Why Do Babies With a Cleft Palate Get Ear Infections?

Babies born with a cleft palate frequently experience fluid build-up in the middle ear and recurrent ear infections because of how the muscles in the roof of the mouth (the palate) function. In a typical palate, a specific muscle called the tensor veli palatini—working with other nearby muscles—helps open the Eustachian tubes when a baby swallows or yawns ^[1][2]. These small tubes open into the upper throat behind the nose, allowing air to ventilate the middle ear and fluid to drain ^[1].

When a baby has a cleft palate, these muscles are abnormally positioned and the normal muscle sling is disrupted ^[1]. Because they cannot pull effectively, the Eustachian tubes do not open as they should, leading to poor ventilation and a build-up of fluid behind the eardrum ^[3][4].

Middle Ear Fluid vs. Ear Infections

It is important to understand the difference between fluid and an actual infection, as they are not the same thing:

• Otitis Media with Effusion (OME): This is the medical term for fluid trapped behind the eardrum without an active infection ^[3]. Because of their anatomy, many babies with a cleft palate develop this non-infectious fluid within the first few days or weeks of life ^[5]. While it is not an infection and does not automatically require antibiotics, the fluid can block sound from traveling through the middle ear—a condition called conductive hearing loss ^[3][6]. This hearing loss is often temporary but requires monitoring so it does not interfere with speech and language development ^[6].
• Acute Otitis Media (AOM): This is an active ear infection. Poor middle ear ventilation and trapped fluid can make a baby more susceptible to these infections, but the presence of fluid alone does not mean your baby has an infection ^[7].

Note: Recurrent ear problems are a common consequence of the palate anatomy and are not caused by anything you did.

Long-Term Management

Because the fluid and infections are linked to the underlying anatomy, ongoing monitoring and individualized care are essential ^[6]. A typical care pathway involves regular reviews by your cleft team, age-appropriate hearing tests, and discussions with an ear, nose, and throat (ENT) specialist if problems persist.

• Monitoring Hearing and Fluid: A hearing test evaluates how well your baby hears, while a clinical ear examination (often using a tool called tympanometry) checks for fluid behind the eardrum. Both are needed regularly ^[6].
• Ear Tubes: If fluid persists and affects hearing, an ENT may recommend placing tiny ventilation tubes in the eardrums ^[8]. These tubes ventilate the middle ear and may improve conductive hearing loss while they function ^[6]. However, they do not guarantee normal hearing and come with tradeoffs, which can include ear drainage, the tubes falling out early, the need for replacement, or small scars on the eardrum ^[8][9].
• Palate Repair Surgery: Surgery to repair the cleft palate aims to reconstruct the muscle sling, which may improve Eustachian tube function over time ^[10][11]. However, some children continue to have middle ear fluid or infections even after the palate is repaired ^[4][12].
• Looking Ahead: Middle ear fluid can fluctuate and persist for months or years in some children ^[12]. While these problems can sometimes improve as a child grows and their facial anatomy changes, this improvement is not guaranteed ^[12][13]. Ongoing surveillance remains crucial even if your child appears to hear well ^[6].

When to Contact Your Doctor

Only a medical examination can diagnose an ear infection. Babies cannot tell you their ears hurt, and symptoms like ear tugging are non-specific. Contact your pediatrician promptly if your infant experiences:

• Fever (especially urgent in infants younger than 3 months)
• Severe or worsening fussiness, crying, or signs of pain
• Pus, fluid, or blood draining from the ear
• Swelling or redness behind the ear
• Poor feeding, dehydration, or unusual sleepiness
• Noticeable changes in how they respond to sound