Complications

Patients with cleft palate may have the following complications: abnormal midface development, velopharyngeal incompetence, speech defects, and abnormal Eustachian tube function.

Clefts of the primary palate usually have underdeveloped maxillary alveolar arches, and facial growth is abnormal. Cleft patients have an incompetent velopharyngeal valve, which results in nasal regurgitation while swallowing, as well as "typical cleft palate speech": Nasal escape of air (heard as snorting or grunting), a hypernasal quality, and difficulty with consonants. Normal infants begin to develop consonants in speech at age nine months, which influences the timing of operative repair of cleft palate. Even after palate repair, velopharyngeal function may not return entirely to normal, and speech therapy is often helpful.

One aspect of patients with cleft palate which will effect virtually every otolaryngologist is the Eustachian tube dysfunction and middle ear disease. In a landmark article in 1971, Bluestone compared the Eustachian tube function of patients with unrepaired cleft palate and normal-palate patients with a history of serous otitis. Although both groups demonstrated evidence of Eustachian tube dysfunction, the cleft palate patients had a "functional" obstruction of the tube at the nasopharyngeal end--as opposed to the "mechanical" obstruction found in serous otitis patients.

Historically, two muscles have been implicated in the Eustachian tube opening--the levator palatini, and the tensor veli palatini. The levator arises from the petrous bone, courses under and parallel to the tube, and inserts into the dorsal surface of the soft palate. The tensor veli palatini originates from the membranous wall of the tube, and converges into a tendon which wraps around the hamulus and inserts into the aponeurosis. Experimental animal studies from Pittsburgh in the 1980s showed that tensor dysfunction was probably responsible for this middle ear disease. However, this point is controversial and there are several authors who feel that abnormalities of the levator cause the ET dysfunction in cleft palate patients.