Otitis media with effusion is a common finding in children with cleft palate. However, although middle ear effusions have been reported to be almost universal among infants with cleft palate, less is known regarding the epidemiology, natural history, and outcome of middle ear disease among older children with cleft palate. Furthermore, considerable controversy surrounds the management of otitis media with effusion in these children: many authors have advocated a policy of early or scheduled ventilation tube insertion on account of the high incidence of hearing loss and speech difficulties; others have advocated a more conservative policy on account of the high incidence of complications from ventilation tubes and lack of evidence supporting a policy of early intervention. In the present paper, we review the epidemiology, aetiology, and natural history of middle ear disease in children with cleft palate. We also discuss the controversies involved in the management of these patients.