The management of patients with cleft lip and palate includes a focus on effective speech and language function. Poor eustachian tube function and middle ear dysfunction mean over 90% of children suffer from otitis media with effusion. This article provides an overview of the anatomy and pathophysiology of acute otitis media and glue ear in the cleft patient. The recommendation is to adopt an MDT approach with close liaison between audiology and otorhinolaryngology. The article explains how untreated, recurrent infection and bouts of fluid buildup can result in metaplasia of middle ear mucosa and atrophy/scarring/atelectasis of the tympanic membrane with a risk of perforation or collapse. The role of pressure equalization tubes is discussed. This is a helpful article that provides a good overview of an important treatment consideration in the patient with cleft lip and palate.