through continual adjustments that are made to the device by the parents at home. The adjustments are made by turning a small screw that protrudes through the skin, usually at a rate of 1 mm per day. This gradual distraction leads to formation of new bone between the two ends. After the process is complete, the osteotomy is allowed to heal over a period of six to eight weeks. A small second surgery is then performed to remove the device. The cleft palate is generally repaired between the ages of 6½ months and 2 years by a plastic surgeon, an oromaxillofacial surgeon, or an otorhinolaryngologist (ENT surgeon). In many centres there is now a cleft lip and palate team comprising these specialties, as well as a coordinator, a speech and language therapist, an orthodontist, sometimes a psychologist or other mental health specialist, an audiologist, and nursing staff. The glossoptosis and micrognathism generally do not require surgery, as they improve to some extent unaided, though the mandibular arch remains significantly smaller than average. In some cases jaw distraction is needed to aid in breathing and feeding. Lip-tongue attachment is performed in some centres, though its efficacy has been recently questioned. A cleft palate (PRS or not) makes it difficult for individuals to articulate speech sounds, which may be due to the physical nature of cleft palate or the hearing loss that is associated with the condition. This is typically why a speech language pathologist and/or audiologist is involved with the patient. Hearing should be checked by an audiologist regularly and can be treated with hearing amplification such as hearing aids. Because middle ear effusion is found in many patients with PRS, tympanostomy (ventilation) tubes are often a treatment option. One study with children showed that patients with PRS displayed a moderate and severe hearing loss most frequently. Planigraphs of temporal bones in these patients displayed an underdeveloped pneumatization of the mastoid bone in all PRS patients and in most patients with cleft palate (without PRS). There were no abnormalities of the inner or middle ear anatomy in patients with PRS. Prognosis Children affected with PRS usually reach full development and size. However, it has been found internationally that children with PRS are often slightly below average size, raising concerns of incomplete development due to chronic hypoxia related to upper airway obstruction as well as lack of nutrition due to early feeding