During normal speech, the soft palate muscle in the mouth moves up and down and touches the back of the throat. To produce oral consonants (letters such as p, w, and x), the soft palate closes against the back of the throat. When the muscle closes tightly against the back of the throat, air cannot come out the nose. Velopharyngeal insufficiency (VPI) is when the soft palate does not close tightly against the back of the throat, leading to air coming out the nose (characterized by hypernasality and/or nasal air emission) during speech. This can cause speech that is difficult to understand.
What causes VPI?
The most common cause of VPI is a cleft palate or a submucous cleft palate. About 20% of children who have a repaired cleft palate will have persistent VPI. Adenoidectomies (removal of adenoids – lymphoid tissue in the back of the nose) can occasionally result in VPI by creating more space between the soft palate and the back of the throat. Usually, VPI that occurs after an adenoidectomy is temporary, improving after a few weeks, and rarely persisting long-term.
Children with velo cardio facial syndrome (DiGeorge syndrome) can have VPI even if they do not have an obvious cleft palate. Traumatic brain injuries or neurological disorders can also result in velopharyngeal incompetence due to muscle weakness or difficulty with muscle coordination of the palate. In some cases, VPI results from an unknown cause.
A note from Mayo Clinic & Aradhya Foundation (MCAF)
How is VPI diagnosed?
A speech pathologist can determine whether the speech deficit is caused by VPI or another speech disorder. A Nas endoscopy is used to view palatal motion during speech and to determine the size and shape of the velopharyngeal gap. A small flexible fiberoptic scope is inserted into the child’s nose to observe how the palate moves while the child is talking. The image helps the otolaryngologist, speech pathologist and plastic surgeon decide on treatment recommendations.
How is VPI treated?
Children with VPI often produce sounds incorrectly and speech therapy is recommended to help them pronounce sounds properly. Research has shown that blowing bubbles and using oral-motor exercises are not effective for improving velopharyngeal function.
Surgery is commonly needed to improve VPI. The most common types of surgery for VPI are Furlow palatoplasty, sphincter pharyngoplasty, pharyngeal flap, or a posterior pharyngeal wall injection augmentation. The size and shape of the velopharyngeal gap will dictate the type of surgery that is necessary. A speech evaluation is recommended approximately six weeks after surgery to re-evaluate speech and determine if therapy is recommended.
Velopharyngeal Insufficiency
A condition where the soft palate is unable to touch the back of the throat to separate the nose from the mouth during speech. This can be caused by a number of factors, including cleft palate, short palate, skeletal abnormalities, neurological impairment, enlarged tonsils, and more
Velopharyngeal Insufficiency Outcomes Prediction Study (VPI-OPS)
During speech, the soft palate (i.e., velum) closes against the back wall of the throat (i.e., pharynx), preventing air flow through the nose.
Velopharyngeal insufficiency, or VPI, is a condition that occurs when the soft palate cannot close against the back wall of the throat during speech. With VPI, too much air escapes through the nose and results in hyper nasal speech – like the voice is coming through the nose.
VPI can substantially impact a child’s speech and make it difficult for others to understand them, which can affect school performance, relationships with friends and family, and self-image.
For these reasons, most children with VPI undergo surgery to improve their speech. There are three general types of surgery performed to treat VPI. Surgeons select one of these surgery types, or variations of a type, based on each patient’s individual situation and their surgical judgment.
Surgery options include:
Pharyngeal flap
In a pharyngeal flap, tissue from the back of the throat is elevated and then connected to the back of the palate. The pharyngeal flap partially obstructs the space between the palate and throat. The partial obstruction significantly reduces the amount of air flow through the nose during speech
Sphincter pharyngoplasty
In a sphincter pharyngoplasty, tissue from the sides of the throat is used to create a pad of tissue on the back of the throat. This narrows the airway passage into the nose, reducing air flow through the nose during speech.
Palate re-repair
In a palate re-repair, the muscles of the palate are reconstructed and repositioned into a more favorable position in the palate. Sometimes this procedure also lengthens the palate. The result is a more effective elevation of the palate, improving the ability of the palate to close against the back of the throat during speech.
Velopharyngeal Insufficiency (VPI)
Velopharyngeal insufficiency (VPI) occurs when the seal between your oral and nasal cavities doesn’t close completely. The condition is often associated with palate defects or genetic disorders. With VPI, air escapes through your nose during speech, causing a nasal sound and other speech issues. Treatment usually involves speech therapy and surgery.
What is velopharyngeal insufficiency?
Velopharyngeal insufficiency (VPI) occurs when the sphincter between your oral and nasal cavities doesn’t close completely. It can make your voice sound nasally or cause speech problems. In severe cases, solid foods or fluids may regurgitate (come up) through your nose.
VPI is a type of velopharyngeal dysfunction. It involves the velopharyngeal sphincter, the juncture between your:
- Nasopharynx, the upper part of your throat (pharynx) that’s behind your nose.
- Oropharynx, the middle part of your pharynx that’s behind your mouth.
A sphincter is a ring of muscle that protects or closes an opening or tube in your body. The velopharyngeal sphincter is active when you swallow or speak.
Who might develop velopharyngeal insufficiency?
VPI is more likely to occur in children with:
- Birth defects affecting their palate (roof of the mouth), such as cleft palate or an abnormally short palate.
- Enlarged tonsils or adenoids.
- Genetic conditions such as Down syndrome or neurofibromatosis.
- Muscle weakness from neurological disorders such as cerebral palsy.
- Tumor in their palate.
The condition also may occur after certain types of surgery or cancer treatment:
- Adenoidectomy (adenoid removal).
- Tonsillectomy (tonsil removal).
- Uvulopalatopharyngoplasty (UPPP surgery, removal of extra tissue at the back of the throat to widen the airway).
- Late effect of radiation therapy to the oropharynx or nasopharynx.
Rarely, a type of “stress VPI” may occur in musicians who play brass or woodwind instruments.
Symptoms and Causes
What can cause velopharyngeal dysfunction?
VPI occurs when there’s a structural problem in the velopharyngeal sphincter. When the sphincter’s seal isn’t complete or tight, air can escape through your nose instead of your mouth. This causes the nasal-sounding voice of VPI.
What are the symptoms of velopharyngeal dysfunction?
The signs and symptoms of VPI include:
- Nasal-sounding voice.
- Problems forming certain words or sounds (for example, the consonants p, b, g, t and d).
- Unexpected sounds coming from your nose during speech.
- Rarely, regurgitation of liquid or food through your nose.
What does velopharyngeal insufficiency sound like?
A person with VPI may sound slightly different when speaking. For example:
- Awkward stops in speech.
- Muffled speech.
- Puffs of air, squeaks or snorts as air escapes through their nose.
- Sounding like they’re speaking through their nose instead of their mouth.
Diagnosis and Tests
- Inspect your throat and sphincter with a fiberoptic Nas endoscope (thin tube with a light and camera on the end).
- Perform speech analysis, listening for the sounds associated with VPI.
- Test with video fluoroscopy, an X-ray that uses barium liquid to show your body’s structures during swallowing and speech.
- Direct visualization of the velum during speech with a flexible endoscope.
Management and Treatment
How is velopharyngeal insufficiency treated?
Velopharyngeal insufficiency treatment usually involves speech therapy and surgery.
Speech therapy can help your child adjust the way they speak to reduce the sounds of VPI. It’s often done before and after surgery.
Surgery aims to create a better seal between the nasal and oral cavities without blocking the airway. Surgical approaches depend on the structural problems involved. A surgeon may:
- Change the shape of the soft palate.
- Expand the pharyngeal wall to decrease the distance to the soft palate.
- Lengthen or readjust the palate muscles.
- Take a flap of muscle from the back wall of the throat and attach it to the palate, called a pharyngeal flap procedure.
- Use fat injections or other fillers to help close the palate.
Some people may wear an oral prosthetic, a custom-made device that pushes their palate higher (like a dental retainer after braces). But these are often difficult to tolerate and are usually used only in people who aren’t good candidates for surgery.
What are the risks of VPI surgery?
Like any surgical procedure, surgery to correct VPI can cause possible complications, including:
- Hypo nasal speech (not enough sound in your nasal cavity during speech).
- Obstruction of nasal airflow.
Prevention
How can I prevent VPI in my child?
There aren’t any strategies to prevent VPI. Avoiding surgery near the palate and pharynx may help reduce the risk of VPI, but those procedures are often medically necessary.
This Information Collected from Aradhya Clinic & Neuro Research Center (ACNRC)
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