Submucous Cleft Palate

What Is a Submucous Cleft Palate?

A submucous cleft palate (SMCP) happens when the roof of the mouth, or palate, doesn't form properly when a baby is developing in the womb. This type of cleft is caused by a separation of the speech muscle under the surface of the palate.

A typical cleft palate is noticed when a baby is born because it looks like an obvious opening in the roof of the mouth. Because the cleft in a submucous cleft palate (PAL-it) is under surface, it's harder to see. A SMCP may be diagnosed early in infancy or later in life. Sometimes it isn't ever noticed and causes no problems.

What Causes Submucous Cleft Palate?

Doctors don't always know why the muscles don't form as they should in the unborn baby's palate. Some SMCPs happen by chance, while others happen as part of a known syndrome or other genetic difference.

What Are the Signs & Symptoms of a Submucous Cleft Palate?

Usually, newborns have an oral exam soon after they're born. But a submucous cleft palate can be very subtle and might not be found during this exam. 

Doctors and parents might notice these symptoms in a child with a submucous cleft palate:

• trouble feeding as an infant (taking a long time to feed, liquid coming through the nose, etc.)
• chronic ear infections and effusions (fluid buildup behind the eardrum)
• speech sound errors
• speech problems that make the child hard to understand
• hypernasality ("nasally sounding" speech)
• nasal air emissions (hearing air leak out the nose during speech)

An oral exam of a child with a submucous cleft palate may show:

• a split in the uvula (called a bifid uvula). The uvula (YOO-vyuh-luh) is the small, bell-shaped bit of flesh hanging at the back of the throat, in the middle of the soft palate.
• a bluish tint to the tissue along the midline of the soft palate (called a “zona pellucida”)
• a notch, or indentation, in the back of the hard palate bone that can be felt when pressing it with a finger

How Is Submucous Cleft Palate Diagnosed?

When a submucous cleft palate is found, the doctor will refer the child to a cleft and craniofacial team for a full evaluation. This team includes:

• a surgeon, who will do a full oral exam to confirm the diagnosis
• a speech-language pathologist (or speech therapist), who will listen carefully for hypernasality and other speech signs that could be related to a submucous cleft palate
• ear, nose, and throat (ENT) surgeon (otolaryngologist) and audiologist to examine the ears and test the hearing
• other care providers who have specialized training in cleft palate

So that the team gets a better picture of the mouth and palate, a child might have these tests:

• a nasopharyngoscopy (nay-so-fair-en-GOS-kuh-pee): The doctor inserts a flexible tube called a scope through the nose to see the back of the throat and how the palate moves during speech.
• a videofluoroscopy (vid-ee-oh-flore-AH-skuh-pee): The doctor uses X-rays to see how the palate moves during speech.

The results from these exams will help the team create a treatment plan, if needed.

How Is Submucous Cleft Palate Treated?

The problems caused by a submucous cleft palate vary from child to child. Some can have speech problems and many ear infections, while others have no symptoms or speech problems.

Children with submucous cleft palate fall into one of these four categories:

1. No surgical repair needed, no speech therapy needed.
2. Surgical repair needed, no speech therapy needed.
3. No surgical repair needed, speech therapy needed.
4. Surgical repair needed, speech therapy needed.

A submucous cleft palate that doesn't affect a child's speech usually is watched carefully by the care team to make sure it doesn't cause problems as the child grows.

Kids who have more serious symptoms (like hypernasality or nasal air emissions) usually will have their palate corrected with surgery.

Children with "cleft palate speech" might benefit from speech-language therapy to help correct any speech sound errors. Also, an otolaryngologist can treat related ear problems — for instance, doing ear tube surgery to drain fluid from the middle ear, prevent future ear infections, and help hearing.

What Else Should I Know?

Doctors should be cautious about doing an adenoidectomy on kids who have a submucous cleft palate. That's because this procedure to remove the adenoids creates more space between the soft palate and the back of the throat. That can put kids with a submucous cleft palate at risk for developing nasal sounding speech. Hypernasality and nasal air emissions during speech are signs of velopharyngeal (vee-low-fair-en-JEE-ul) dysfunction (VPD). This happens because the soft palate, the flexible part of the palate back near the throat, does not close tightly during speech, which lets air and sound escape through the nose.