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Objective: To describe the impact of timing of tympanostomy tube insertion on the number of tubes received and complications in children with routine tube placement., Design: Retrospective case series., Setting: Tertiary care children's hospital., Participants: Records from a consecutive sample of 401 children with cleft palate were reviewed. Sixty-five patients with isolated cleft palate and 82 patients with cleft lip and palate had follow-up until 5 years of age and were included., Interventions: Tympanostomy tubes., Main Outcome Measure(s): Number of tubes received and tube-related complications. The hypothesis was formulated prior to data collection., Results: Males comprised 55.8% of included patients, and tubes were placed in 98.6% of patients at a median age of 6.5 months. Effusion was documented at first tube placement for 96.5% of patients. Most (67.4%) patients required replacement of tubes, and 10.6% required long-term tubes. Complications included otorrhea (71.0%), myringosclerosis (35.2%), granulation (22.8%), perforation (17.9%), retained tubes (5.5%), and cholesteatoma (1.4%). Cleft lip and palate ( P < .001) and otorrhea ( P = .023) were associated with tube placement before palatoplasty. Patients with tube placement before palatoplasty ( P = .033), genetic disorders ( P = .007), failed newborn hearing screen ( P = .012), otorrhea ( P < .001), and granulation ( P < .001) received more tubes., Conclusions: Nearly universal effusion in patients with cleft palate supports the need for routine tube placement. The potential for otorrhea and requiring more tubes should be weighed against the risks associated with prolonged effusion when considering tube placement before palatoplasty.