What Is A Velopharyngeal Insufficiency?

“Velopharyngeal” refers to the area at the very back of the oral cavity, where the soft palate (the velum) meets the throat (the pharynx). The pharynx is made up of two areas:

• The nasopharynx is the upper part of your throat that sits behind your nose. 

• The oropharynx is the lower part of your throat that sits behind your mouth. 

Between these two areas is a ring of muscle called the velopharyngeal sphincter. When you speak or swallow, the sphincter contracts, closing off the passage and separating the two areas. Velopharyngeal insufficiency (VPI) means that this sphincter isn’t fully closing as it should.

We can produce sound by passing air from the lungs, through the vocal cords, and out through the mouth or nose. However, in order to turn those sounds into clear speech, the air needs to be directed solely through the mouth. That’s where the velopharyngeal sphincter comes in, ensuring that air is only expelled through the mouth.

In children with VPI, air escapes up through the nasal cavity when they speak. This can affect how they form certain words, particularly those with consonants like p, b, d, and t. If you practice saying these letters, you can feel that they require you to create some resistance to the air with your tongue or lips, and then add pressure to push the air out. But in VPI, the resistance and pressure will force air up the nose instead. 

VPI can cause your child’s speech to sound nasal, distorted or muffled. You might also notice odd noises like squeaks, snorts or puffs of air escaping their nose when they speak. This can not only affect your child’s ability to communicate clearly, it can also cause them frustration, anxiety and embarrassment.

When your child swallows, the velopharyngeal sphincter tightens, making sure that food and drink can only go one way: down the throat. In children with VPI, the sphincter allows some food or drink to move upwards and into the nasopharynx area. This might cause the food or drink to come out through the nose. 

This is called nasal regurgitation, and it can be quite uncomfortable, distressing and embarrassing for a child to experience. It can also cause the child to aspirate (inhale) the food or liquid, which can cause coughing, choking and respiratory infections. 

VPI is caused by a structural problem with the velopharyngeal sphincter. The most common causes of these structural issues include:

• Palate defects. The most common cause of VPI, a cleft palate develops during the first few weeks of pregnancy when the tissue that forms the roof of the mouth does not join correctly. The National Institute of Craniofacial Research estimates that 2,650 babies are born with cleft palates each year in the United States. According to Stanford Children's Health, about 20% of children with repaired cleft palates experience velopharyngeal insufficiency. VPI can also occur in babies with other cleft defects, like an abnormally short palate.

• Genetic disorders. Certain genetic conditions can cause VPI, such as Down's syndrome, neurofibromatosis, and velocardiofacial syndrome. The latter is a genetic disorder that occurs when a piece of chromosome 22 is missing. Children born with velocardiofacial syndrome usually experience heart defects, cleft palate, a distinct facial appearance, speech and feeding problems, and learning difficulties. Even when a cleft palate is not present, children with this condition can have VPI.

• Adenoid enlargement and removal. Your child's adenoids sit in the nasopharynx – the part of the throat behind the nose – near the velopharyngeal sphincter. They work with the tonsils to trap germs in the mouth and nose. MedlinePlus says that adenoids begin shrinking at about age five and are almost completely gone by your child's teenage years. However, if the adenoids are repeatedly getting infected, or they’re enlarged and blocking the child’s airway, they may be surgically removed. This procedure creates space between the velum and the back of the throat, which can cause VPI. This is usually temporary, but in some cases it can be long-term.

• Neurological disorders. Conditions like cerebral palsy can cause muscle weakness. Because the velopharyngeal sphincter is a muscle, it can also be affected.

• Tumors. A tumor in the soft palate or throat can damage the surrounding tissues and affect the velopharyngeal sphincter.

• Radiation therapy. Receiving radiotherapy to the head and neck area can damage the oral tissues, including the velopharyngeal sphincter.

• Surgery. As well as adenoid removal, other surgeries in the velopharyngeal area can cause VPI. These include tonsillectomy (tonsil removal) and uvulopalatopharyngoplasty (removal of tissue to widen the airway).

• Unknown causes. In some cases, the cause of velopharyngeal insufficiency is unknown.

If you suspect that your child may have velopharyngeal insufficiency, your healthcare professional may refer you to a speech pathologist. A speech pathologist will be able to put a small scope in your child's nose to see how the palate moves when they are talking (a nasendoscopy).

Minor cases could be improved through speech therapy. One of the following surgeries (with tongue-twisting names) may be recommended depending on the size and type of gap in your child's pharynx:

• Furlow palatoplasty. This procedure realigns palatal muscles, lengthening and thickening the velum, so it can naturally reach the back of the throat.

• Sphincter pharyngoplasty. This involves taking tissue from both sides of the tonsils and connecting them at the back of the throat to create a narrower opening.

• Pharyngeal flap. A flap of tissue is taken from the back of the throat and added to the velum.

• Posterior pharyngeal wall augmentation. Implant materials are placed in the walls of the throat, either through incision or injection.

If your child has one of these procedures, speech therapy will likely be recommended to help them relearn how to pronounce certain sounds after recovering from the surgery.

If your child has a cleft palate, it can affect more than the roof of their mouth and the way they speak – it can also impact the positioning, size, shape, and number of their teeth. And consistent exposure to the air can dry up saliva and allow bacteria to flourish. According to studies performed by the University of Washington, people with this facial difference may have abnormal salivary glands that can adversely affect their oral health, too. So people with clefts tend to have a higher than average rate of tooth decay.

Therefore, practicing good oral hygiene and seeing a dental professional for regular check-ups is of the utmost importance to ensure a future with healthy teeth. Start brushing early, at least twice a day. It's recommended that you schedule your child's first dental appointment early. Many dentists suggest bringing children with clefts in for a check-up well before their first birthday so they can identify potential issues.

Whether your child has velopharyngeal insufficiency due to a cleft or another reason, be sure to ask your dental professional if they have any recommendations on how to best care for your child's specific needs. If you return regularly for check-ups, your dental professional will be able to monitor for developing tooth decay or any other oral hygiene issues and treat them early.

It can be scary when your child develops an unexpected health condition, but you can help them stay positive and use this as a great learning tool for their future. When they overcome this, they'll realize they can overcome anything. You've got this!

Oral Care Center articles are reviewed by an oral health medical professional. This information is for educational purposes only. This content is not intended to be a substitute for professional medical advice, diagnosis or treatment. Always seek the advice of your dentist, physician or other qualified healthcare provider.