Sir, submucous cleft palate can be defined as the abnormal attachment of the palatal muscles with intact oral and nasal mucosa.1 This produces functional difficulties for the patient including speech problems, feeding difficulties or middle ear dysfunction. However, only 10% of cases are symptomatic.2

Clinically, the cardinal signs of a submucous cleft palate are a bifid uvula, a V-shaped notch at the back of the hard palate, a translucent line in the mid-line of the soft palate and a short palate. It should, however, be noted that a bifid uvula occurs in isolation in about 0.1-3% of the population3,4,5 and that not all of the above signs need to be present to diagnose a submucous cleft palate.6,7

A 68-year-old man was referred to our ENT colleagues with what was thought to be a polyp on his uvula. He had suffered from middle ear problems throughout his life. The ENT surgeons felt that rather than a polyp it was more likely to be a bifid uvula and queried a diagnosis of submucous cleft palate and subsequently referred him to our cleft team.

On examination it was noted that the patient had hyponasal speech with constant air escape during conversation. He commented that people found him difficult to understand, especially whilst conversing on the telephone. The patient was edentulous and wearing a complete upper denture (Fig. 1). His uvula was clearly seen to be bifid. He exhibited a V-shaped notch at the back of the hard palate and his soft palate was noted to be short (Fig. 2). There was no translucent line on the soft palate and no evidence of previous palatal surgery. There was no familial cleft history of note.

Figure 1
figure 1

The edentulous patient with bifid uvula and V-shaped notch at the back of the hard palate

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Figure 2
figure 2

The edentulous patient with bifid uvula and V-shaped notch at the back of the hard palate

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This case highlights the importance of a sound history and clinical evaluation in any patient presenting with speech problems. This gentleman had been fitted with a number of complete upper dentures. Numerous health care professionals had the opportunity to diagnose the condition but on each occasion his underlying submucous cleft remained unnoticed. The patient suffered long term middle-ear dysfunction due to the altered anatomical form of the Eustachian tube musculature.

The condition of submucous cleft palate is uncommon, having an incidence of 1:1,200 births.2,3 In this case it is unfortunate that the definitive diagnosis has been made so late in the patient's life despite suffering from classical speech problems and clinical signs that would point to a diagnosis of submucous cleft palate.8

The patient was offered surgery to correct the cleft but declined as he felt that both the diagnosis and treatment option had come too late to be worthwhile.