Velopharyngeal Insufficiency (VPI)

Velopharyngeal insufficiency (VPI) happens when there’s an issue with the ring of muscle (velopharyngeal sphincter) located between your child’s mouth (oral cavity) and the inside of their nose (nasal cavities).

Normally, this ring of muscle closes when your child speaks so air goes through your child’s mouth. In velopharyngeal insufficiency, air goes through your child’s nose so it sounds like they’re talking through their nose instead of their mouth. Their voice sounds nasal. The condition may cause speech issues.

Symptoms of velopharyngeal insufficiency

This condition can affect how your child speaks. Your child may have:

• Muffled speech so their voice sounds flat or monotone
• Difficulty forming certain words or sounds
• Nasal-sounding voice
• Snorts, squeaks or puffs of air that come from their nose when they speak
• Fluid or vomit that comes out of their nose

Your child’s voice may also cut in and out when they speak.

VPI causes

This condition may happen if your child’s velopharyngeal sphincter doesn’t fully close during fetal development. You may first notice speech issues when your child is 4 to 6 years old. Some children have underlying conditions that increase their risk for VPI.

Risk factors

Conditions that increase the risk for VPI include:

• Adenoidectomy
• Cleft palate or an abnormally short palate
• Muscle weakness from nervous system issues, like cerebral palsy
• Genetic conditions, like Down syndrome or neurofibromatosis
• Tumor in their palate

Complications of velopharyngeal insufficiency

Research shows that symptoms of the condition, such as noises coming from their nose, may make a child feel self-conscious. Your child may feel frustrated because it’s hard for them to communicate. Reach out to their care team for support.

How do doctors diagnose this condition?

A healthcare provider will ask you about your child’s symptoms. They’ll also check your child’s soft palate. They may do tests like:

• Speech analysis: A speech-language pathologist will listen while your child talks. They may listen for sounds like whistling or if it’s hard for your child to say consonants like P, B, D, G and T.
• Videofluoroscopy: This is a video X-ray that providers use to check your child’s velopharyngeal sphincter.
• Nasal endoscopy: Your child’s provider does this test to check the inside of your child’s nose (nasal cavities).

How is this condition treated?

Velopharyngeal insufficiency treatment may combine speech therapy and/or surgery to fix the sphincter. For instance, your child may have a pharyngoplasty. This procedure changes the shape of your child’s soft palate and throat. Or they may have a pharyngeal flap, which closes the gap between your child’s soft palate and throat. Other surgeries treat the condition by:

• Expanding the wall of their throat to reduce the distance between their throat wall and soft palate
• Lengthening or readjusting palate muscles
• Closing the gap with fillers, like fat injections

Your child’s healthcare provider may recommend a device that raises your child’s palate, which reduces the gap between their throat wall and soft palate. The device is like a dental retainer that people wear after having braces.

What are the risks of VPI surgeries?

Surgery may cause complications, like:

• Hyponasalality: Surgery may cause swelling in your child’s soft palate or nearby tissues. The swelling may affect how air flows through their nose. Your child may sound like they have a cold.
• Hypernasality: Sometimes, surgery doesn’t completely fix the issues that make your child sound as if they’re talking through their nose.
• Obstructive sleep apnea: VPI surgery may narrow the opening of your child’s throat and cause obstructive sleep apnea.

When should I seek care for my child?

Talk to your child’s pediatrician if your child’s voice seems flat or sounds like they’re talking through their nose. They’ll check your child’s palate and throat. If they have concerns, they’ll refer you to specialists for more tests.

What can I expect if my child has this condition?

Surgery often corrects the issue. Most children benefit from speech therapy after surgery, too. Sometimes, children still have symptoms after surgery. They may need additional procedures.

Can adults have VPI?

They can, but it’s not common. VPI in adults may be a complication of:

• Tonsillectomy
• Uvulopalatopharyngoplasty (UPPP surgery)
• Radiation therapy to treat throat cancer