J Am Acad Audiol 2020; 31(03): 185-194
DOI: 10.3766/jaaa.18085
Thieme Medical Publishers 333 Seventh Avenue, New York, NY 10001, USA.

Tele-Audiological Surveillance of Middle Ear Status among Individuals with Cleft Lip and/or Palate in Rural South India

Pavithra Ravi
*   Department of Speech, Language and Hearing Sciences, Sri Ramachandra Institute for Higher Education and Research (Deemed to be University), Chennai, India
Vidya Ramkumar
*   Department of Speech, Language and Hearing Sciences, Sri Ramachandra Institute for Higher Education and Research (Deemed to be University), Chennai, India
Akilan Rajendran
*   Department of Speech, Language and Hearing Sciences, Sri Ramachandra Institute for Higher Education and Research (Deemed to be University), Chennai, India
Prasanna Kumar Saravanam
†   Department of ENT, Head and Neck Surgery, Sri Ramachandra Institute for Higher Education and Research (Deemed to be University), Chennai, India
Subramaniyan Balasubramaniyan
*   Department of Speech, Language and Hearing Sciences, Sri Ramachandra Institute for Higher Education and Research (Deemed to be University), Chennai, India
Roopa Nagarajan
*   Department of Speech, Language and Hearing Sciences, Sri Ramachandra Institute for Higher Education and Research (Deemed to be University), Chennai, India
› Author Affiliations
Further Information

Publication History

29 October 2018

Publication Date:
24 May 2020 (online)



A community-based program for the comprehensive management of communication disorders among individuals with cleft lip and/or palate (CLP) was implemented in two rural districts in the state of Tamil Nadu, India. The program was successful in terms of early surgical repair, orthodontic management and speech correction; however, audiological surveillance was challenging due to poor follow-up rates.


The aim of the study was to compare tele-audiological and in-person audiological surveillance to identify the most beneficial approach for the identification and treatment of middle ear disease (MED) in individuals with CLP in this rural community-based program.

Research Design:

Quasi-experimental study.

Study Sample:

All beneficiaries older than 5 years actively seeking services in Cuddalore (n = 44) and Thiruvannamalai (n = 65) districts of Tamil Nadu, India, were included in the study. Individuals in Cuddalore district were assigned to the tele-audiological surveillance group, whereas individuals in Thiruvannamalai district were assigned to the in-person audiological surveillance group.


In the tele-audiological surveillance group, video-otoscopy examinations were performed by trained community-based rehabilitation workers (CBRWs). Pure-tone audiometry and tympanometry were performed by an audiologist from the tertiary care hospital through remotely accessed equipment using broadband internet at the participants’ homes and monthly camps. Findings from those with suspected MED were forwarded to the otolaryngologist at the tertiary care hospital for remote diagnoses and treatment plans. Subsequently, CBRWs relayed the otolaryngologist’s recommendations to the individuals receiving services at the community. In the in-person audiological surveillance group, video-otoscopy, pure-tone audiometry, and tympanometry were performed by the audiologist following standard testing procedures at monthly camps. Individuals with suspected MED and impacted cerumen were referred for in-person diagnoses and treatment plans. Follow-up audiological surveillance was conducted in both districts after implementation of the otolaryngologist’s recommendations.

Data Analysis:

The coverage, follow-up rate for intervention and cost-outcomes from the provider's perspective were analyzed and compared between two groups.


Tele-audiological surveillance provided superior coverage (68%) compared with in-person audiological surveillance (38%). The tele-audiological surveillance group showed greater follow-up compliance (61%) than the in-person audiological surveillance group (19%) for treatment plans such as cerumen management and hearing aid fitting provided locally. Compared with in-person audiological surveillance, tele-audiological surveillance resulted in cost saving of USD 47 per individual.


Tele-audiological surveillance was beneficial for the purpose of identifying and providing treatment in patients having CLP with MEDs in rural locations.

We thank Transforming Faces, Canada for their funding support and Medtronic India Pvt. Ltd for equipment support.


  • American Cleft-Palate Craniofacial Association 2009 Parameters for evaluation and treatment of patients with cleft lip/palate or other craniofacial anomalies. American Cleft Palate-Craniofacial Association. March, 1993. Cleft Palate Craniofac J 30. (S1–16, Suppl)
  • Blaiser KM, Behl D, Callow-Heusser C, White KR. 2013; Measuring costs and outcomes of tele-intervention when serving families of children who are deaf/hard-of-hearing. Int J Telerehabil 5 (02) 3-10
  • Bluestone CD, Paradise JL, Beery QC, Wittel R. 1972; Certain effects of cleft palate repair on eustachian tube function. Cleft Palate J 9: 183-193
  • Brennan-Jones CG, Eikelboom RH, Bennett RJ, Tao KF, Swanepoel W. 2018; Asynchronous interpretation of manual and automated audiometry: agreement and reliability. J Telemed Telecare 24 (01) 37-43
  • Creese A, Parker D. 1994. Cost Analysis in Primary Health Care: A Training Manual for Programme Managers. Geneva, Switzerland: WHO Publishers Centre;
  • Dharmar M, Simon A, Sadorra C, Friedland G, Sherwood J, Morrow H, Deines D, Nickell D, Lucatorta D, Marcin JP. 2016; Reducing loss to follow-up with tele-audiology diagnostic evaluations. Telemed J E Health 22 (02) 159-164
  • D’Mello J, Kumar S. 2007; Audiological findings in cleft palate patients attending speech camp. Indian J Med Res 125 (06) 777-782
  • Ekman B, Borg J. 2017; Provision of hearing aids to children in Bangladesh: costs and cost-effectiveness of a community-based and a centre-based approach. Disabil Rehabil Assist Technol 12 (06) 625-630
  • Elliott G, Smith AC, Bensink ME, Brown C, Stewart C, Perry C, Scuffham P. 2010; The feasibility of a community-based mobile telehealth screening service for Aboriginal and Torres Strait Islander children in Australia. Telemed J E Health 16 (09) 950-956
  • Feniman MR, Souza AG, Jorge JC, Lauris JR. 2008; Otoscopic and tympanometric findings in infants with cleft lip and palate. Braz J Otorhinolaryngol 74 (02) 248-252
  • Flynn T, Möller C, Jönsson R, Lohmander A. 2009; The high prevalence of otitis media with effusion in children with cleft lip and palate as compared to children without clefts. Int J Pediatr Otorhinolaryngol 73 (10) 1441-1446
  • Hassall S, Wootton R, Guilfoyle C. 2003; The cost of allied health assessments delivered by videoconference to a residential facility for elderly people. J Telemed Telecare 9 (04) 234-237
  • Kifle M, Mbarika VWA, Datta P. 2006; Interplay of cost and adoption of tele-medicine in Sub-Saharan Africa: the case of tele-cardiology in Ethiopia. Inf Syst Front 8 (03) 211-223
  • Kuehn DP, Moller KT. 2000; Speech and language issues in the cleft palate population: the state of the art. Cleft Palate-Craniofacial J 37 (04) 348
  • Millard T, Richman LC. 2001; Different cleft conditions, facial appearance, and speech: relationship to psychological variables. Cleft Palate-Craniofacial J 38 (01) 68-75
  • Pearce W, Ching TYC, Dillon H. 2009; Brief communications hearing services using tele-audiology to remote areas. Aust New Zealand J Audiol 31 (02) 96-100
  • Ramkumar V, John KR, Selvakumar K, Vanaja CS, Nagarajan R, Hall JW. 2018; Cost and outcome of a community-based paediatric hearing screening programme in rural India with application of tele-audiology for follow-up diagnostic hearing assessment. Int J Audiol 57 (06) 407-414
  • Roine R, Ohinmaa A, Hailey D. 2001; Assessing telemedicine: a systematic review of the literature. Can Med Assoc J 165 (06) 765-771
  • Strauss RP, Broder H, Helms RW. 1988; Perceptions of appearance and speech by adolescent patients with cleft lip and palate and by their parents. Cleft Palate J 25 (04) 335-342
  • Subramaniam V, Manuprasad S, Kallikkadan HH, Vijay Kumar K. 2015; Otological and audiological manifestations in cleft lip and cleft palate children: a clinical study. Int J Otorhinolaryngol Head Neck Surg 1 (01) 7-10
  • World Health Organization (WHO) 1991. Report of the Informal Working Group on Prevention of Deafness and Hearing Impairment Programme Planning, Geneva, 18–21 June 1991. Geneva, Switzerland: World Health Organization;