Natural History of Tympanic Membrane Retraction in Children with Cleft Palate

Abstract

Objectives: The natural history of tympanic membrane retraction is unpredictable. To obtain prognostic information for guiding surveillance and treatment, a cohort of children with retraction from cleft palate were prospectively followed for over 5 years.

Materials and methods: This was a prospective observational study at a tertiary academic institution. Children with pars tensa retraction were selected from a cohort of 143 children with cleft palate. Thirty-seven ears were assessed with otoendoscopic image capture and audiometry at a median age of 9 years and reassessed at a median follow-up interval of 6.4 years. The severity of tympanic membrane retraction in the serial images of each ear was compared by four pediatric otolaryngologists blinded to the dates of the images.

Results: Initially, 19/37 retractions (51%) demonstrated contact with the incus and/or promontory. Follow-up images were rated as stable (n=16) or better (n=12) for 28/37 retractions (76%). Of the nine retractions that became more extensive, two developed cholesteatoma (5% of the total). No ossicular erosion developed in ears without cholesteatoma. Conductive hearing loss (4-tone average air-bone gap >25 decibels hearing level) was initially present in five ears, worsened in one, and normalized without intervention in others. No ears with initial normal hearing developed hearing loss.

Conclusion: Most tympanic membrane retractions remained stable or improved over time in this cohort of children who were at a risk of persistent eustachian tube dysfunction. Clinically significant progression occurred infrequently, justifying the conservative approach taken to manage these retractions. Such data are necessary to weigh the potential benefit of preventive intervention over observation.

Figure 1. a, b

Serial otoendoscopic images taken of the right tympanic membrane in a child with cleft palate. (a) Pars tensa retraction contacting the promontory, long process of the incus, stapes capitulum, and stapedius tendon. (b) Spontaneous lateralization of the retraction noted 7 years later with no further evidence of any ossicular contact

Figure 2. a, b

Otoendoscopic images taken of the right tympanic membrane from the same ear on the same day. (a) Diffuse retraction of the pars tensa with obvious ossicular contact but no definitive erosion of the incus. (b) Change in angulation of the scope clearly demonstrates distal erosion of the incus long process