Velopharyngeal Insufficiency (VPI)

by Dr. Christopher Chang, last modified on 4/13/21.

Introduction

Patients with velopharyngeal insufficiency (VPI) are typically children who are born with cleft lip or palate. However, this condition may also be caused as a complication of an overly aggressive tonsillectomy, adenoidectomy, uvula and/or palate (UPPP) surgery.

In essence, during the act of swallow or talking with certain sounds, the uvulo-palate structure lifts and seals against the back wall of the mouth preventing foods / liquids and air respectively from entering into the nasal passages. If VPI is present, a patient will sound nasal while talking due to a continuous stream of air escaping into the nose (hyper-nasal). With swallow, food and liquids will regurgitate up into the nose.

Needless to say, although not life-threatening, this condition has profound impact on quality of life and social interactions.

Watch Video on What is VPI?

Evaluation

In order to determine whether VPI is present, nasal endosocpy is performed to evaluate what happens with the palate during swallow and speech. The endoscope is hooked to a video camera to record the entire exam. It is most important to obtain both video AND audio recordings so one can correlate what one sees with what one hears. Here is a YouTube video of a 6 year old child undergoing this exam in our clinic who is suspected of having VPI. Click here to get a larger screen view within YouTube.

The key questions that are being answered with this exam are:

Is there a space between the soft palate and back wall of the throat during phonation?
If so, where is the space located (center, right, left, broad-based)?
How big is this space (tiny or huge)?
What is the orientation of this space?

Here is a video of a normally functioning velopharynx in an adult without VPI.

Once the fiberoptic scope is placed in the back of the nose called the nasopharynx, recording begins and the patient is requested to state specific words geared towards maximal palate closure. Such sounds typically contain the letter "s", "sh", "p", or "b" known as sibilants and plosives respectively.

A NORMAL examination is shown above. Note that the palate (which is moving up and down with talking) makes a tight closure with the back wall preventing any air escape.

Real-time MRI scan can also be used to assess veloopharyngeal function. More info here.

If VPI is present, there are a variety of ways it can be fixed surgically including Furlow palatoplasty, posterior pharyngeal flap, posterior pharyngeal wall injection, and sphincter pharyngoplasty. For more information on each of these surgical options, watch this video!

Below are examples of VPI in adults and children due to a variety of reasons via nasal endoscopy.

Example 1: Uncoordinated Velopharyngeal Closure 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.
Example 2: 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.
Example 3: 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.
Example 4: Right Lateral Velopharyngeal Insufficiency The prior examples 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.
Example 5: 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.
Example 6: 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 which was 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.
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).

Treatment

Depending on the size and type of VPI present, a variety of techniques can be used to correct the VPI.

For small VPI openings, injection nasopharyngoplasty can be performed. In adults, this can be done without sedation as shown in this video.

For large VPI openings, the VPI correction is best done by a plastic or ENT surgeon experienced in cleft palate repair, even if the VPI is not due to a cleft palate such as occurrence after UPPP surgery. Such surgeries include:

Watch Video on 4 Ways to Surgically Treat VPI

Specifics of the repair can be found elsewhere which is beyond the scope of this article. However, knowing the size, orientation, and location of the VPI is quite useful in planning what type of surgery as well as how large a flap to create. If too big a flap is created, nasal obstruction with hypo-nasal speech will result. If the flap is too small, hypernasal speech will persist. The perfect outcome is the perfectly sized flap placed exactly where the hole is allowing for proper speech and adequate nasal breathing.

For more information regarding nasal speech in general, click here.

In any case, here are some video examples of VPI correction as well as incomplete resolution after surgery:

Example 1: 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.

Example 2: 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 which was 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.

Example 3: 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).

Links

Velopharyngeal Insufficiency (VPI)

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