Velopharyngeal Inadequacy

Describe what is meant by velopharyngeal incompetence (VPI)?

1. The velopharyngeal structures cannot produce full closure of the velopharyngeal port.

2. The velopharyngeal system is structurally inadequate for production of good speech.

3. The structure of the velopharyngeal system or its neuromotor control is inadequate for production of good speech.

4. An individual’s speech is perceived as showing characteristics associated with disorders of the velopharyngeal system.

What terms are associated with VPI?

Velopharyngeal incompetence, inadequacy, deficiency, or insufficiency.

Is there a difference in the meaning of the relative terms associated with VPI?

These terms are specific to different aspects of inadequacy of the velopharyngeal mechanism:

1. Incompetence refers to impaired motion of the velopharyngeal mechanism.

2. Insufficiency refers to tissue deficiency of the velum.

3. Inadequacy refers to a combination of incompetence and insufficiency, and is the more generic term. Therefore, velopharyngeal inadequacy is more properly referred to as VPI.

What are the symptoms and signs of VPI?

Speech: Hypernasality, compensatory misarticulations, airflow escape, facial grimacing.

Reflux: Oronasal regurgitation (fluids >> solids).

Hearing loss (conductive): Eustachian tube dysfunction.

What is the hallmark characteristic of VPI on perceptual speech evaluation?

Hypernasality.

The majority of articulated phonemes in the English language require competency or closure of the velopharyngeal port. Which phonemes in English require an open velopharyngeal port?

1. /m/

2. /n/

3. /ng/

What is the incidence of VPI post-cleft palate repair?

The incidence varies between 7% and 25% post-palate repair.

What are the etiologies of VPI?

1. Idiopathic insufficiency of palatal musculature.

2. Congenital palatal insufficiency.

3. Submucous cleft palate (SMCP).

4. Post-cleft palate repair.

5. Postpharyngeal flap or pharyngoplasty.

6. Postadenoidectomy or adenoid involution.

7. Enlarged tonsils.

8. Postmidface advancement.

9. Neurogenic causes.

10. Adynamic velopharyngeal sphincter.

11. Functional or hysterical hypernasality.

12. Palatopharyngeal disproportion.

What is the most common cause of VPI?

Post-cleft palate repair.

What anatomically makes up the velopharyngeal space?

Velum/soft palate (anterior border), posterior pharyngeal wall (posterior border), lateral pharyngeal walls (lateral borders).

What muscles contribute to closure of the velopharynx?

Levator veli palatini, superior pharyngeal constrictor, palatopharyngeus, tensor tympani, musculus uvulae.

What is the most important muscle regarding closure of the velopharyngeal space for speech?

Levator veli palatini muscle.

Discuss functions during opening and closing of the velopharynx.

Opening of the velopharynx: Facilitates breathing and normal speech production of nasal phoneme articulations.

Closure of the velopharynx: Allows normal speech production of oral consonants and prevents oronasal reflux.

How does the velopharynx close?

The velum moves posteriorly and superiorly, the posterior pharyngeal wall moves anteriorly, the lateral pharyngeal walls move medially, and the tonsils and adenoids may augment or interfere with the function of the walls during velopharyngeal closure.

Who contributes to the evaluation of VPI?

An interdisciplinary team consisting of:

1. Plastic surgeon

2. Speech/language pathologist

3. Otolaryngologist

4. Audiologist

5. Radiologist

6. Geneticist

How should VPI be evaluated?

The initial assessment of speech should be based on a perceptual assessment by a trained speech-language pathologist. Based on this assessment a patient is given a diagnosis of VPI. Whereas not all speech-language pathologists make this diagnosis based on a numeric scale, use of such scales is highly recommended for consistency and interrater reliability. Patients who are given a diagnosis of VPI can then undergo further testing.

Indirect methods: Mirror test, nasometry

Direct methods: Nasopharyngeal endoscopy, multiview videofluoroscopy

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