Velopharyngeal insufficiency is incomplete closure of a sphincter between the oropharynx and nasopharynx, often resulting from anatomic abnormalities of the palate and causing hypernasal speech. Diagnosis is direct inspection with a fiberoptic nasoendoscope. Treatment is with speech therapy and surgery.
Closure of the velopharyngeal sphincter is normally achieved by the sphincteric action of the soft palate and the superior constrictor muscle. Closure is impaired in patients with cleft palate, repaired cleft palate, congenitally short palate, submucous cleft palate, palatal paralysis, and, sometimes, enlarged tonsils. Velopharyngeal insufficiency may also result when adenoidectomy or uvulopalatopharyngoplasty is done in a patient with a congenital underdevelopment (submucous cleft) or paralysis of the palate.
Symptoms and Signs of Velopharyngeal Insufficiency
Speech in a patient with velopharyngeal insufficiency is characterized by hypernasal resonant voice, nasal emission of air, nasal turbulence, and inability to produce sounds requiring oral pressure (plosives). Severe velopharyngeal insufficiency results in regurgitation of solid foods and fluids through the nose. Inspection of the palate during phonation may detect palatal paralysis.
Diagnosis of Velopharyngeal Insufficiency
Direct inspection with a fiberoptic nasoendoscope
Velopharyngeal insufficiency is suspected in patients with the typical speech abnormalities.
Palpation of the midline of the soft palate may detect an occult submucous cleft, usually in patients with bifid uvula. Direct inspection with a fiberoptic nasoendoscope is the primary diagnostic technique.
Multiview videofluoroscopy during connected speech and swallowing (modified barium swallow), done in collaboration with a speech pathologist, should be used only when other diagnostic measures do not provide the necessary information.
Treatment of Velopharyngeal Insufficiency
Surgical repair and speech therapy
Treatment of velopharyngeal insufficiency consists of speech therapy and surgical correction by a palatal elongation pushback procedure, posterior pharyngeal wall implant, pharyngeal flap, or pharyngoplasty, depending on the mobility of the lateral pharyngeal walls, the degree of velar elevation, and the size of the defect. A palatal lift prosthesis (from a prosthodontist) may also be helpful.
