International Journal of Pediatric Otorhinolaryngology 115 (2018) 38–40

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International Journal of Pediatric Otorhinolaryngology

journal homepage: www.elsevier.com/locate/ijporl

Cleft lip and palate associated hearing loss in Brazilian children T

a,∗ b c
Ricardo Neves Godinho , Tania Sih , Cássio da Cunha Ibiapina ,
Márcia Helena Miranda de Freitas Oliveirad, Ana Luiza de Freitas Rezended,
Renata Victória Tassarae
a
College of Medical Sciences of Minas Gerais, Pontifical Catholic University of Minas Gerais, Brazil
b
Medical College of University of São Paulo, São Paulo, Brazil
c
Medical College of Federal University of Minas Gerais, Brazil
d
Federal University of Minas Gerais, Brazil
e
College of Medical Sciences of Minas Gerais, Brazil

A R T I C LE I N FO A B S T R A C T

Keywords: Introduction: Cleft lip and palate children have chronic otitis media related to Eustachian Tube dysfunction and
Cleft palate associated conductive hearing loss. In this group of children, communicative skill development limitations, in
Conductive hearing loss association with orofacial aesthetics and functional disorders, can lead to behavioral, educational and social
Children problems.
Ventilation tubes
Methods: We evaluated the minimum hearing threshold and the air-bone gap (ABG) in a range from 500 to
Air-bone gap
4000 Hz for 4–14 years old cleft lip and palate children (CLPC). This cross-sectional study took place in a
multiprofessional tertiary care center and involved 89 CLPC with bilateral or unilateral postforamen or trans-
foramen malformation, divided into two groups: those aged 4–7 and 8–14 years. The hearing tests of 89 children
were evaluated: 53 (group I) aged from 4 to 7 years (67.9% male) and 36 (group II) aged from 8 to 14 years
(55.6% female).
Results: The minimum hearing threshold 500-4 KHz mean (MHT 500-4 KHz) was 19.4 dB for all children. MHT
500-4 KHz was 21.2 dB and 17.5 dB respectively for the group I and group II. Both groups demonstrated a
minimum hearing threshold of up to 70 dB at certain frequencies. The global ABG 500-4 KHz average was
16.6 dB (SD 12.5): 19.7 dB (SD 12.9) in group I and 13.2 dB (SD 11.1) in group II.
Conclusion: The worst hearing thresholds were found in children of 4–7 years old: 21.2 dB MHT 500-4 KHz and
19.7 ABG 500-4 KHz, what is a disadvantage for them, as the normal hearing thresholds are up to 15 dB. The
children of 8–14 years old had MHT 500-4 KHz of 17.5 dB, and ABG 500-4KHZ OF 13.2 with up to 70 dB of
hearing loss.

1. Introduction
Children with orofacial clefts affecting the palate (post-foramen and
transforamen) often exhibit important changes in tubal cartilage and
along the course and insertion of the tensor veli palatine and levator
veli palatine muscles due to the absence of union between the muscle
fibers on both sides, at the soft palate midline [1]. The tensor veli pa-
latine muscle is responsible for the opening and closing of the Eu-
stachian tube, and when this structure does not function properly, it
compromises the ventilation and gas exchanges of the mastoid and
middle ear and creates conditions for the persistence of otitis media
with chronic effusion. In addition, there are structural changes of the
eardrum, such as retractions, atelectasis and perforations [2–5].
Effusion in the middle ear and changes in the eardrum causes dif-
ficulties in the transmission of sound, which restricts the process in-
volved in the organization and categorization of acoustic information
(auditory processing) [3].
Whether related to repeat infections or not, these changes lead to
conductive hearing loss that may be reversible or not [1,6–11].
Hearing loss, even at light to moderate levels, greatly interferes with
the perception of spoken language. According to descriptions by
Northern and Downs, chronic childhood hearing disorders may man-
ifest themselves, as a reduction in auditory comprehension, which
could result in incapacity to learn. This type of situation can aggravate
the social and educational impact caused by the facial differences and
the frequent articulatory alterations in children with cleft lip/palate

∗
Corresponding author. Aimores street, 888 – Funcionarios, Belo Horizonte, Minas Gerais, 30 140 904, Brazil.
E-mail address: drricardogodinho@gmail.com (R.N. Godinho).

https://doi.org/10.1016/j.ijporl.2018.08.038
Received 26 April 2018; Received in revised form 7 August 2018; Accepted 29 August 2018
Available online 31 August 2018
0165-5876/ © 2018 Published by Elsevier B.V.
R.N. Godinho et al. International Journal of Pediatric Otorhinolaryngology 115 (2018) 38–40

[12]. Table 1
Descriptive analysis of the ABG in the entire sample.
2. Objective

Evaluate the audiometric profile of children with cleft palate treated

at a specialized center for craniofacial anomalies in Belo Horizonte, one
of Brazil's three most influential capitals.

3. Material and methods

This study was approved by the Research Ethics Committee (COEP)

numero de registro no COEP. It is a historical cohort study, carried out
between 2008 and 2010 at CENTRARE (Centro de Tratamento e
Table 2
Reabilitação de Fissuras Labiopalatais e Deformidades Craniofaciais,
Descriptive analysis of the ABG in group I.
Belo Horizonte, Brazil), with cross-sectional analysis of children with
labiopalatine fissures (cleft lip/palate). Frequency Ranges Descriptive measurements (Hz)

We evaluated the audiometric tests of 89 children with cleft lip and in Hz Median Mean SD
palate (transforamen and post-foramen) aged between 4 and 14 years,
split into two groups: from 4 to 7 years of age (group I) and 8–14 years 500 23.0 25.0 15.5
of age (group II). Group I was composed of 53 children (67.9% male) 1000 20.0 21.1 15.7
2000 10.0 13.3 12.0
and group II of 36 children (55,6% female). All the children who visited
4000 15.0 19.4 13.7
the center and had audiologic testes on the time studied were included.
Among the children of group I, 62,3% of the cleft lip and palate OVERALL 16.3 19.7 12.9
were transforamen; 33,7% were post-foramen. In group II, 61,1% were
transforamen/30,6% were post-foramen; and 8,3% were submucuous.
Children underwent tonal threshold audiometry in both ears to as- Table 3
sess tonal thresholds for air and bone conduction pathways (examina- Descriptive analysis of the ABG in group II.
tion performed in an acoustic cabin, using a Midimate 622 – Madsen Frequency Ranges Descriptive measurements (Hz)
audiometer). The audiometric examinations were provided by the
CENTRARE audiologists. in Hz Median Mean SD

We used the Hearing Threshold Range (HT) for air and bone con- 500 10.0 17.5 15.6
duction pathways. The HT Mean was calculated for 500, 1000, 2000 1000 10.0 12.3 13.6
and 4000 Hz. The air-bone gap (ABG) is the difference between the HT 2000 5.0 6.6 8.9
of the air and bone conduction pathways. 4000 15.0 16.4 13.3
The normal values for speech frequency, for children under 7 years
OVERALL 8.8 13.2 11.1
old (group I), are from 0 to 15 dBNA, according to Northern and Downs
[12], while the normal values for children over 7 years old (grupo II),
are from 0 to 25 dBNA, according to Lloyd and Kaplan [13]. II.
In our statistical analysis, we used the measurements of minimum,
maximum, mean and standard deviation. In order to compare groups
for the incidence of an event between two categorical variables, the chi- 5. Discussion
squared and Fischer exact tests were used.
Results with a probability of significance lower than 5% (p < 0.05) From all the children who visited the center and had audiologic tests
were considered statistically significant. on the time studied, 27 of the 89 children presented normal hearing
bilaterally and 12 had unilateral normal hearing. Therefore 62 children
4. Results had abnormal hearing tests.
Tests performed on children from group I and II showed that the HT
HT analysis by airway at 4 frequencies (500, 1,000, 2000 and was 21.2 and 17.5 dBNA. Although, analysing the entire sample (chil-
4000 Hz) showed a mean of 19.4 dBNA for all children (aged from 4 to dren aged from 4 to 14 years), at 500 Hz, it was observed the lowest HT
14 years). In group I, HT mean was 21.2 dBNA and 17.5 dBNA in group found was 0 dBNA in bone pathway conduction and the highest was
II. 70 dBNA in airway conduction. At 4000 Hz the lowest HT found was
Descriptive analysis of the ABG at the frequencies of 500, 1,000, −10 dBNA in bone pathway conduction and the highest was 65 dBNA
2000 and 4000 Hz among the sample demonstrated that audiometric in airway conduction.
measurements ranged between −10 dBNA in bone pathway conduction Similar to other authors on the topic, this study indicates an ex-
and 70 dBNA in airway conduction, with an overall ABG (Table 1) mean pressive number of children with cleft lip/palate presenting patterns of
of 16.6 dBNA. conductive hearing loss [3–6,14]. Analysis of the ABG was therefore
The audiometric results from group I showed an ABG mean of carried out with the aim of measuring the potentially reversible hearing
19.7 dBNA (Table 2). disorder. Throughout the sample, the overall ABG mean was
The audiometric results from group II showed an ABG mean of 16.6 dBNA. In group I, the ABG mean was 19.7 dBNA,. In group II, the
13.2 dBNA (Table 3). ABG mean was 13.2 dBNA. In this way, the younger childrenshow
According to the classifications of Northern and Downs [12] and conductive hearing loss of greater intensity during the period in which
Lloyd and Kaplan [13], 27 of the 89 children presented normal hearing they are developing important socialization and learning skills. Ac-
bilaterally: 8 from group I, and 19 from group II. The ones who pre- cording to Imbery, TE et al., patients with cleft palates have eustachian
sented normal hearing only in the left (5 in total) side were 3 children tube dysfunction which results in persistent conductive hearing loss,
of group I, and 2 children of group II. Finally, 7 children presented highlighting the importance of long-term follow-up [15].
normal hearing only in the right side: 2 from group I and 5 from group Although the older children had mean HT within normal ranges,

39
R.N. Godinho et al.
and mean ABG lower than the younger children, group II probably
demonstrated more significative hearing disorders in the initial phases
of language acquisition and literacy. While they may have tested within
the normal range for hearing, we cannot exclude the possible auditory
processing changes that could influence the development of their cog-
nitive and school skills to a greater or lesser degree.
Treating children with cleft lip/palate therefore requires a multi-
profissional team and hearing care should begin in the first months of
life. Short-term and long-term benefits include achieving the desired
learning for each age range, a reduction in ear infections with a cor-
ollary decrease in complications, such as tympanic perforation and
cholesteatoma formation [7]. Inadequate treatment is costly and has a
serious impact on the quality of life of both the children and their fa-
milies. Each service must reassess its routine with the aim of providing
the best conditions for each patient in the distinct areas that involve
orofacial clefts such as speech, swallowing, breathing and hearing, as
well as adequate social insertion. [16], [17], [18].
The surgical approach to children with cleft lip/palate is a special
challenge in developing countries and all efforts must be made to
transform the reality of these patients, giving them the support they
deserve. We cannot allow a reversible hearing disorder, which can be
treated through a straightforward and low-cost procedure, as a venti-
lation tube insertion, to become an obstacle to the adequate intellectual
development of the child, compromising his/her full and proper social
inclusion.
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