Velopharyngeal Dysfunction

What is Velopharyngeal Dysfunction (VPD)?

During normal speech and swallowing, the muscles in the pharynx and palate can function to close off the nasopharynx from the oropharynx.  This prevents fluids from refluxing into the nose with drinking and prevents air escaping through the nose with speaking. When VPD occurs, speech often sounds very nasal.

Types and causes of Velopharyngeal Dysfunction

There are several types of VPD, based on the underlying cause. These include:

Velopharyngeal Insufficiency (VPI) - Caused by anatomical defects, such as the following:

• History of cleft palate or submucous cleft (overt or occult)
• Short velum
• Deep pharynx (cranial base anomalies)
• Irregular adenoids
• Enlarged tonsils in the pharynx
• Aggressive surgical removal of tissue in the pharynx or palate

Velopharyngeal Incompetence (VPI) - Caused by a neurophysiological disorder:

• Cranial nerve damage causing velar paralysis or paresis
• Central neurological dysfunction
• Injury (head trauma, cerebral palsy, stroke)
• Neuromuscular disorder (i.e., myasthenia gravis, muscular dystrophy, etc.)

What are symptoms of Velopharyngeal Dysfunction?

• Nasal grimacing during speech
• Nasal air escape during speech
• Difficulty pronouncing certain sounds such as s, sh, p, t, d, and b sounds

Treatment of Velopharyngeal Dysfunction

• Surgery
• Pharyngeal augmentation:
  
  • Injection of a substance in the posterior pharyngeal wall
  • Can use fat, collagen, gel solutions, hydroxyapatite, or Deflux
  • Good for small, localized gaps or irregularities of the posterior pharyngeal wall
• Furlow double opposing Z-plasty palatoplasty:
  
  • Often used as a primary palate repair but can be used as a secondary repair to lengthen velum
  • Appropriate for narrow, coronal gaps
• Pharyngeal flap:
  
  • Flap is elevated from the posterior pharyngeal wall and sutured into the velum to partially close the nasopharynx in midline
  • Lateral ports are left on either side for nasal breathing and production of nasal sounds
  • Good for midline gaps or deep (anterior-posterior) gaps
• Sphincter Pharyngoplasty:
  
  • Posterior tonsillar pillars, sometimes including the palatopharyngeus muscles, are released at their base, brought posteriorly and superiorly, and sutured together on the posterior pharyngeal wall to form a sphincter and narrow the opening between the nose and mouth
  • Good for lateral gaps (due to bowtie closure) or narrow coronal gaps
• Buccal flaps:
  
  • Tissue from the insides of the cheek are sewn into the soft palate to lengthen the palate
  • Used at some centers during primary palatoplasty. Also commonly used as an adjunct for secondary palatal lengthening in the setting poor length, deviant scarring and/or fistula
  • Sometimes requires a secondary surgery to divide and inset
• Prosthetic Devices:
  
  • Used if surgery is not an option
  • Palatal Obturator
  • To close or occlude an open cleft, palatal defect or fistula
• Speech Bulb Obturator (Speech Aid):
  
  • To occlude nasopharynx when the velum is short (velopharyngeal insufficiency)
  • Can be combined with a palatal obturator
• Palatal Lift:
  
  • To raise the velum when velar mobility is poor (velopharyngeal incompetence)
  • Commonly used with dysarthria 
• Limitations of a Prosthetic Device:
  
  • Can be expensive and not covered by insurance
  • Requires insertion and removal
  • Has to be redone periodically due to growth
  • Can be lost or damaged
  • May be very uncomfortable
  • Compliance is often poor
  • Doesn't permanently correct the problem
  • Most centers use prosthetic devices only if surgery is not possible