OBSERVATIONS AND COMMENTARY In this issue Observations and Commentary chronic drainage from the right ear was observed replaces Letters to the Editor. This is a new fea- on otologic examination. Nasoendoscopic evalu- ture which will appear as required. The column ation was conducted. At rest, the right eustachian will carry a variety of material including cor- tube orifice was lower than the left. The obtura- respondence and clinical description. It begins tor bulb was adjacent to the right eustachian tube with a case report by Drs. D'Antonio, Gay, orifice and in close proximity to that of the left. Muntz, and Marsh. Neither redness nor excoriation were observed at either eustachian tube orifice. During swal- lowing, blowing, and speech, the prosthesis was observed to extend well above the level of max- Obturation and Eustachian Tube Dysfunction? imum velopharyngeal closure. During dynamic This letter presents a brief case study that activity, the right eustachian tube orifice was shows a possible relationship between an inap- contacted by the obturator and the left orifice was propriately fitted pharyngeal extension obturator brought into close approximation with the bulb. and unmanageable chronic middle ear disease in The obturator was systematically reduced us- a patient with postpalatoplasty velopharyngeal in- ing direct observation through the flexible na- sufficiency. ‘ soendoscope for guidance and confirmation. An The patient, a 53-year-old female, was born asymmetric reduction was necessary to achieve with a left unilateral complete cleft lip and pa- clearance between the prosthesis and both eu- late. She had significant signs and symptoms of stachian tube orifices at rest and during function persistent velopharyngeal insufficiency following while maintaining velopharyngeal closure for surgical lip and palate repair in early childhood. speech and swallowing. Following reduction, These were managed successfully for 20 years there was no contact between the eustachian tube with a pharyngeal extension obturator. Two years orifices and the prosthesis during speech or non- prior to evaluation at our Institute she sustained speech tasks. The patient reported immediate significant facial trauma in an automobile acci- subjective improvement. The roaring sensation dent, which resulted in an inability to wear the and dull ache disappeared immediately. Observ- obturator. A replacement obturator was made. able otologic symptoms improved slightly within Upon its insertion, she immediately began ex- 4 days and dramatically within 1 week. The re- periencing a roaring sensation in the right ear. vised obturator subsequently was adjusted later- She subsequently developed severe otalgia and ally and posteriorly to optimize velopharyngeal recurrent acute otitis media with otorrhea on the closure during speech and swallowing. right. Hearing loss and infection also were The patient continued to be followed by her present in the left ear, to a lesser degree than in referring otolaryngologist. One month after the the right. Although treatment with antihistamines obturator revision, all symptoms had disappeared and antiobiotics resulted in improvement, fre- in the left ear. For the right ear, which had the quent exacerbations and remissions occurred in more chronic disease, symptoms continued to im- the following months. prove. Two months following management, her The prosthodontist, who had initially fabricated symptoms had almost completely resolved. the obturator, made several modifications in an However, there was residual pathology in the attempt to alleviate her symptoms. Recontouring right ear, for which a revision mastoidectomy was of the obturator, however, had no effect on the performed by her referring otolaryngologist, who problem. Middle ear ventilating tubes were still follows her. The patient now reports ex- placed bilaterally to relieve the recurrent infec- periencing the longest symptom-free period (4 tions. Subsequently, tympanoplasty and months) since the initial trauma over 2% years mastoidectomy were performed to remove granu- earlier. lation tissue that filled the right middle ear and This case report addresses several important mastoid. However, the otologic symptoms issues. In spite of 2 years of management, oto- recurred immediately. logic treatment failed repeatedly, and numerous The patient was referred to our Institute for alterations to the prosthesis did not achieve im- further evaluation and treatment. An auditory provement in symptoms. Direct observation of the perceptual speech evaluation documented satis- obturator in situ, at rest, and during dyanmic ac- factory nasal resonance with the obturator in tivity, allowed immediate assessment of prosthe- place and gross hypernasality and nasal emission sis position relative to the level of velopharyngeal when it was removed. Bilateral otitis media with sphincter closure and the eustachian orifices, and 78 OBSERVATIONS AND COMMENTARY 79 documented the previously unrecognized asym- group for chronic middle ear disease. Some of metric eustachian orifice height. Using this in- these patients have postpalatoplasty velopharyn- - formation, step-by-step tailoring of the prosthesis geal insufficiency managed by prosthetic obtu- using direct visual assessment was accomplished rators. It is unknown whether inappropriate by our prosthodontist. The height of the obtura- obturator fit may be a compounding factor for tor bulb was reduced to lie below the eustachian ear disease in some of these patients. In our pa- tube orifices bilaterally, both at rest and in func- tients, the possible relationship between the ob- tion, yet remain at the level of maximum turator and her otologic symptoms was not given velopharyngeal closure for speech. Resolution of adquate attention in spite of her impression that symptoms and preservation of intelligible speech the two were causally linking. We recognize that ensued. the experience of one case cannot be generalized The experience of one case does not permit to imply a causal relationship between palatal ob- linkage between obturator position and middle turators and middle ear symptoms in other pa- ear disease. Nevertheless, the immediate subjec- tients. However, this case is presented to stimulate tive reduction in pain and observed improvement further investigation and to document the advan- in middle ear disease following reduction in ob- tages of direct nasopharyngeal observation when turator height in this patient does suggest that the fitting palatal prostheses. proximity of the obturator to the eustachian tube orifices was a causal factor in this patient. Linda L. D'Antonio. Ph.D. Without this management, based on information W.D. Gay, D.D.S. obtained from direct nasopharyngeal observation, Harlan R. Muntz, M.D. it is unclear how long the patient would have con- Jeffrey L. Marsh, M.D. tinued with significant pain and debilitating mid- Cleft Palate and Craniofacial Deformities dle ear disease. Institute Children's Hospital Patients with cleft palates are in a high risk St. Louis, MO 63110 I Think I've Read Something About That! provided by the author(s), which describe the Over the past few years, I have amassed a large subject content of the article. number of journal articles that ended up stuffed A review of past issues reveals that prior to in folders and filed in a somewhat haphazard volume 19(4), key words were included in arti- fashion. Alphabetizing this collection served to cles published in the Cleft Palate Journal. I would lessen my frustration when trying to find a par- expect that, given the growing popularity of small ticular article. However, when asked what infor- office and lab computers, more individuals will mation I had in a particular area, memory was utilize computer data bases for article library pur- the only retrieval tool at my disposal. I was in poses. The inclusion of key words in a published trouble! Attempts at card catalogues with article greatly simplifies this process. In fact, it referencing by subject area helped somewhat, but would greatly simplify card cataloguing as well. were time consuming. Today, there is a growing I would like to suggest that ACPA consider trend for clinicians, researchers, educators, and renewing the practice of including key words in students to utilize microcomputers for a number the Cleft Palate Journal. Asking authors to in- of purposes. With the development of commer- clude three or four key words on the title page cially available database software, one such pur- of submitted manuscripts would provide useful pose involves the computerized cataloguing of information to those using either card or com- articles in much the same fashion as Medlars puter catalogues, at little cost. (Medical Literature Analysis and Retrieval Sys- Jerry Moon, Ph.D. tem). As with Medlars, "key words" are required Research Scientist in order to catalogue personal article libraries. Department of Speech Pathology and Audiology The library can then be searched on any one or University of Iowa combination of key words to extract a list of refer- Iowa City, Iowa ences in any area of interest. A number of jour- nals (e.g., Archives of Physical Medicine and Following conversations with Dr. Moon and Rehabilitation, Journal of Applied Physiology, others, we decided to resume publication of key American Journal of Orthodontics) include as words beginning with this issue. part of the manuscript a number of key words, The Editor 80 Cleft Palate Journal, January 1988, Vol. 25 No. 1 Feeding Infants with