14.4 Tonsils

Voice

Disorders of the larynx sometimes can be seen in children with cleft palates. Persistent huskiness needs to be investigated and consultation with a speech pathologist and ENT surgeon is important. Very rarely, small thickenings on the vocal cord, called vocal nodules, are seen, and in The New Children's Hospital Cleft Palate Clinic this condition is quite uncommon. Speech therapy usually avoids most of the laryngeal disorders.

The vocal cords can be viewed by the ENT surgeon by using mirrors or flexible fibre optic instruments.

Further Information

To obtain further information on "Cleft Lip and Palate: A Parent's Guide", please contact Belinda Liston:

Belina Liston
Cleft Palate Clinic Coordinator
The Cleft Palate Clinic
The Children's Hospital at Westmead
Locked Bag 4001
WESTMEAD NSW 2145
AUSTRALIA
T: + 61 2 9845 2079
F: + 61 2 9845 2078
E: BelindaS4@chw.edu.au