CONCLUSIONS
A major striking data is deriving from this systematic review: despite
promising - albeit preliminary - results for adenoidectomy in treating
middle ear disease in the CP±L population, research in this field seems
to have stopped in the mid-Seventies. This happened despite all articles
included in this review report adenoidectomy (either with or
tonsillectomy) as a valuable tool in treating middle ear disease in this
population. A single article [18] failed to achieve statistical
significance in its (albeit positive) results and suggested age as a
major confounder for the results in this population. This objection has
been indeed confirmed by studies confirming that middle ear disease in
CP±L children tends to improve with age[5].
It might be objected that the articles included in the systematic review
lack a prospective design and their methodology - unremarkable in their
historic context - might not hold up to today’s technological standards.
Nevertheless, upon rating and review, they all appear to have been
conducted meticulously, and their content cannot be ignored.
Studies on the role of adenoidectomy in this population have been
hampered by the constant fear that the procedure could have detrimental
effects on the velopharyngeal function, often already impaired in this
patient group[19]. This relatively common sequela of adenoidectomy
has been linked to specific morphological characteristics [20,21],
with a globally heterogeneous prevalence across studies. It has to be
noted that even such a low incidence of velopharyngeal insufficiency in
the selected studies appears too optimistic not to be related to a
methodological bias in reporting complications. Such a hypothesis
becomes even more realistic if we take a closer look at the speech
evaluation methods used in the reviewed articles and to the scattered
data reporting, as already described in the results. Furthermore, these
evaluations nevertheless do not take into account the evolutions of the
adenoidectomy technique in the endoscopic era. Not only power-assisted
adenoidectomy has become a reliable tool in the general pediatric
population [22], but its use in performing selective adenoidectomies
has been widely demonstrated as a safe and reproducible tool also in the
CP±L population with no detrimental effect on speech [23] and
velopharyngeal insufficiency[13,24]. Unfortunately, no study at
present evaluated partial endoscopic adenoidectomy for middle ear
disease in cleft patients.
It is also to be noted that current scientific reports confirm that
adenoidectomy still represents a treatment choice in CP±L, despite its
indications being presently limited to nasal breathing difficulties and
obstructive sleep apnoea[25,26].
Therefore if we take into account:
a) the preliminary good results on middle ear disease reported in the
original, albeit outdated works on adenoidectomy in cleft children;
b) the introduction of less invasive modern endoscopic partial
adenoidectomy techniques;
c) the efficacy of adenoidectomy in treating OME also in large scale
meta-analysis; and
d) the routine use of adenoidectomy in the cleft population of other
indications.
It comes as a surprise that no prospective studies on this subject have
been proposed. The extremely wide use of tympanostomy as a first-line
treatment for OME and ORCHL in this patient group represents a further
direct consequence of the paucity of data on adenoidectomy and middle
ear disease in the cleft population.
It has to be noted that this systematic review is limited in its
strength as it included all article types, focusing on a wide range of
middle ear conditions and with heterogeneous evaluation tools, but the
lack of a significant bulk of literature on the subject made any further
refinement impossible. Nevertheless, a call for stronger evidence on the
subject emerges preponderantly. An unclear aspect of this review is
worth examining in-depth, i.e. the relationship in the CP±L population
between tympanostomy and adenoidectomy. As much as this interplay is
important, only one reviewed study reported performing tympanotomy in
nearly all patients, but with an unclear timing, while tympanostomy
wasn’t apparently performed on these patients. This overall management
clashes with current trends in CP±L patients with middle ear disease, so
the results in these regards should be further put into context with
future studies. Our literature review furthermore showed a complete lack
of evidence in the use of tympanostomy tubes concurrent with
adenoidectomy in the CP±L population, as no studies addressing this
particular subgroup was identified.
In the present context of middle ear disease in the cleft population, it
would be unreasonable to suggest adenoidectomy as an alternative to
tympanostomy. There is nevertheless a specific area of intervention
where adenoidectomy could represent a powerful additional tool that
requires urgent investigation. Cleft patients requiring re-tympanostomy
(a population with a known higher risk of long-term otologic
sequelae[5]) might benefit from concurrent tympanostomy and
adenoidectomy to lower the risk of further tympanostomies. Prospective
RCT of partial adenoidectomy in these patients would be feasible,
ethical, and might hold great potential. Possible positive results might
therefore help delineate a new and wider role for this old-fashioned
technique.
DATA AVAILABILITY STATEMENT
The data that support the findings of this study are available from the
corresponding author upon reasonable request.
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TABLES
Table 1- Characteristics of the included studies