Definition

Velopharyngeal insufficiency is the improper closing of the velopharyngeal sphincter (soft palate muscle) during speech characterized by an acute nasal quality of the voice.

  Description

At the back of the mouth is a circle of structures that include the tonsils, the tongue, and the palate. During speech, this apparatus must close off the nose for proper articulation of the explosive consonants "p," "b," "g," "t," and "d." If it does not close, there is a snort sound produced through the nose. Improper function of this structure also produces a nasal tone to the voice.

  Causes and symptoms

There are three main causes for this defect:

• Cleft palate is a congenital condition, producing a defect in the palate that allows air to escape upward during speech.
• If tonsil and adenoid surgery is done improperly, velopharyngeal insufficiency may result. The occurrence rate is approximately one in every 2,000-3,000 tonsillectomies.
• Nerve or muscle disease may paralyze the muscles that operate the velopharyngeal sphincter.

The primary symptom is the speech impediment. Some people develop a change in their speaking pattern or a series of facial grimaces to try to overcome the difficulty. If the condition is acute, regurgitation through the nose may occur.

  Diagnosis

Examination of the velopharyngeal sphincter through ultrasound scans, fiber-optic nasopharyngoscopy, and videofluoroscopy will reveal the extent of velopharyngeal insufficiency. Speech and velopharyngeal sphincter movement are compared to make the diagnosis.

  Treatment

Velopharyngeal insufficiency is treated with a combination of surgery and speech therapy. There are several surgical procedures that can be performed to correct the physical malfunction. They include:

• Pharyngeal flap procedure that moves the skin flap from the pharynx to the soft palate.
• Palatal push-back that separates the hard and soft palate in order to lengthen the soft palate.
• Pharyngoplasty that lengthens the soft palate by turning the pharyngeal skin flaps.
• Augmentation pharyngoplasty that inserts an implant into the pharyngeal wall to enlarge it, thus narrowing the velopharyngeal opening.
• Velopharyngeal sphincter reconstruction.

  Prognosis

The combination of surgery to correct the insufficiency and speech therapy to retrain the voice successfully alleviate velopharyngeal insufficiency.

   Key Terms:

Adenoids Lymph glands just above the tonsils and the palate. Cleft palate Congenital defect marked by a split in the roof of the mouth. Nasopharyngoscopy A diagnostic procedure that examines the nasal passageways and pharynx with an instrument outfitted with an optical system. Pharynx A canal located between the mouth cavity and the esophagus. Tonsillectomy Surgical removal of the tonsils. Tonsils Lymph glands in the throat, just behind the back teeth.

   Resources:

Books

• English, Gerald M. Otolaryngology. Philadelphia: J. B. Lippencott Co., 1990.

Periodicals

• Conley, S. F., et al. "Identification and Assessment of Velopharyngeal Inadequacy." American Journal of Otolaryngology 18 (Jan./Feb. 1997): 38-46.
• Eufinger, H., et al. "Speech Results and Velopharyngeal Morphology Following 151 Cranially Based Velopharyngoplasties." Folia Phoniatrica et Logopedica 47 (1995): 193-198.
• Huang M. H., S. T. Lee, and K. Rajendran. "Anatomic Basis of Cleft Palate and Velopharyngeal Surgery: Implications from a Fresh Cadaveric Study." Plastic & Reconstructive Surgery 101 (Mar. 1998): 613-627.
• Morris, H. L., et al. "Clinical Results of Pharyngeal Flap Surgery: the Iowa Experience." Plastic & Reconstructive Surgery 95 (Apr. 1995): 652-662.
• Ren, Y. F., A. Isberg, and G. Henningsson. "Velopharyngeal Incompetence and Persistent Hypernasality after Adenoidectomy in Children without Palatal Defect." Cleft Palate-Craniofacial Journal 32 (Nov. 1995): 476-482.
• Sell, D., and L. Ma. "A Model of Practice for the Management of Velopharyngeal Dysfunction." British Journal of Oral & Maxillofacial Surgery 34 (Oct. 1996): 357-363.