Velopharyngeal insufficiency – causes, symptoms and treatment

To understand Velopharyngeal Insufficiency, it is good to know what it is and what it does in your body. Velopharyngeal insufficiency is the inability of the body to temporarily close the communication between the nasal cavity and the mouth. This happens due to anatomic dysfunction of the soft palate. Another thing that can cause this is the lateral or posterior wall of the pharynx. Velopharyngeal insufficiency (VPI) also occurs after adenoidectomy because the adenoids are in the same area where Velopharyngeal valve closes.

That sort of dysfunction ends up making the individual to have functional problems with speech, chewing, swallowing and breathing. Velopharyngeal insufficiency basically includes any structural defect of the velum or pharyngeal walls at the level of the nasopharynx. Ideally, the term insufficiency is used when the defect is anatomical and not a neurological problem. It can be frustrating when a loved one is diagnosed with velopharyngeal insufficiency although there are ways to treat it.

For you to produce that sound you desire, there are so many structures in your mouth and throat that will have to work together to produce it. For this complicated structure to be successful, all the structures have to work properly, if any of them is not, then, there will be a noticeable speech abnormality. When some parts of the throat and roof of the mouth are not formed correctly, vocalization of some sounds such as ‘p’s sound weak. Hypernality, an airy nasal buzz causes this.

The roof of the mouth would rise to block airflow into the nasal passages in a normal speech pattern. This is very important to force the air out of your mouth to enable fullness and clarity while you speak. Children with velopharyngeal insufficiency are not able to form a complete seal with the roof of their mouth and when the air escapes into the nasal cavity, they end up forming telltale sounds.

Velopharyngeal Insufficiency – Causes

It is important to note that speech formation abnormalities can cause similar symptoms but Velopharyngeal insufficiency is specifically due to a failure of structures in the mouth and throat. Velopharyngeal insufficiency can be caused by a variety of disorders such as structural, genetic, functional or even acquired.

Velopharyngeal insufficiency is normally associated with a cleft palate. This condition can result if adenoidectomy is done on a patient with cleft palate or submucous palate. A cleft palate is a gap in the soft and hard palate and it occurs when the baby is still in the womb when the two growth palates that form a baby’s jaw don’t fuse completely in the womb.

There is also a chance of a child developing velopharyngeal insufficiency even when the cleft palate has been surgically repaired by an ENT. Another cause is when a child is born with a short palate that is not long or large enough to block the pharynx.

Abnormal physiological separation of the oropharynx from the nasopharynx can also be another cause. Swollen or enlarged tonsils can lead to the closure of the pharynx. Where the adenoids were blocking a gap between the palate and the pharynx are removed, the unblocked gap ends up being exposed and the air flows in inappropriately during the speech.

Velopharyngeal Insufficiency – Symptoms

It is important to note that a firm diagnosis of a speech abnormality can be very complex and it requires a specialist in ear and testing protocols of speech. This is because it can be easily be mistaken with other abnormalities in its disorder group such as apraxia. Scheduling an appointment with an ENT for precise diagnosis will clear your doubts and get you proper and effective treatment.

Velopharyngeal Insufficiency – Diagnosis

Velopharyngeal insufficiency cannot be approached on a single operation because anatomical structures diverge a lot among different individuals. Based on the anatomical situation of an individual, the surgeon is able to use diagnostic tools and decide the best technique to be used. Since every individual case is different, every operation is aimed at achieving the best possible results. For velopharyngeal insufficiency to be correctly diagnosed multidisciplinary evaluation and several tests are required. The following tests are normally conducted:

Speech analysis

The quality of the speech is the first thing that is evaluated in a patient. This evaluation is also known as speech analysis. Actually, this is the gold standard evaluation of velopharyngeal insufficiency (VPI). It is done by a speech scientist who listens to the voice, articulation, motor speech and velopharyngeal function of a patient. Hypernasality of the voice is the main symptom where the patient is unable to create normal resonance due to nasal air emission.

Nasometry

This is a test to calculate the ratio between the nasal and oral sound emissions. It is done by comparing the rations of the patient with a normal ratio and standard deviation. When the preoperative situation is compared with a postoperative ratio, the results will determine whether the operation was successful. The child will also be examined for obstructive sleep apnea syndrome and if the results are positive, then this is what will be first treated.

If the results are negative, the physician will do a speech analysis and where the patient has an indication for surgical treatment, the next thing is the visualization of mouth and pharyngeal cavity. Normally, visualization and rudimentary or speech analyzation are combined.

Nasoendoscopy

This is a non-radiographic technique whereby the physician uses a scope to enter the mouth or nasal sinus of the patient. A flexible scope is used although in certain situations a rigid scope is used. This technique provides an overview of the anatomy of the velopharynx during phonation. The location and movement of the vocal tract and especially the soft palate and the lateral wall of the pharynx can be visualized with nasoendoscopy.

However, there are limitations to this because it is hard to get an overview with nasoendoscopy using a rigid scope in small children when there are abnormalities or obstructions in the nasal cavity. This is mostly observed in children with a history of cleft palate or submucous cleft palate. Another limitation is that nasoendoscopy is known to cause irritation of the mucosa especially when the child does not cooperate.

Videofluoroscopy

This is a radiographic technique and it mostly demonstrates the lateral and posterior wall of the pharynx. Considering the children undergo radiographic examinations frequently makes this technique questionable. This is because children are more sensitive to radiographic examinations than adults. Videofluoroscopy provides an overview of the lateral and posterior walls of the pharynx. It also provides information about the length and movement of the soft palate, posterior and lateral walls.

The main limitation of multiview videofluoroscopy is the possibility of misinterpretation of certain shapes of gaps and anatomic structures. However, this is one of the most frequently used diagnostic tools used.

Magnetic resonance imaging

Magnetic resonance imaging mostly referred to as MRI is a relatively new approach for diagnosing velopharyngeal insufficiency which is noninvasive. It uses the property of nuclear magnetic resonance to image nuclei of atoms inside the body. MRI can be repeated more often in short periods of time because it is non-radiographic.

Moreover, there are different studies which have shown that MRI is a better diagnostic tool than videofluoroscopy in case of visualizing the anatomy of the velopharynx. There are a few limitations of the MRI. To begin with, artifacts can be shown on the images when a patient moves during imaging. Another limitation is that artifacts will be shown when a patient has orthodontic appliances.

Children who are claustrophobic are also limited from using this technique as well. When using this technique, nasoendoscopy is still needed because the MRI scanner movement leads to artifacts on the images. The MRI is a more expensive diagnostic tool than nasoendoscopy and videofluoroscopy technique combined. These are the reasons why this technique is not widely used.

Velopharyngeal Insufficiency – Treatment

First of all, parents should be the most active members in helping their children’s treatment team. They can do this by following up every advice given by the surgeon. It is also important for the parent to work with the child during the speech therapy sessions. Several short sessions every day are very good and it is one of the best ways to help your child to recover as a parent.

More so, the treatment of velopharyngeal insufficiency entirely depends on the type and cause of the problem. Normally, the treatment of velopharyngeal insufficiency requires surgery and when it is done, it does not change the way the child has already learned to talk. This is where the surgery comes in to help the child learn how to make sounds correctly after the operation. Speech therapy is also necessary to retrain your child’s throat and palate. A dedicated speech therapist and home exercises are also recommended.

When the problems cause is due to Velopharyngeal mislearning, then the speech therapy alone can correct abnormal speech. Treatment of velopharyngeal insufficiency is a combination of speech therapy and corrective surgery in most cases. The surgery is for addressing the underlying defect.

Other procedures that are recommended include the pharyngeal flap, pharyngoplasty, implants, and prosthetics. All this will requires a whole team of healthcare professionals, a plastic surgeon, dentist, ENT, audiologist among others. All this is done to ensure your child gets full support and treatment.

The bottom line

Correction of velopharyngeal insufficiency (VPI) seems to have positive results after a planned surgery. Every individual is different and for effective diagnosis, confirmation by hearing and imaging is very effective. Remember that different diagnostic procedures can give different results due to the fact that what you hear does not necessarily reflect what is seen.

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