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Long-Term Monitoring: Speech, Hearing, and Orthodontics

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After cleft palate repair, children require years of monitoring by a specialized cleft team. The most common long-term needs include ear tubes to prevent hearing loss, speech therapy to address nasal-sounding speech (VPI), and early orthodontic devices to support upper jaw growth.

Key Takeaways

  • • Almost all children born with a cleft palate develop fluid in the middle ear and require ear tubes to prevent conductive hearing loss.
  • • Speech-language pathologists monitor children for Velopharyngeal Insufficiency (VPI), which can cause overly nasal speech and air leaks.
  • • Speech therapy is essential for helping children unlearn compensatory grunts or clicks they may have developed to make up for early palate air leaks.
  • • Many children with a cleft palate are missing permanent teeth, most commonly the lateral incisors next to the front teeth.
  • • Orthodontists monitor jaw growth closely, frequently using expanders or face masks to correct midface deficiency and make room for adult teeth.

After the initial palate repair, your child enters a phase of long-term monitoring. Because a cleft palate affects the way the ears drain, the way the jaw grows, and the way speech sounds are formed, your “Cleft Team” will watch these areas closely for several years. This monitoring is designed to catch small issues before they become larger challenges for your child’s development and self-esteem.

Hearing and Ear Health

Almost all children born with a cleft palate will experience Otitis Media with Effusion (OME), which is a buildup of non-infected fluid in the middle ear [1][2].

  • Why It Happens: The muscles that open the Eustachian tube (the tube that drains the ear into the throat) are the same muscles that are affected by the cleft. Even after surgery, these muscles may not work perfectly, leading to fluid buildup and a type of “muffled” hearing called conductive hearing loss [3][4].
  • Tympanostomy Tubes (Ear Tubes): To prevent hearing loss and speech delays, surgeons often place small ventilation tubes in the eardrum. These are frequently inserted at the same time as the palate repair [5][6].
  • Long-Term Monitoring: Some children may need more than one set of tubes as they grow. Research indicates that children who need two or more sets of tubes may have a higher chance of needing secondary speech surgery later [7][8].

Speech Development and VPI

As your child begins to talk, a Speech-Language Pathologist (SLP) will monitor for a condition called Velopharyngeal Insufficiency (VPI). This is when the palate is either too short or doesn’t move well enough to seal off the nose from the mouth during speech [9][10].

  • Signs of VPI: You may notice hypernasality (it sounds like the child is “talking through their nose”) or nasal air emission (you can hear air escaping the nose during sounds like “p,” “b,” or “s”) [11][12].
  • Compensatory Articulation: To make up for the air leak, some children develop “extra” sounds, like grunts or clicks made in the throat (called glottal stops). While surgery is required to fix the physical air leak (VPI), speech therapy is the primary treatment to unlearn these behavioral “compensatory” habits [11][13].
  • Diagnosis: If VPI is suspected, the team may use a tiny camera (nasendoscopy) or a specialized X-ray (videofluoroscopy) to see exactly how the palate is moving [11][9].

Orthodontics and Jaw Growth

The growth of the upper jaw can be affected by the original cleft and the scar tissue from early surgeries. Your child will see an orthodontist regularly to monitor these developments.

  • Common Issues: Many children with a cleft are missing permanent teeth (hypodontia), most commonly the lateral incisors next to the front teeth [14][15]. (Note: If your child has an isolated cleft palate with an intact gumline, this specific dental issue is much less common). They may also develop a Class III malocclusion, where the upper jaw looks smaller or sits further back than the lower jaw (midface deficiency) [16].
  • Orthodontic Tools:
    • Expanders: These are used to widen the upper jaw to make room for teeth [17].
    • Maxillary Protraction (Face Mask): This is a device worn at night that gently pulls the upper jaw forward to encourage growth [18][19].
    • Bone-Anchored Maxillary Protraction (BAMP): A newer method using small temporary implants to help move the jaw forward more effectively in some children [20][21].

Regular check-ins with your team ensure that each of these areas—hearing, speech, and dental growth—is addressed at the optimal time for your child’s unique needs.

Frequently Asked Questions

Why do children with a cleft palate frequently need ear tubes?
Children with a cleft palate often have trouble draining fluid from their middle ear because the muscles in the Eustachian tube are affected. Ear tubes help ventilate the ear, drain this fluid, and prevent conductive hearing loss that could delay speech development.
What is Velopharyngeal Insufficiency (VPI)?
VPI occurs when the palate is too short or doesn't move well enough to completely seal off the nose from the mouth during speech. This causes a child's voice to sound overly nasal or allows air to escape through their nose when making certain sounds.
Why is my child making grunting or clicking sounds when they talk?
Children with a cleft palate sometimes develop extra sounds, like grunts or clicks in the throat, to make up for an air leak in their palate. Speech therapy is the primary treatment to help unlearn these compensatory habits.
How do doctors test for VPI or other speech issues?
If a speech-language pathologist suspects VPI, the cleft team may use a tiny camera called a nasendoscopy or a specialized X-ray called a videofluoroscopy. These tools let the doctors see exactly how the palate moves while your child is speaking.
Will my child need braces or an expander after cleft palate surgery?
Yes, regular orthodontic monitoring is very common. The original cleft and surgical scar tissue can restrict upper jaw growth, so children often need palate expanders or a face mask to make room for adult teeth and guide jaw development.

Questions for Your Doctor

  • • How many sets of ear tubes has my child had, and does the number of ear infections they've had increase the risk that they'll need speech surgery later?
  • • During a speech evaluation, have you noticed 'extra' sounds like glottal stops or grunts (compensatory articulations) that we should work on in therapy?
  • • Is my child showing signs of Velopharyngeal Insufficiency (VPI), and at what point would you recommend a resonance study like nasometry or videofluoroscopy?
  • • Based on my child's current jaw growth, do you anticipate we will need an expander or 'face mask' (maxillary protraction) in the next few years?
  • • Are any of my child's permanent teeth missing (hypodontia), and how will that affect our long-term orthodontic plan?
  • • How often should my child have a formal audiology (hearing) test to ensure that fluid in their ears isn't affecting their language development?

Questions for You

  • • Have I noticed my child's speech sounding 'nasal' or like air is escaping through their nose when they talk?
  • • Does my child seem to struggle to hear me, or do they frequently ask me to repeat myself?
  • • Am I noticing any patterns in how my child makes certain sounds, like 'p' or 'b', that seem different from other children their age?
  • • How am I feeling about the 'marathon' of care? Do I have a system for tracking all these different specialist appointments?

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References

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    The Cleft palate-craniofacial journal : official publication of the American Cleft Palate-Craniofacial Association 2018; (55(4)):590-595 doi:10.1177/1055665617730361.

    PMID: 29554447
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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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    Clinical oral investigations 2016; (20(7)):1389-401 doi:10.1007/s00784-016-1828-x.

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    Comparison of Eustachian tube ventilation function between cleft palate and normal patients using sonotubometry.

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    Speech Symptoms of Velopharyngeal Insufficiency and the Incidence of Secondary Speech Surgery in 10-Year-Old Children With Unilateral Cleft Lip and Palate: Comparison of 2 Randomized Surgical Methods for Primary Palatal Surgery.

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  13. 13

    Does Successful Surgical Treatment of Velopharyngeal Insufficiency Aid in the Remediation of Compensatory Misarticulation Errors?

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    A Longitudinal Study of the Presence of Dental Anomalies in the Primary and Permanent Dentitions of Cleft Lip and/or Palate Patients.

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  15. 15

    Tooth agenesis code (TAC) in complete unilateral and bilateral cleft lip and palate patients.

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  16. 16

    Three-Year Follow-Up of a Patient With Unilateral Cleft Lip and Palate Treated With Maxillary Protraction and Alveolar Bone Grafting: An Approach Exploring the Potential Power of Growth.

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  17. 17

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  18. 18

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  19. 19

    Bone-anchored maxillary protraction in patients with unilateral cleft lip and palate.

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  20. 20

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  21. 21

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This page explains long-term monitoring for children with a cleft palate for educational purposes only. Always consult your child's cleft team or pediatrician for specific medical advice and personalized treatment plans.

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