Background: Levator sling palatoplasty with transection of the tensor tendon significantly decreases the need for pharyngeal flap to 4% in cleft palate patients. (Cutting. Op Tech Plast Reconstr Surg. 2:215,1995 and Sommerlad. Proc Am Assoc Plast Surgeons. 80:75,2001). Critical to this procedure is division of the tensor veli palatini tendon, allowing for radical transposition of the levator veli palatini in the inferior and superior direction to re-create the levator sling. Other studies have suggested that cutting the tensor tendon may have deleterious effects on Eustachian tube function as the tensor veli palatini is a prime opener of the Eustachian tube (Barsoumian. Cleft Palate Craniofac J 35:101,1998 and Huang. Plast Reconstr Surg 100:833,1977). Alternatively, Eustachian tube function during levator sling palatoplasty may be improved by pulling the tendon medially, and suturing the tendon to the hamulus before tendon transection (tensor tenopexy). This technique theoretically places the Eustachian tube in a more open conformation, improving middle ear ventilation. This multi-institutional study is designed to compare the effects of tensor veli palatini transection and tensor tenopexy on Eustachian tube function.

Methods: A retrospective review of all patients undergoing cleft palate repair at 2 institutions was conducted. Patients who were syndromic or >16 months of age at time of surgery were not included. Three groups were studied: veloplasty without transection of the tensor tendon or levator sling palatoplasty (Group 1) (n=32), veloplasty with transection of the tensor tendon and levator sling palatoplasty (Group 2) (n=33), and veloplasty with tensor tenopexy and levator sling palatoplasty (Group 3) (n=47). Group 1 patients underwent surgery at a single institution and the age at which study patients stopped needing myringotomy tubes was obtained through an institutionally maintained database. Groups 2 and 3 underwent surgery at a second institution. Surveys were sent to parents of all study patients in Groups 2 and 3 inquiring the age at which patients stopped needing myringotomy tubes. Nonresponders were sent another survey and received a follow-up phone call. Percentages of patients requiring myringotomy tubes at each age were compared between the 3 groups by ANOVA analysis.

Results: Group 1 provided 64 ears for analysis (mean f/u 66 months). In Group 2, 16/33 patients were successfully contacted (48.5%), providing 31 ears for analysis (mean f/u 60 months). In Group 3, 26/47 patients were successfully contacted (55.3%), providing 52 ears for analysis (mean f/u 40 months). Comparison of Groups 1 and 2 revealed a statistically significant decrease in the need for myringotomy tubes in patients who had not undergone tensor tendon transection compared with patients who had undergone tensor tendon transection by age 7 (Group 1: 38%, Group 2: 61%; P < .05). Patients who had the tensor tenopexy procedure (Group 3) stopped needing myringotomy tubes at an earlier age compared with both Groups 1 and 2. At the age of 7, patients in Group 3 had a statistically significant decrease in the need for myringotomy tubes compared to Group 2 (Group 3: 23%, Group 2: 61%; P < .001). Similarly, at the age of 7, patients in Group 3 had a decrease in the need for myringotomy tubes compared to Group 1. This difference neared statistical significance (Group 3: 23%, Group 1: 38%; P = 0.09).

Conclusion: Tensor tenopexy appears to have a modest effect on improving middle ear ventilation when compared to both palatoplasty with and without transection of the tensor tendon. Transection of the tensor tendon during levator sling palatoplasty may slightly increase duration of myringotomy tube treatment when compared to palatoplasty without tensor tendon transection. In light of the significant decrease in the need for pharyngeal flap in patients undergoing tensor tendon division with levator sling palatoplasty, the improvement in speech results should outweigh the minor negative effects on Eustachian tube function.