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Ears, Hearing, and Speech Development

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At a Glance

A cleft palate affects muscles connecting the mouth to the ears, often causing middle ear fluid and conductive hearing loss. It can also cause Velopharyngeal Insufficiency (VPI), resulting in nasal-sounding speech that may require ear tubes, speech therapy, or secondary surgery.

Key Takeaways

  • • Children with a cleft palate often develop fluid in the middle ear because the muscle that opens the Eustachian tube is not positioned correctly.
  • • Surgeons frequently place tympanostomy tubes (ear tubes) during palate repair to drain fluid and improve hearing.
  • • Velopharyngeal Insufficiency (VPI) occurs when the palate cannot fully close off the nose from the mouth, causing nasal-sounding speech.
  • • Regular monitoring by an audiologist and speech-language pathologist is critical to catch hearing loss and speech delays early.

Because the roof of the mouth and the ears are connected by a shared set of muscles, a cleft palate affects more than just eating and speaking. It can also impact how your child hears and how they learn to produce sounds. Understanding the link between the palate, ears, and speech is vital for ensuring your child reaches their full potential.

Why Cleft Palate Affects the Ears

Inside the head, there are small tubes called Eustachian tubes that connect the back of the throat to the middle ear. Their job is to drain fluid and equalize pressure. These tubes are opened and closed by a specific muscle in the palate called the tensor veli palatini (TVP) [1][2].

In a child with a cleft palate, this muscle is often not attached or positioned correctly [3][4]. This causes the Eustachian tube to stay closed, leading to:

  • Otitis Media with Effusion (OME): A buildup of thick, “glue-like” fluid in the middle ear [1][5].
  • Conductive Hearing Loss: This fluid acts like an earplug, making it harder for sounds to reach the inner ear [6].

To help, many cleft teams recommend tympanostomy tubes (ear tubes). These are tiny tubes placed in the eardrum to drain fluid and let air into the middle ear [6][7]. Many surgeons perform this quick procedure at the same time as the palate repair to simplify care for the family [6].

Speech Development and “Air Leaks”

The goal of palate surgery is to create a functional barrier between the mouth and the nose. When we speak, the soft palate should lift and close against the back of the throat to prevent air from escaping through the nose. This is called velopharyngeal closure [5].

If the palate is too short or doesn’t move well enough to create this seal, it results in Velopharyngeal Insufficiency (VPI) [8][9]. This literally means that air is leaking through the nose when it shouldn’t. Signs of VPI in a toddler include:

  • Hypernasality: The child sounds like they are “talking through their nose.”
  • Nasal Air Emission: You may hear a soft “puff” of air coming out of the nose when the child says sounds like p, b, t, or d [8][10].
  • Compensatory Articulation: The child may learn to make sounds in the back of the throat (like “grunting” sounds) because they cannot build up enough air pressure in their mouth [9][11].

The Role of Early Monitoring

Your child’s Speech-Language Pathologist (SLP) and Audiologist are key partners in this journey.

  • Hearing Checks: Regular audiology visits ensure that even temporary hearing loss from fluid is caught early, so it doesn’t delay language development [12][13].
  • Speech Evaluation: The SLP will monitor your baby’s babbling and early words. If they notice signs of VPI, they will determine if it can be fixed with speech therapy (to correct learned habits) or if a secondary surgery is needed to physically close the gap [8][14][15].

Early intervention is powerful. By keeping up with regular ear and speech check-ups, you are giving your child the tools they need to communicate clearly and confidently [16][17].

Frequently Asked Questions

Why do babies with a cleft palate often need ear tubes?
A cleft palate affects the muscles that open the Eustachian tubes, preventing normal fluid drainage from the middle ear. Ear tubes help drain this thick fluid and let air in, which prevents conductive hearing loss and supports language development.
What is Velopharyngeal Insufficiency (VPI)?
VPI happens when the soft palate is too short or doesn't move enough to create a seal against the back of the throat. This allows air to escape through the nose during speech, causing a nasal sound.
How can I tell if my toddler is having cleft palate speech issues?
Signs include your child sounding like they are talking through their nose, a soft puff of air coming from the nose during sounds like 'p' or 'b', or your child making grunting sounds in the back of their throat to compensate.
Can speech therapy fix cleft palate speech issues?
Speech therapy can correct learned speech habits and improve articulation, but it cannot fix a physical gap. If air leaking through the nose is caused by a physical issue with the palate, a secondary surgery may be needed.

Questions for Your Doctor

  • • How often should my baby have their hearing checked by an audiologist?
  • • Does my baby have fluid in their middle ears right now, and would you recommend ear tubes at the same time as the palate repair?
  • • How do you specifically repair the muscles (like the tensor veli palatini) to help my baby's ears drain better?
  • • What are the 'red flags' I should listen for in my toddler’s speech that might suggest air is leaking through the nose?
  • • If my child needs speech therapy, can you recommend a therapist who specializes in 'cleft palate speech'?
  • • At what point would we consider instrumental tests like a 'nasendoscopy' to look at how the palate moves?

Questions for You

  • • Have you noticed your baby pulling at their ears or not responding to quiet sounds?
  • • Is your baby starting to make 'pressure' sounds like 'p,' 'b,' 't,' or 'd,' or do those sounds seem muffled or airy?
  • • Does it seem like your child is more difficult to understand than other children their age?
  • • Are you comfortable with the plan for regular hearing and speech check-ups, even if your child seems to be doing well?

Want personalized information?

Type your question below to get evidence-based answers tailored to your situation.

Research & Literature The Surgery Timeline: Repairing the Palate

References

  1. 1

    The role of the tensor veli palatini muscle in the development of cleft palate-associated middle ear problems.

    Heidsieck DS, Smarius BJ, Oomen KP, Breugem CC

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

    PMID: 27153847
  2. 2

    Tensor veli palatini electromyography for monitoring Eustachian tube rehabilitation in otitis media.

    Picciotti PM, Della Marca G, D'Alatri L, et al.

    The Journal of laryngology and otology 2017; (131(5)):411-416 doi:10.1017/S0022215117000482.

    PMID: 28294083
  3. 3

    Differences in the Tensor Veli Palatini Between Adults With and Without Cleft Palate Using High-Resolution 3-Dimensional Magnetic Resonance Imaging.

    George TN, Kotlarek KJ, Kuehn DP, et al.

    The Cleft palate-craniofacial journal : official publication of the American Cleft Palate-Craniofacial Association 2018; (55(5)):697-705 doi:10.1177/1055665617752802.

    PMID: 29360409
  4. 4

    Differences in the Tensor Veli Palatini Muscle and Hearing Status in Children With and Without 22q11.2 Deletion Syndrome.

    Perry JL, Kotlarek KJ, Spoloric K, et al.

    The Cleft palate-craniofacial journal : official publication of the American Cleft Palate-Craniofacial Association 2020; (57(3)):302-309 doi:10.1177/1055665619869142.

    PMID: 31446782
  5. 5

    The role of tensor veli palatini muscle (TVP) and levetor veli palatini [corrected] muscle (LVP) in the opening and closing of pharyngeal orifice of Eustachian tube.

    Gyanwali B, Li H, Xie L, et al.

    Acta oto-laryngologica 2016; (136(3)):249-55 doi:10.3109/00016489.2015.1107192.

    PMID: 26624574
  6. 6

    Impact of Tympanostomy Tube Placement on Hearing Outcomes in Children With Cleft Palate-Related Otitis Media: Retrospective Analysis of a Primary Single-Stage Cleft Palate Repair Cohort.

    Wijnants N, Widdershoven JCC, van Boxel SCJ, et al.

    Ear, nose, & throat journal 2025; 1455613251376792 doi:10.1177/01455613251376792.

    PMID: 40995937
  7. 7

    Hearing Outcomes in Patients with Cleft Lip and Palate in a Resource Limited Setting.

    Boonpiraks K, Nawachartkosit Y, Charunruengterakul N, Setabutr D

    The Cleft palate-craniofacial journal : official publication of the American Cleft Palate-Craniofacial Association 2025; (62(6)):943-949 doi:10.1177/10556656241234570.

    PMID: 38380871
  8. 8

    Understanding Nasal Emission During Speech Production: A Review of Types, Terminology, and Causality.

    Oren L, Kummer A, Boyce S

    The Cleft palate-craniofacial journal : official publication of the American Cleft Palate-Craniofacial Association 2020; (57(1)):123-126 doi:10.1177/1055665619858873.

    PMID: 31262198
  9. 9

    Speech and language characteristics in individuals with nonsyndromic submucous cleft palate-A systematic review.

    Boyce JO, Kilpatrick N, Morgan AT

    Child: care, health and development 2018; (44(6)):818-831 doi:10.1111/cch.12613.

    PMID: 30136310
  10. 10

    Differences in velopharyngeal pressures during speech sound production in patients with unilateral cleft lip and palate (UCLP) and healthy individuals.

    Miller S, Kallusky J, Zimmerer R, et al.

    German medical science : GMS e-journal 2024; (22()):Doc02 doi:10.3205/000328.

    PMID: 38651020
  11. 11

    Successful and rapid response of speech bulb reduction program combined with speech therapy in velopharyngeal dysfunction: a case report.

    Shin YJ, Ko SO

    Maxillofacial plastic and reconstructive surgery 2015; (37(1)):22 doi:10.1186/s40902-015-0022-4.

    PMID: 26258115
  12. 12

    Prognostic Factors for Hearing Outcomes in Children with Cleft Lip and Palate.

    Yang CH, Lai JP, Lee AC, et al.

    Plastic and reconstructive surgery 2019; (143(2)):368e-374e doi:10.1097/PRS.0000000000005219.

    PMID: 30688899
  13. 13

    Exploring the relationship between conductive hearing loss and cleft speech characteristics in children born with cleft palate.

    Baker S, Wren Y, Zhao F, Cooper F

    International journal of pediatric otorhinolaryngology 2021; (148()):110820 doi:10.1016/j.ijporl.2021.110820.

    PMID: 34218052
  14. 14

    Current Controversies in Diagnosis and Management of Cleft Palate and Velopharyngeal Insufficiency.

    Ysunza PA, Repetto GM, Pamplona MC, et al.

    BioMed research international 2015; (2015()):196240 doi:10.1155/2015/196240.

    PMID: 26273595
  15. 15

    [Velopharyngeal insufficiency in children].

    De Buys Roessingh A, El Ezzi O, Richard C, et al.

    Revue medicale suisse 2017; (13(550)):400-405.

    PMID: 28714631
  16. 16

    Early Cleft Palate Repair is Associated With Lower Incidence of Velopharyngeal Insufficiency Surgery.

    Stanton EW, Rochlin D, Lorenz HP, Sheckter CC

    The Journal of craniofacial surgery 2025; (36(3)):781-785 doi:10.1097/SCS.0000000000010540.

    PMID: 39178397
  17. 17

    The Implications of Nasal Substitutions in the Early Phonology of Toddlers With Repaired Cleft Palate.

    Hardin-Jones MA, Chapman KL

    The Cleft palate-craniofacial journal : official publication of the American Cleft Palate-Craniofacial Association 2018; (55(9)):1258-1266 doi:10.1177/1055665618767421.

    PMID: 29624438

This page explains hearing and speech development for children with a cleft palate for educational purposes. Always consult your cleft team, audiologist, or speech-language pathologist for personalized medical advice.

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