Definition

Velopharyngeal insufficiency is the improper closing
of the velopharyngeal sphincter (soft palate muscle)
during speech characterized by an acute nasal quality of
the voice.

Description

At the back of the mouth is a circle of structures that
include the tonsils, the tongue, and the palate. During
speech, this apparatus must close off the nose for proper
articulation of the explosive consonants “p,” “b,” “g,” “t,”
and “d.” If it does not close, there is a snort sound produced
through the nose. Improper function of this structure
also produces a nasal tone to the voice.

Causes and symptoms

There are three main causes for this defect:
• Cleft palate is a congenital condition, producing a
defect in the palate that allows air to escape upward
during speech.
• If tonsil and adenoid surgery is done improperly,
velopharyngeal insufficiency may result. The occurrence
rate is approximately one in every 2,000-3,000
tonsillectomies.
• Nerve or muscle disease may paralyze the muscles that
operate the velopharyngeal sphincter.
The primary symptom is the speech impediment.
Some people develop a change in their speaking pattern
or a series of facial grimaces to try to overcome the difficulty.
If the condition is acute, regurgitation through the
nose may occur.

Diagnosis

Examination of the velopharyngeal sphincter through
ultrasound scans, fiber-optic nasopharyngoscopy, and
videofluoroscopy will reveal the extent of velopharyngeal
insufficiency. Speech and velopharyngeal sphincter
movement are compared to make the diagnosis.

Treatment

Velopharyngeal insufficiency is treated with a combination
of surgery and speech therapy. There are several
surgical procedures that can be performed to correct the
physical malfunction. They include:
• Pharyngeal flap procedure that moves the skin flap
from the pharynx to the soft palate.
• Palatal push-back that separates the hard and soft palate
in order to lengthen the soft palate.
• Pharyngoplasty that lengthens the soft palate by turning
the pharyngeal skin flaps.
• Augmentation pharyngoplasty that inserts an implant
into the pharyngeal wall to enlarge it, thus narrowing
the velopharyngeal opening.
• Velopharyngeal sphincter reconstruction.

Prognosis

The combination of surgery to correct the insufficiency
and speech therapy to retrain the voice successfully
alleviate velopharyngeal insufficiency.