Velopharyngeal Insufficiency

5 Key Points – Velopharnygeal Insufficiency

Velopharyngeal Insufficiency and its aetiology, clinic picture, diagnosis and management can be summarised in 5 key points.

1. Velopharyngeal Insufficiency is the inability of the soft palate (velum) to close against the posterior pharyngeal wall.
2. The commonest cause Velopharyngeal dysfunction is cleft secondary palate.
3. Dysfunction classically presents with hypernasal sound and inability to say Plosive sounds
4. Velopharyngeal issues can be diagnosed by a Speech evaluation and confirmed with Nasopharyngoscopy.
5. Surgical options for Velopharyngeal depend on the degree of VPI gapping and lateral wall motion.

Definition of Velopharyngeal Insufficency

Velopharyngeal Insufficency is the inability to completely close the space between the soft palate and posterior pharyngeal wall (velophrayngeal port or orifice).

Anatomy of Soft Palate and Pharnyx

The velopharyngeal port/orofice is bordered anteriorly by the velum, bilaterally by the lateral pharyngeal walls, and posteriorly by the posterior pharyngeal wall.

Velopharyngeal competence results from sufficient apposition of the velar mucosa against the posterior pharyngeal wall and from motion of the lateral pharyngeal wall that causes sphincteric closure of the velopharyngeal port.

Causes of Velopharyngeanl Insufficiency

The most common cause of VPI is a cleft secondary palate.

Other causes of VPI include:

• Hemifacial microsoma (15% incidence)^​2​.
• Submucous Cleft Palate (majority are asymptomatic)
• Neuromuscular abnormalities

Clinical Picture of Velopharyngeal Insuffuciency

Hypernasal Speech

The soft palate cannot close the velopharyngeal orifice, air escapes into the nose. This results in hypernasal speech. This can be associated with nasal air emissions and facial grimacing.

Sounds

Plosive (B,P) and Fricatives (F,S) Sounds

• The patient cannot articulate these sounds
• These sounds require closure of the velopharyngeal port.

Nasal Consonants (M, N, NG)

• The patient can articulate these sounds.
• These sounds require air passage from oropharynx to nasopharynx.
• Velopharyngeal competence is not required to produce these sounds.

Consonant omissions and glottal stops are two common pathologic compensatory speech patterns that such patients exhibit but are not directly caused by VPD. Instead, they are maladaptive compensatory speech patterns often present in patients with VPD^​3​. Other speech articulation errors include distortions and substitutions.

This dysfunction can result in delayed language development or decreased intelligibility of speech.

Diagnosis of Velopharnygeal Insufficiency

VPI can be diagnosed by both clinical and investigation means.

Clinical

Perceptual evaluation of speech by an experienced speech language pathologist is the standard.

Investigations

Multiview video fluoroscopy and nasopharyngoscopy both provide visual information (i.e., closure pattern and closure rating) that is valuable for surgical planning. They can also detect sagittal deficiency closure pattern occurring in patients with VPI after cleft palate surgery.

However, the need to avoid radiation if centers are migrating away from fluoroscopy has caused most cleft centers to migrate to direct nasopharyngoscopy^​4​.

Radiological investigations for VPI at 00:34 seconds of video. (Source: Fauquier ENT)

Treatment of Velopharyngeal Insufficency

Posterior Pharyngeal Wall Injection

Indicated in small VPI Gaps.

Pharyngeal Flap

Pharyngeal flap is a highly effective method of treating velopharyngeal insufficiency. This procedure involves elevating a rectangular flap, based superiorly or inferiorly, from the posterior pharynx and insetting it into the soft palate. The posterior raw surface of the flap is typically lined with trapezoidal flaps raised from the nasal side of the soft palate to limit contraction. The flap serves to obstruct air leakage into the nasal passage during speech. Extremely wide flaps can, consequently, also result in obstructive sleep apnea. In such situations, sphincter pharyngoplasties (Hynes) are sometimes used to avoid this potential complication. Indicated in large VPI gaps with lateral side wall motion.

Furlow Double-Opposing Z-plasty

An effective method of treating VPI associated with submucous cleft palate or following conventional push-back palatoplasty procedures. Several studies suggest that the size of the preoperative velopharyngeal gap, as determined by preoperative nasendoscopy, is the most important determinant of velar competence after Furlow palatoplasty^​5,6​.

Sphincter Pharyngoplasty

Indicated in large VPI gaps with no lateral side wall motion.​​​​​​​ This is a secondary (speech) procedure for cleft palate. It rotates the posterior tonsillar pillars (which contains the palatopharyngeus muscles) as a superiorly based flap. This narrows the velopharyngeal sphincter.

References

1. 1. Kummer AW. A Pediatrician’s Guide to Communication Disorders Secondary to Cleft Lip/Palate. Pediatric Clinics of North America. February 2018:31-46. doi:10.1016/j.pcl.2017.08.019
2. 2. Funayama E, Igawa H, Nishizawa N, Oyama A, Yamamoto Y. Velopharyngeal insufficiency in hemifacial microsomia: analysis of correlated factors. Otolaryngol Head Neck Surg. 2007;136(1):33-37. doi:10.1016/j.otohns.2006.08.020
3. 3. Dudas J, Deleyiannis F, Ford M, Jiang S, Losee J. Diagnosis and treatment of velopharyngeal insufficiency: clinical utility of speech evaluation and videofluoroscopy. Ann Plast Surg. 2006;56(5):511-517; discussion 517. doi:10.1097/01.sap.0000210628.18395.de
4. 4. Fisher D, Sommerlad B. Cleft lip, cleft palate, and velopharyngeal insufficiency. Plast Reconstr Surg. 2011;128(4):342e-360e. doi:10.1097/PRS.0b013e3182268e1b
5. 5. Woo A. Velopharyngeal dysfunction. Semin Plast Surg. 2012;26(4):170-177. doi:10.1055/s-0033-1333882