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