Treatment of Hyper-Nasal Speech (Velopharyngeal Insufficiency)

by , last modified on 9/14/16
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The most common cause of nasal speech is typically HYPO-nasality from some type of nasal obstruction resulting in reduced nasal airflow:

However, there is a type of nasal speech due to the exact opposite reason whereby too much nasal airflow occurs during speech resulting in what is known as HYPER-nasal speech.

Hyper-nasality is due to a persistent opening between the mouth to the nose during enunciation of all speech sounds. Normally, complete closure should occur with certain sounds like /s/, /sh/, /b/, and /p/. Such sounds are called plosives and sibilants. This link provides a cartoon animation of how each sound in the English language is produced from an anatomical standpoint.

Such hyper-nasality always occurs in kids with cleft palate whereby there is a hole in the roof of the mouth. However, more rarely, it could also be due to a weakness in the soft palate that fails to lift and adequately seal itself against the back wall of the mouth. This condition is known as velopharyngeal insufficiency or VPI. This may be present from birth (submucosal cleft) or even acquired such as (rarely) after UPPP, tonsillectomy and/or adenoidectomy.

Treatment truly depends on the actual location and size of this persistent mouth-nasal opening or velopharyngeal insufficiency.

If due to cleft palate, treatment requires closure by an experienced plastic or ENT surgeon who specializes in this particular field (our office does not perform cleft palate surgery).

If due to incompetence of the soft palate, there are a variety of methods to achieve closure. The important thing regardless of treatment approach is that COMPLETE anatomic closure is NOT the goal. Rather DYNAMIC functional closure is the true goal.

What is the difference?

Well, if complete anatomic closure is achieved, there will be no nasal airflow and the patient will be unable to breath thru the nose at all. Furthermore, nasal speech will persist, but it will now be a HYPO-nasal speech (too little or no nasal airflow) rather than a HYPER-nasal speech (too much nasal airflow).

Dynamic functional closure is when complete closure occurs ONLY during appropriate speech enunciations, but remains open during nasal breathing.

As such... Treatment depends first on

  • WHERE the opening is located and
  • HOW LARGE this opening is when it should be closed and
  • ORIENTATION of the opening

The best way to achieve identification and size measuring is via video nasal endoscopy whereby a flexible fiberoptic endoscope is threaded through the nose and while a patient is speaking, carefully examinig the back of the nose where dynamic soft palate closure should occur. The video below shows this exam being done in a child, but it can also be easily performed on an adult as well.

Recording audio and video is important so that playback in slow motion and freeze frame can be obtained. Only in this manner can a precise understanding of a given patient's hyper-nasality be achieved.


Speech therapy can always be tried first prior to any surgical intervention as well as use of an oral obturator (see example #7 below). However, if maximal speech therapy fails to resolve hyper-nasality, surgical approaches can be pursued.

If surgery is pursued, the goal is to achieve just the right amount of closure where velopharyngeal insufficiency is present... and no more. TOO much closure will result in nasal obstruction which is also undesirable.

For a small opening, injection of filler agents like cymetra or radiesse can achieve closure relatively quickly and painlessly (video). Furthermore, at least in adults, such closure can be achieved without any sedation using only local anesthesia. This method is the only type of treatment our office provides.

For larger openings, it is best to be seen in a craniofacial clinic. A list of such regional clinics can be found here. For purposes of full disclosure, our office is affiliated with the INOVA Fairfax Craniofacial Clinic.

Too reiterate, given how important this concept is... If too big a surgical closure is created, nasal obstruction with hypo-nasal speech will result. If the surgical closure is too small, hyper-nasal speech will persist. The perfect outcome is the perfectly sized closure placed exactly where the hole is allowing for proper speech and adequate nasal breathing.

Examples of video and audio exams are provided below along with general treatment approaches in each scenario.

Example 1: Uncoordinated Velopharyngeal Closure

Audio - Standard Passage

Note the nasal sounding speech. On exam, the palate does not move in coordination with speech. However, at other times, it does move properly. With good speech therapy, this should improve over time. Of note, the lumpy mass coming down from the ceiling is the adenoids.

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Example 2: Velopharyngeal Insufficiency

Note the nasal sounding speech (hypernasal). On exam, one can see air bubbles where air is escaping between the soft palate and back wall of the nasopharynx (throat). This case is different from example 1 as in this case, it never makes a tight seal. Surgical correction was by bulking up the posterior wall by injection nasopharyngoplasty until a tight seal occurred.

Example provided courtesy of Dr. James Thomas.

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Example 3: After Cleft Palate Repair with Small Central Velopharyngeal Insufficiency

Note the nasal sounding speech (hypernasal), especially with plosives /p/, /b/ (pah, bah) and the sibilant 'sh'. Note the air escape demonstrated by bubbles. Also, the palate never really makes a tight seal with the back wall centrally known as velopharyngeal insufficiency. However, there is a lateral squeeze present. Surgical procedures to correct this velopharyngeal insufficiency focus on closing this central gap without affecting the lateral aspects. Such procedures include posterior pharyngeal flap (see example 6 below) or posterior pharyngoplasty (injection or graft). In this child, the tonsils and adenoids aid in speech and removal may result in worsening of speech quality. This small opening can be easily resolved by injection nasopharyngoplasty.

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Example 4: After Cleft Palate Repair with Large Central Velopharyngeal Insufficiency

Compared to the prior example, this child who is also after cleft palate repair has nasal speech due to a very large central velopharyngeal insufficiency. There is some degree of palate elevation as well as lateral squeeze, but not enough to provide complete closure which is always present. In the distance, you can see the child's epiglottis.

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Example 5: Right Lateral Velopharyngeal Insufficiency

The prior examples #3 & 4 were all due to central velopharyngeal insufficiency. However, lateral velopharyngeal insufficiency also exists, but is more rare. This example shows a child without any history of cleft palate who has a small insufficiency on the right side. Note the bubbles that emanate from this small opening. There is a nice tight closure elsewhere.

It seemed that the child had a temporary mild right soft palate paralysis that resolved spontaneously along with resolution of the velopharyngeal insufficiency after about 1 month.

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Example 6: Resolved Central Velopharyngeal Insufficiency After Pharyngeal Flap Surgery

This adult patient underwent pharyngeal flap surgery to correct a central velopharyngeal insufficiency after cleft palate repair as a child. Note the bridge of mucosa from the soft palate to the posterior wall which is the flap. When relaxed, there is an opening on either side of the flap (called "lateral ports") to allow for nasal breathing. When talking, the lateral ports close to prevent air escape.

The risks with the procedure include creating too small a flap which would result in persistent hyper-nasal speech (see next example) or too large a flap which would result in nasal obstruction and a hypo-nasal speech. A skilled plastic surgeon is able to create the perfect sized flap that's not too large or too small as in this case.

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Example 7: UN-Resolved Velopharyngeal Insufficiency After Pharyngeal Flap Surgery and Obturator Use

This adult patient underwent pharyngeal flap surgery to correct a central velopharyngeal insufficiency after cleft palate repair. Unlike the prior example where there was complete closure of the lateral ports with phonation, this unfortunate patient has a small VPI on both sides (note the bubbles).

In order to resolve this VPI, the patient used an obturator in order to completely close the lateral ports thereby eliminating his hypernasal speech. However, use of an obturator resulted in near-complete nasal obstruction.

Watch the video which shows a small VPI without the obturator as well as VPI resolution with obturator (along with nasal obstruction).

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Example 8: Failed Pharyngeal Flap Surgery With Persistent Left VPI

This patient underwent pharyngeal flap surgery to correct a velopharyngeal insufficiency after cleft palate repair several years prior. However, unlike the prior example #6 which is a perfect outcome, there is a persistent large opening on the left side resulting in a large left velopharyngeal insufficiency causing hypernasal speech. Also, the pharyngeal flap is shifted right of midline instead of being perfectly in the middle.

This patient's pharyngeal flap failed in 2 aspects resuling in VPI. First, the flap was created right of midline resulting in no lateral port on the right and a very large left lateral port. Second, the flap was made too small so even if the flap was perfectly in the midline, most likely VPI would still have occurred.

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Example 9: Adenoid Hypertrophy

Audio - Standard Passage

Note the nasal sounding speech (hyponasal). On exam, the patient also had fluid in the ears. Looking in the back of the nose, large adenoid tissue is seen which looks like a pink cauliflower growing down from the top. The adenoids are so large that they are obstructing the eustachian tube opening preventing adequate ventilation with the ear resulting in fluid build-up. The large adenoids is the cause of the nasal sounding speech. Treatment was adenoidectomy (adenoid removal). Watch a video of an adenoidectomy being performed.

Read more about large adenoids here.

Other common anatomic causes of hyponasal speech include deviated septum, turbinate hypertrophy, and allergies. Often these issues along with large adenoids cause a "snotty" nose in kids.


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Please contact our office for an appointment to figure out what kind of hyper-nasal speech you have!

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