Velopharyngeal Insufficiency (VPI)
- What is velopharyngeal insufficiency?
- How much experience do you have treating velopharyngeal insufficiency?
- Who gets VPI?
- What does VPI sound like?
- How is VPI treated?
What is velopharyngeal insufficiency?
Soft palate at rest
Velopharyngeal insufficiency is a disorder resulting in the improper closing of the velopharyngeal sphincter (soft palate muscle in the mouth) during speech, allowing air to escape through the nose instead of the mouth.
During speech, the velopharyngeal sphincter must close off the nose to properly pronounce strong consonants such as "p," "b," "g," "t" and "d."
To close off the nose from the mouth during speech, several structures come together to achieve velopharyngeal closure.
Normal speech
These include the velum (soft palate or roof of the mouth), the lateral pharyngeal walls (side walls of the throat) and the posterior pharyngeal wall (the back wall of the throat).
If the velopharynx is not closed, snort sounds may be produced through the nose.
Improper function of this structure also produces a nasal tone in the voice.
How much experience do you have treating velopharyngeal insufficiency?
Our craniofacial team has a great deal of experience treating velopharyngeal insufficiency. Two speech pathologists on the team specialize in identifying VPI speech symptoms and in differentiating VPI from other speech problems.
They also perform specialized radiological tests to assess velopharyngeal function in children.
Two otolaryngologists (ear, nose and throat specialists) are experienced in specialized endoscopic tests (viewing the inside of an organ) to assess velopharyngeal function in children.
Our team has surgeons skilled in performing speech surgeries and a dentist who works with a speech pathologist to make prosthetic speech appliances.
Who gets VPI?
Any child with cleft palate is at risk for VPI.
The most common cause of VPI is a history of cleft palate or submucous cleft (cleft covered by the lining or mucous membrane of the roof of the mouth).
About 20 to 30% of children who have cleft palate with or without cleft lip will have persisting VPI after their palate repair. A small %age of children with submucous cleft palate will also have VPI.
Sometimes VPI develops after an adenoidectomy (a surgical procedure to remove adenoids or lymphoid tissue in the back of the nose).
Children who are born with weak throat muscles or who suffer a traumatic brain injury that results in weak throat muscles may have VPI. Sometimes children have VPI from an unknown cause.
What does VPI sound like?
The two main speech symptoms of velopharyngeal insufficiency are hypernasality and nasal air emission.
Speech with VPI
Hypernasality is sometimes called nasal speech. In English the sounds "m," "n" and "ng" are the only sounds that should resonate nasally. Hypernasality occurs when sounds other than these resonate through the nose, and it varies from mild to severe.
Some other consonants can be produced without velopharyngeal closure, including "h," "w," "y," "l" and "r."
The rest of the consonants are referred to as pressure consonants because they require buildup of air pressure in the mouth to produce normal sounds.
Nasal air emission occurs when air escapes through the nose on pressure consonants, and it can sound like puffs, squeaks or snorts, or it might make speech sound muffled.
Children sometimes develop unusual speech sounds to compensate for their VPI. A common one is a glottal stop, produced by stopping air with the vocal cords (as one would do when saying "uh oh").
Some other sounds are made by awkward stopping or restricting air with the tongue in the throat or mouth in unusual ways.
How is VPI treated?
Children may have other issues that affect their speech.
When figuring out whether your child has VPI, it is just as important to find out if your child has difficulties with articulation (the way they make sounds), speech coordination (putting the sounds together) and voice (producing a sound from the voice box or larynx).
As speech develops, children form lifelong speech habits. Good speech habits might not develop if the child cannot direct air through the mouth. If poor speech patterns persist, they are often hard to change later.
Our goal is to eliminate VPI to enable a child to develop normal speech patterns. In addition to closing the velopharynx during speech, it is important that your child be able to breathe through their nose.
A team of professionals does a careful exam of each child. VPI is usually treated with surgery or with a speech appliance, often called an obturator.
Speech Therapy
Some speech problems linked with VPI, such as mispronouncing words, can be treated by speech therapy.
Treatment focuses on teaching the child the correct manner and place of articulation. In most cases, VPI speech symptoms cannot be decreased solely by speech treatment.
Speech Appliances
Obturator
Sometimes an obturator is recommended to treat VPI.
An obturator is like a modified dental retainer with a speech bulb or palatal lift attached to the back. Each obturator is shaped uniquely to fit the patient's muscle movements.
The steps to make the appliance are taken by the dentist over several visits to the dental clinic.
A speech pathologist joins the team in the final stages of fitting the obturator and helps to monitor its ongoing effectiveness. It is worn during the day and taken out at night for sleep.
An obturator can be a short- or long-term option for children with VPI. It can be used before or instead of surgery. Some children start with an obturator and have surgery when they are older and some children continue to use an obturator as adults.
Speech Surgery
There are several surgical procedures designed to treat VPI. All are performed inside the mouth under general anesthesia. Most times, the child needs to stay in the hospital overnight.
At Children's, procedures performed most often are the Furlow palatoplasty and the sphincter pharyngoplasty.
The Furlow palatoplasty is designed to bring the abnormally positioned muscles of the palate into a more normal position so the palate can move better.
Speech with VPI after surgery
When doing a sphincter pharyngoplasty, the surgeon moves tissue from the back of the throat closer to the back of the palate.
Most times this surgery is recommended when the surgeon decides that the palate is working as well as it can, but the back of the throat isn't moving correctly.
Sometimes a child will have minimal movement of the palate or the throat and may require both of these surgeries to be done at the same time.
Some patients who have surgery will still have VPI and may require additional surgery.
If your child is a good candidate for surgery, your surgeon and the speech pathologist will discuss the type of surgery that is needed and when it should be performed. Your child's speech will be checked again after surgery.