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The Role of the Tensor Veli Palatini Muscle in the Development of Cleft Palate-Associated Middle Ear Problems

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The Role of the Tensor Veli Palatini Muscle in the Development of Cleft Palate-Associated Middle Ear Problems Clin Oral Invest DOI 10.1007/s00784-016-1828-x REVIEW The role of the tensor veli palatini muscle in the development of cleft palate-associated middle ear problems David S. P. Heidsieck1 & Bram J. A. Smarius1 & Karin P. Q. Oomen2 & Corstiaan C. Breugem1 Received: 8 July 2015 /Accepted: 17 April 2016 # The Author(s) 2016. This article is published with open access at Springerlink.com Abstract Conclusion More research is warranted to clarify the role of Objective Otitis media with effusion is common in infants the tensor veli palatini muscle in cleft palate-associated with an unrepaired cleft palate. Although its prevalence is Eustachian tube dysfunction and development of middle ear reduced after cleft surgery, many children continue to suffer problems. from middle ear problems during childhood. While the tensor Clinical relevance Optimized surgical management of cleft veli palatini muscle is thought to be involved in middle ear palate could potentially reduce associated middle ear ventilation, evidence about its exact anatomy, function, and problems. role in cleft palate surgery is limited. This study aimed to perform a thorough review of the lit- Keywords Cleft palate . Eustachian tube . Otitis media with erature on (1) the role of the tensor veli palatini muscle in the effusion . Tensor veli palatini muscle Eustachian tube opening and middle ear ventilation, (2) ana- tomical anomalies in cleft palate infants related to middle ear disease, and (3) their implications for surgical techniques used in cleft palate repair. Introduction Materials and methods A literature search on the MEDLINE database was performed using a combination of the keywords Otitis media with effusion is very common in infants with an Btensor veli palatini muscle,^ BEustachian tube,^ Botitis media unrepaired cleft palate under the age of 2 years. At the time of with effusion,^ and Bcleft palate.^ cleft palate repair, more than 90 % of the middle ears contain Results Several studies confirm the important role of the ten- mucoid material (Bglue ear^)[1, 2]. Although its prevalence is sor veli palatini muscle in the Eustachian tube opening mech- reduced after surgical cleft palate repair, a significant number anism. Maintaining the integrity of the tensor veli palatini of children continue to suffer from middle ear disease through- muscle during cleft palate surgery seems to improve long- out their child- and adulthood [3, 4]. Special attention is re- term otological outcome. However, anatomical variations in quired as recurrent middle ear problems can result in tympanic cleft palate children may alter the effect of the tensor veli membrane retraction, cholesteatoma, and (irreversible) hear- palatini muscle on the Eustachian tube’s dilatation ing loss [3, 5, 6]. Especially during the learning phase of these mechanism. infants, hearing loss can have a significant negative effect on their development of speech, language, and (social) behavior [4, 5, 7]. * Corstiaan C. Breugem [email protected] Optimal otological management in cleft palate patients has historically been a point of discussion, with ventilation tubes 1 Division of Plastic, Reconstructive and Hand Surgery, Wilhelmina often being inserted preventively at the time of cleft palate Children’s Hospital, University Medical Center Utrecht, repair. Although routine ventilation tube insertion leads to KE.04.140.0, P.O. Box 85090, 3508 AB Utrecht, The Netherlands short-term hearing gain, the long-term otological outcome of 2 Division of Otorhinolaryngology, Wilhelmina Children’sHospital, these patients does not appear to be superior to outcomes of University Medical Center Utrecht, Utrecht, The Netherlands patients receiving ventilation tubes merely on indication [8, 9]. Clin Oral Invest There is also evidence that a conservative approach even 5 clinical studies that are presented in Tables 1, 2, 3,and4. improves long-term otological outcome [4, 5, 8]. The outcomes of these studies will be discussed from here on. The high incidence of middle ear problem in cleft palate children is thought to be caused by Eustachian tube dysfunc- tion, that is the result of aberrations of the paratubal muscles Evaluation that are normally responsible for Eustachian tube opening [10–12]. The hampered Eustachian tube function results in Before the most relevant studies retrieved from our search will poor ventilation of the middle ear cavity, which subsequently be discussed, a short overview of the related anatomy and leads to a negative pressure and a retracted tympanic mem- opening mechanism of the Eustachian tube is given. brane with mucous secretion [13]. Eventually, this can result in otitis media with effusion, defined by the presence of mid- Eustachian tube and tensor veli palatini muscle anatomy dle ear effusion for at least 3 months [14]. Next to paratubal muscle abnormalities, Eustachian tube dysfunction can be The course of the Eustachian tube—from the middle ear to- caused by peritubal lymphoid hyperplasia resulting from wards nasopharynx—is anterior, inferior, and medial (Fig. 1). soiling of nutrition in the nasal cavity [15]. Other potential The tube opens in the nasopharynx just posterior to the infe- etiologies include altered Eustachian tube compliance [16], rior turbinate. Interior of the tube is a mucosal lining abnormalities of the nasopharyngeal orifice [17], and other surrounded by cartilage, with the most lateral third of the tube Eustachian tube tissue aberrations [18, 19]. being surrounded by a bony exoskeleton [17]. A heavy sheath Current surgical techniques used in cleft palate repair are of soft tissue overlies the cartilage [41] and paratubal muscles primarily focused on restoring the barrier between the oral and (i.e., tensor veli palatini, levator veli palatini, salpingopharyngeus nasal cavity and constructing a levator veli palatini muscle muscle, tensor tympani muscle, and medial pterygoid muscle) sling. By maximizing the levator veli palatini muscle sling [42, 43]. The cartilage is C-shaped in cross-section with its con- function in velopharyngeal closure, the possibility of develop- cave side lateral, inferior, and anterior and can be divided in a ing hypernasal speech is reduced [20]. The adjacent tensor medial and lateral part called the medial and lateral lamina veli palatini muscle is recognized to be involved in middle (Figs. 2 and 3a)[19]. Only the superior part of the lateral lumen ear ventilation; however, evidence about its exact functions is surrounded by cartilage while the larger inferior membranous and anatomy remains inconclusive. Some surgeons prefer to part is not [12]. transect the tensor veli palatini muscle (i.e., tenotomy) to assist The tensor veli palatini muscle originates from the cranial mobilization and closure of palatal tissue during cleft repair. base and the lateral side of the auditory tube [43–45](Fig.1). Others prefer to perform a tenopexy or release it by fracturing These two origins give rise to two muscle layers which are the pterygoid hamulus around which the tendon passes [21]. easily separable due to the parallel course of their muscle Controversy regarding the effect of these procedures on fibers [44]. The cranial base origin extends from the scaphoid Eustachian tube function and middle ear ventilation however fossa of the great wing of the sphenoid bone anteriorly to the remains. A more recent study on the effects of tensor veli sphenoid spine posteriorly. Different opinions exist about the palatini muscle preservation on Eustachian tube function tensor veli palatini muscle’s auditory tube origin. Some re- [21] prompted us to do a thorough review of the literature with searchers reported an attachment to both the cartilaginous regard to (1) the role of the tensor veli palatini muscle in and membranous parts of the lateral Eustachian tube [15, 41, Eustachian tube opening and middle ear ventilation, (2) ana- 45, 46], while others concluded that only the cartilaginous part tomical anomalies in cleft palate infants related to middle ear is the true origin of the tensor veli palatini muscle [12, 44, 47]. disease, and (3) their implications for surgical techniques used Furthermore, Huang et al. [45] found that the tensor veli in cleft palate repair. palatini muscle is attached to both parts of the lateral Eustachian tube over its entire length, while Ishijima et al. [48] concluded that the anterior part of the tensor veli palatini muscle has no attachment to the lateral lamina. Abe et al. [44] Methods even described five different types of tensor veli palatini mus- cle origins. Barsoumian et al. [49] considered the dilatator An electronic literature search of the MEDLINE database was tubae muscle, connecting the tensor veli palatini muscle to conducted using a combination of the following search terms: the lateral wall of the Eustachian tube, as a distinct structure Bcleft palate and otitis media,^ Bcleft palate and ventilation from the tensor veli palatini muscle despite connective tissue tube,^ Bcleft palate and tensor veli palatini,^ and Btensor veli alliance and intermingling of some muscle fibers. In a larger palatini and Eustachian tube.^ Our search yielded 53 relevant study, Abe et al. on the other hand found no evidence for studies, including 6 experimental animal studies, 6 experi- distinction between the dilatator tubae muscle and the tensor mental studies involving humans, 8 histological studies, and veli palatini muscle [44]. Fibers of the two tensor veli palatini Clin Oral Invest Table 1 Overview of studies involving animal models
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