**6. Watchful waiting for OME**

Many studies have indicated that although reconstructive surgery for CLP improves linguis‐ tic ability, language development depends on the extent to which hearing ability is main‐ tained [23, 26]. If OME is not treated properly, long‐term hearing loss can negatively influence the language development of children [27]. Hearing loss in children suffering from CLP can also affect their academic comprehension and learning performance [20, 27, 28]. Bess et al. indicated that even if children suffer hearing loss in only one ear, academic performance can still be seriously affected in up to 33% of patients and up to 40% of patients are unable to par‐ ticipate in regular activities or interactions due to hearing loss [29]. It has been found that chil‐ dren with cleft palate are prone to specific psychological problems [30, 31]. Children suffering from this condition may also display behavioral difficulties due to feelings of isolation [29].

Up to 90% of infants born with CLP suffer from OME before their first birthday [2]; therefore, it is recommended that otologic tests be conducted as soon as possible after birth to ascertain whether fluid has collected in the middle ear [21, 32]. The use of a pneumatic otoscope is the fastest and most direct method used for the inspection of the eardrum for color and contour and determining whether fluid has collected in the middle ear. It should be noted that the effectiveness of a pneumatic otoscope to test for OME depends on the experience and skill of the clinicians, the patient's full cooperation, and the anatomical structure of the ear canal [2].

Another method for inspecting the eardrum is videotelescopy. A telescope is placed against the eardrum through the external ear canal, and a charge‐coupled device (CCD) camera cap‐ tures images of the eardrum. The resulting magnified images can be presented on a mon‐ itor, thereby allowing clinicians to accurately diagnose middle ear effusion [33]. Guo and Shiao conducted a prospective study on the diagnostic efficacy of videotelescopy, pneumatic otoscopy, and tympanometry for the detection of pediatric OME. Their results demonstrate that the sensitivity, specificity, and accuracy of the videotelescopy were 97.8, 100, and 98.0%, respectively. These values significantly exceed the accuracy of conventional tests using pneu‐ matic otoscope and tympanometry [33]. Videotelescopy provides clinicians with visual infor‐

Pneumatic otoscopy and even videotelescopy are difficult to administer on newborns and small infants with CLP. Thus, objective acoustic immittance testing plays an important role in the diagnosis of OME in CLP patients [34]. Tympanometry is the most commonly used acoustic immittance test to measure pressure changes in the middle ear and the compliance of the eardrum [27]. Chen et al. found that the specificity of tympanometry, when used to test for OME in infants with CLP, was relatively low (only 59.6%). When used to test infants within 9 months of age, specificity dropped to only 37.5% [28]. Furthermore, when infants are crying or unable to cooperate during testing, it can be difficult to maintain airtight conditions in the

Pure tone audiometry can also be used to facilitate the diagnosis of OME; the results may reveal conductive or mixed hearing loss. The cooperation of children is required for this

mation with which to validate the accuracy of the pneumatic otoscopy.

ear, thereby preventing successful completion of the examination.

**5. Examination and diagnosis**

100 Designing Strategies for Cleft Lip and Palate Care

Alt first identified the relationship between CLP and hearing impairment in 1878, and OME has since been the subject of investigation [39]. The severe complications caused by OME in CLP children can have far‐reaching consequences; therefore, determining the optimal treat‐ ment strategy is a topic worthy of in‐depth exploration.

Many researchers have recommended watchful waiting as a treatment of choice for OME among children with CLP, particularly when parents prefer to avoid or postpone surgery. Muntz reported that more than 50% of CLP children who develop OME naturally recover from OME and have no need to undergo ventilation tube surgery after 3 years of age [40]. Flynn et al. studied the longitudinal prevalence of OME in CLP children between 7 and 16 years of age and found that middle ear problems gradually dissipate between 7 and 13 years of age [41]. Rynnel‐ Dagoo et al. found that 82% of the CLP children with or without OME had a normal hearing at 3–4 years of age, indicating recovery from OME [42]. Smith et al. found that the Eustachian tube function of most children with CLP significantly improved by 6–7.5 years of age [43].

A number of researchers have reported that OME and Eustachian tube function improve as the patient grows older [41, 43, 44], recommending watchful waiting for CLP children with OME for a period of 3–6 months from the diagnosis of effusion [41, 43–45]. During the observa‐ tion period, patients can wear hearing aids to attain the same hearing performance of children with ventilation tubes [45]; however, it should be noted that children may find hearing aids inconvenient or may worry about the social stigma associated with wearing such aids [27, 46].
