Velopharyngeal insufficiency is a disorder of structure that causes a failure of the velum (soft palate) to close against the posterior pharyngeal wall (back wall of the throat) during speech in order to close off the nasal cavity during oral speech production. This is important because speech requires sound from the vocal folds and airflow from the lungs to be directed into the oral cavity (mouth) for the production of all speech sounds, with the exception of nasal consonants (m, n, and ng). If complete closure does not occur during speech, this can cause hypernasality (a resonance disorder) and/or audible nasal emission during speech (a speech sound disorder). In addition, there may be inadequate airflow to produce most consonants, making them sound weak or omitted.Kummer AW. (2020). Speech/Resonance Disorders and Velopharyngeal Dysfunction. In Kummer, AW. Cleft Palate and Craniofacial Conditions: A Comprehensive Guide to Clinical Management, 4th Edition. Burlington, MA: Jones & Bartlett Learning.
The terms "velopharyngeal insufficiency", "velopharyngeal incompetence", "velopharyngeal inadequacy", and "velopharyngeal dysfunction" have often been used interchangeably, although they may also refer to distinct tangential concepts. "Velopharyngeal dysfunction" now refers to abnormality of the velopharyngeal valve, regardless of cause. Velopharyngeal insufficiency includes any structural defect of the velum or mechanical interference with closure. Causes include a history of cleft palate, adenoidectomy, irregular adenoids, cervical spine anomalies, or oral/pharyngeal tumor removal.Peter D. Witt, D’Antonio. Velopharyngeal insufficiency and secondary palatal management. Clinics in plastic surgery. 1993. Oct;20(4):707-21. In contrast, "velopharyngeal incompetence" refers to a neurogenic cause of inadequate velopharyngeal closure. Causes may include stroke, traumatic brain injury, cerebral palsy, or neuromuscular disorders.Kummer AW, Marshall J, and Wilson M. (2015). Non-cleft causes of velopharyngeal dysfunction: Implications for Treatment. International Journal of Pediatric Otorhinolaryngology, 79(3):286-95. It is important that the term "velopharyngeal insufficiency" is used if it is an anatomical defect and not a neurological problem.Wermker K, Lünenbürger H, Joos U, Kleinheinz J, Jung S et al. Results of speech improvement following simultaneous push-back together with velopharyngeal flap surgery in cleft palate patients. J Craniomaxillofac Surg. 2013 Sep 13. pii: S1010-5182(13)00219-9.
Anatomy
Diagnosis
Speech analysis Velopharyngeal insufficiency can be diagnosed by a speech pathologist through a perceptual speech assessment. Speech characteristics of VPI include hypernasality (too much sound in the nasal cavity during speech) and/or audible nasal emission of air during speech. Nasal emission can also cause the consonants to be very weak in intensity and pressure. The patient may develop compensatory productions for consonants, where the sounds are produced in the pharynx (throat area) where there is adequate airflow.Kummer AW. (2020). Speech and Resonance Assessment. In Kummer, AW. Cleft Palate and Craniofacial Conditions: A Comprehensive Guide to Clinical Management, 4th Edition. Burlington, MA: Jones & Bartlett Learning.4. Kummer AW. (2011). Perceptual assessment of resonance and velopharyngeal dysfunction. Seminars in Speech and Language, 32(2), 159-167.
Nasometry Nasometry is a method of measuring the acoustic correlates of resonance and velopharyngeal function through a computer-based instrument. Nasometry testing gives the speech pathologist a nasalance score, which is the percentage of nasal sound of the total (nasal plus oral) sound during speech. This score can be compared to normative values for the speech passage. Nasometry is useful in the evaluation of hypernasality because it provides objective measurements of the function of the velopharyngeal valve. As such, it is often used for pre-and post-surgical comparisons and to determine speech outcomes as a result of certain surgical interventions.Kummer AW. (2020). Nasometry. In Kummer, AW. Cleft Palate and Craniofacial Conditions: A Comprehensive Guide to Clinical Management, 4th Edition. Burlington, MA: Jones & Bartlett Learning.Sweeney, T., & Sell, D. (2008). Relationship between perceptual ratings of nasality and nasometry in children/adolescents with cleft palate and/or velopharyngeal dysfunction. International Journal of Language and Communication Disorders, 43(3), 265–282.
Nasopharyngoscopy Nasopharyngoscopy is endoscopic technique in which the physician or speech pathologist passes a small scope through the patient's nose to the nasopharynx. The nasal cavity is typically numbed before the procedure, so there is minimal discomfort. Nasopharyngoscopy provides a view of the velum (soft palate) and pharyngeal walls (walls of the throat) during nasal breathing and during speech. The advantage of this technique over videofluoroscopy is that the examiner can see the size, location, and cause of the velopharyngeal opening very clearly and without harm (e.g., radiation) to the patient. Even very small openings can be visualized. This information is helpful in determining appropriate surgical or prosthetic management for the patient. The disadvantage of this technique is that the vertical level velar elevation is less obvious than with videofluoroscopy, although this is not a big concern.Kummer AW. (2020). Nasopharyngoscopy. In Kummer, AW. Cleft Palate and Craniofacial Conditions: A Comprehensive Guide to Clinical Management, 4th Edition. Burlington, MA: Jones & Bartlett Learning.Lam DJ, Starr JR, Perkins JA, Lewis CW, Eblen LE, Dunlap J, Sie KC. A comparison of nasoendoscopy and multiview videofluoroscopy in assessing velopharyngeal insufficiency. Otolaryngol Head Neck Surg. 2006 Mar;134(3):394-402.Henningsson G, Isberg A. Comparison between multiview videofluoroscopy and nasoendoscopy of velopharyngeal movements. Cleft Palate Craniofac J. 1991 Oct;28(4):413-7
Videofluoroscopy Multiview videofluoroscopy is a radiographic technique to view the length and movement of the velum (soft palate) and the posterior and lateral pharyngeal (throat) walls during speech. The advantage of this technique is that the entire posterior pharyngeal wall can be visualized. Disadvantages include the following: 1. This procedure requires radiation, which is a particular concern for children. 2. It is not well tolerated by some children because it requires injection of barium into the nasopharynx through a nasal catheter. 3. The resolution (clarity of the image) is not nearly as good as nasopharyngoscopy. 4. Small or unilateral openings cannot be seen because the X-ray beam takes a sum of all the parts. 5. It only provides a two-dimensional view, and therefore, multiple views are needed to see the entire velopharyngeal mechanism.Willging JP. Velopharyngeal insufficiency. Curr Opin Otolaryngol Head Neck Surg. 2003 Dec;11(6):452-5. Comparison between multiview videofluoroscopy and nasoendoscopy of velopharyngeal movements."/>Havstam C, Lohmander A, Persson C, Dotevall H, Lith A, Lilja J. (2005). Evaluation of VPI-assessment with videofluoroscopy and nasoendoscopy. British Journal of Plastic Surgery, 58(7), 922-931. This diagnosis method is useful in assessing velopharyngeal (VP) closure in healthy individuals vs individuals who experience velar backed articulation (BA); given that it was found that healthy individuals had VP closure occur before tongue movement, whereas individuals with BA had VP closure occur after tongue movement when articulating words.
Magnetic resonance imaging A relatively new approach in the diagnosis is magnetic resonance imaging (MRI), which is noninvasive. MRI uses the property of nuclear magnetic resonance to image nuclei of atoms inside the body. MRI is non-radiographic and therefore can be repeated more often in short periods of time. In addition, different studies show that the MRI is better as an imaging tool than videofluoroscopy for visualizing the anatomy of the velopharynx. There are some limitations of the MRI however. Unlike videofluoroscopy and nasopharyngoscopy, MRI does not show the movement of the velopharyngeal structures during speech. In addition, artifacts can be shown on the images when the patient moves while imaging or if the patient has orthodontic appliances. MRI is limited in children who are claustrophobic. Finally, MRI is much more expensive than videofluoroscopy or nasopharyngoscopy. Because of these limits, MRI is currently not widely used for clinical diagnostic purposes.S. Vadodaria, T. E. E. Goodacre and P. Anslow; Does MRI contribute to the investigation of palatal function?; Br J Plast Surg. 2000 Apr;53(3):191-9.Ruda, JM, Krakovitx, P, Rose AS. (2012). A Review of the Evaluation and Management of Velopharyngeal Insufficiency in Children. Otolaryngology Clinics, 45(3), 653-669.
Treatment
Speech pathology Speech therapy will not correct velopharyngeal insufficiency. The condition results from abnormal structure and requires physical management (surgery, or a prosthetic device if surgery cannot be done). Speech therapy is appropriate to correct the compensatory articulation productions that develop as a result of velopharyngeal insufficiency. Speech therapy is most successful after correction of velopharyngeal insufficiency. Speech pathologists who are associated with a cleft palate/craniofacial team are most qualified for this type of therapy.Kummer AW. (2011). Speech therapy for errors secondary to cleft palate and velopharyngeal dysfunction. Seminars in Speech and Language, 32(2), 191-199. Kummer AW. (2020).Kummer AW. (2020). Speech Therapy. In Kummer, AW. Cleft Palate and Craniofacial Conditions: A Comprehensive Guide to Clinical Management, 4th Edition. Burlington, MA: Jones & Bartlett Learning.
Operation techniques
In patients with cleft palate, the palate must be repaired through a palatoplasty for normal velopharyngeal function. Despite the palatoplasty, 20-30% of these patients will still have some degree of velopharyngeal insufficiency, which will require surgical (or prosthetic) management for correction. Therefore, a secondary operation is necessary.Jessica Collins et al. Ontario, Canada. Pharyngeal flap versus sphincter pharyngoplasty for the treatment of velopharyngeal insufficiency: A meta-analysis. J Plast Reconstr Aesthet Surg. 2012 Jul;65(7):864-8. There is not one single operative approach to surgical correction of VPI. The surgical approach typically depends on the size of the velopharyngeal opening, its location, and the cause.Ysunza A, Pamplona C, Ramírez E, Molina F, Mendoza M, Silva A. Velopharyngeal surgery: a prospective randomized study of pharyngeal flaps and sphincter pharyngoplasties, Plast Reconstr Surg. 2002 Nov;110(6):1401-7. With diagnostic tools the surgeon is able to decide which technique should be used based on the anatomical situation of the individual. The goal of every operation is to achieve the best possible result with the technique assigned to each individual case, without causing upper airway obstruction and sleep apnea.Nowadays the procedure that is chosen the most from the palatoplasties is the pharyngeal flap or sphincter palatoplasty.
Pharyngeal flap