What is velopharyngeal dysfunction (VPD)?
A person’s speaking voice takes on a nasal tone when too much air flows through the nose. This happens when the moving tissue at the back of the roof of the mouth, called the soft palate or the velum, fails to close an opening called the velophayngeal port. The result is called velopharyngeal dysfunction (VPD).
VPD is most common in children as it is often associated with other birth/genetic conditions or surgical procedures, such as the removal of tonsils or adenoids. It can be caused by things that happen in adulthood such as surgeries for oral cancer or due to neurologic conditions.
Similar terms are sometimes used to describe different types of velopharyngeal dysfunction (VPD). These include:
- Velopharyngeal Insufficiency (VPI): Structural defects resulting in insufficient tissue to accomplish closure
- Velopharyngeal incompetence: The soft palate lets air into the nose because of a muscular or nerve problem, rather than because of the structure of the back of the mouth.
- Velopharyngeal mislearning: The palate is functioning properly, but a child has learned an unusual speech pattern that doesn’t use it properly.
Sometimes more than one of these types of VPD is present.
Who is at risk of developing velopharyngeal insufficiency (VPI)?
Besides cleft palate, velopharyngeal insufficiency is also common in children with other genetic conditions including:
- Down syndrome
- Velocardiofacial/Digeorge/22Q Deletion Syndrome, which sometimes includes a cleft palate
- Kabuki syndrome, which affects multiple parts of the body
- Neurofibromatosis, which causes tumors to grow in the nervous system
In adults, brain injuries and neurological conditions that weaken muscles are linked to the development of VPI.
Symptoms and Causes
What are the symptoms of velopharyngeal insufficiency (VPI)?
A person with VPI might have hypernasal speech, which means there is too much air resonating in the nose and it sounds as if they are speaking through the nose. What they say might be harder to understand, and they might have difficulty making certain sounds because there isn’t enough air pressure in their mouth. The air escaping through the nose might make a sound, such as a snort or a squeak. This is sometimes called “nasal turbulence.” In severe cases, food or liquid might escape through the nose while the person is eating.
There are also things people with VPI do, consciously or subconsciously, to compensate for the problem. They include:
- Nasal grimace, which is an attempt to tighten the facial muscles that makes talking look like hard work
- Talking more loudly or less loudly
- Substituting sounds that are easier to make for the correct sound
What causes velopharyngeal insufficiency (VPI)?
The most common cause of VPI is a cleft palate, a birth defect in which there is an opening in the roof of the mouth because the palate didn’t form properly. Repair of the cleft palate may or may not also eliminate the VPI problem.
Other causes include:
- Other present-at-birth conditions affecting the structure of the mouth or head
- Large tonsils that interfere with the closing of the velopharyngeal port
- VPI can develop after surgery to remove the adenoids, glands in the roof of the mouth that sometimes have to be removed if they grow too large. When this happens the VPI usually goes away after a few weeks, if note ENT follow up is needed.
- A brain injury, or neurological problems caused by a stroke or a disease
Diagnosis and Tests
How is velopharyngeal insufficiency (VPI) diagnosed?
VPI can be diagnosed through a combination of tests that assess both how the patient speaks and the anatomy of the mouth.
An ENT often in combination with a speech-language pathologist can assess the amount of air that flows through the nose while a patient speaks, how well the speech can be understood and the way different parts of the mouth move during speech. The tests used in diagnosis of VPI may include:
- Endoscopy, using a medical device with lights attached that allow doctors to see inside the mouth
- Videofluoroscopy, a type of X-ray that uses a liquid called barium to provide contrast that makes it easy for a doctor to examine the back of the mouth
Neither procedure requires sedation.
Management and Treatment
How is velopharyngeal insufficiency (VPI) treated?
A combination of speech therapy and surgery is usually used to treat VPI. The surgery is needed to fix the structural problem, but won’t correct the way a child talks because of the habits the child has learned to compensate for VPI. Therapy is usually necessary before and after surgery. Velopharyngeal mislearning can be treated with therapy and without surgery.
Different surgical techniques can be used, depending on the specifics of the problem. Surgeries include sphincter pharyngoplasties, pharyngeal flaps, furlow palatoplasties, and injection pharyngoplasties. Prosthetic (artificial) devices such as a palatal obturator, which is similar to a dental retainer, are sometimes used temporarily or as an alternative to surgery.
Outlook / Prognosis
What is the outlook for patients with velopharyngeal insufficiency (VPI)?
Surgery to repair velopharyngeal insufficiency has a success rate that is sometimes estimated in the range of 80-90 percent (although different researchers use different standards for how much improvement is required to call it a success, and most outcomes are subjective). Further improvement comes later with the addition of speech therapy.
Children who have surgery for VPI usually stay in the hospital overnight, and sometimes for more than one night. Complications are not common, and usually are related to breathing obstructions during sleep, leading to snoring and sometimes to sleep apnea.
When should I see a doctor about velopharyngeal insufficiency (VPI)?
If you notice a strong nasal tone in your child’s speech, or something about the way the child eats or breathes doesn’t seem right, make an appointment with a doctor. Early action is important for children with VPI because the speech therapy might involve unlearning habits the child has developed to compensate for the dysfunction. Those habits can be harder to break if they’ve been in place for a long time.
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