Velopharyngeal Insufficiency (VPI)

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.

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.

How is VPI diagnosed?

To diagnose VPI, a healthcare provider will likely:

• Feel your palate to detect any abnormalities.
• Inspect your throat and sphincter with a fiberoptic nasoendoscope (thin tube with a light and camera on the end).
• Perform speech analysis, listening for the sounds associated with VPI.
• Test with videofluoroscopy, 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.

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:

• Hyponasal speech (not enough sound in your nasal cavity during speech).
• Obstruction of nasal airflow.
• Obstructive sleep apnea.
• Worsened hypernasal speech.

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.

What can I expect if my child has this condition?

Surgery corrects VPI in as many as 85% of cases. But some people may still have symptoms or require repeat surgery.

Often, a child with VPI has learned speech habits and needs speech therapy to adjust after surgery.

When should I ask my child’s healthcare provider about VPI?

Talk to your child’s healthcare provider if you notice unusual speech patterns, habits or sounds. If you notice a strong nasal tone during speech, it could be VPI. Early treatment can help prevent long-term habits that can be harder to break.

A note from Cleveland Clinic

Velopharyngeal insufficiency (VPI) occurs when the seal between your oral and nasal cavities doesn’t close completely. The condition allows air to escape from your nose instead of your mouth during speech. If your child has speech issues and speaks nasally, talk to your pediatrician about VPI.