In children with cleft palate, hearing loss and middle ear effusions are frequent complications. Knowledge of the variant eustachian tube anatomy in patients with cleft palate can provide a better understanding of potential middle ear pathology. Timely diagnostic testing and appropriate interventions are important in the management of these complex patients. Pressure equalization tubes play a role in the management of middle ear effusions; however, the timing of placement is often debated for patients with cleft palate. As treatment is prolonged, there is greater concern for speech and language development. The multidisciplinary team approach is critical in optimizing outcomes.