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By Mr. Tim Mitchell, Consultant ENT Surgeon, Royal Southampton Hospital

Hearing is important in the development of speech and language, learning and behaviour.

There are 3 kinds of reasons for hearing loss:

1. Inner ear problems (sensorineural hearing loss, essentially nerve damage)
2. Middle ear problems (conductive hearing loss)
3. Outer ear problems (conductive hearing loss)

Conductive hearing loss can be treated by surgery or hearing aids, while sensorineural hearing loss cannot be surgically treated.

Children born with clefts palates are prone to hearing loss due to middle ear problems, specifically glue ear.

It is not really known why glue ear develops, but it is thought that it is due to poor eustachian tube function. The eustachian tube connects the middle ear to the back of the nose, and its purpose is to equalise the air pressure between these two areas. If it doesn't work properly, there might be differences in pressure between the middle ear and the nose, and the lining of the middle ear can produce mucus. This mucus (the ‘glue' in glue ear) is not dangerous, but it does affect the transmission of sound through the middle ear and therefore impairs hearing.

Risk factors for glue ear include:

• Cleft palate
• Gender (boys are more likely than girls to develop glue ear)
• Formula milk (breast-fed babies tend to develop glue ear less often)
• Childcare facilities (children who spend time with lots of other children are more likely to
• Parental smoking

Treatment Options:

A. Do nothing.
B. Get rid of the glue ear
C. Ignore the glue ear, but boost hearing

A. Do nothing

This is an option if the glue ear is not too severe and if it seems likely that the child will grow out of it in the near future. Many children not born with clefts develop glue ear, and this is a valid option for many of them. A child born with a cleft palate is much less likely to grow out of it quickly, and this is therefore not usually a good option for them, since speech and language development, learning and behaviour could all be affected if hearing is impaired over a longer period of time.)

B. Get rid of the glue ear

There are 2 ways of treating glue ear surgically:

1. Inserting grommets (a grommet is, in essence, an artificial eustachian tube inserted into the ear drum which equalises pressure continuously)
2. An adenoidectomy (this is an operation to remove the adenoids). This is not usually considered for children born with cleft palate, since it could affect the ability of the palate to form a seal with the back of the mouth and therefore affect speech.)

It is thought that grommets could help prevent middle ear damage, since there is a possibility that long-term glue ear can cause ear damage if it is left untreated. However, there are also disadvantages:

• Inserting grommets requires an operation and therefore a general anaesthetic. This is why grommets are often inserted at the time of a palate repair or another operation.
• They fall out, usually after 9-12 months
• They can cause infections (though this is uncommon)
• They can cause perforations and scarring to the ear drum.

C. Ignore the glue ear and boost hearing

Using hearing aids can improve hearing and avoid an operation. However, as with grommets, there are disadvantages:

• Children can't wear them all the time (e.g. in bed or when swimming).
• They require maintenance (new moulds as a child's ears grow, batteries, someone needs to know how to turn them on and off and how to adjust volume settings)
• They advertise hearing loss (however, younger children tend to cope with hearing aids very well in this respect. Their friends don't tend to notice anything different about them)
• Hearing aids have no effect on middle ear disease.

It is possible to use grommets and hearing aids in combination, though this could increase the chances of infection. If this is the treatment option and the child does develop an infection, the grommets may have to be removed.

T-tubes (a larger type of grommet that is less likely to fall out) are sometimes used in older children, but they are too big for most small children and are also more likely to causescarring and perforation.

In conclusion

It is important to treat hearing loss since it is such an important aspect of a child's development. It is not, however, possible to have a general preference for one treatment method over another. Every child is different and will have different needs. Treatment choices will depend on the individual needs of each particular child.