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VPI is most often treated through surgical procedures such as pharyngeal flap and sphincter pharyngoplasty.
The most used techniques for the surgical management of velopharyngeal insufficiency (VPI) are:
- Furlow palatoplasty or double-opposing Z-plasty for palatal lengthening
- Pharyngeal flap
- Dynamic sphincter pharyngoplasty (DSP)
Although some researchers have advocated for the use of injectable or implantable alloplastic and autologous materials for posterior pharyngeal augmentation, these approaches are not currently in common usage.
No single procedure can treat all VPI patients. Instead, the type of surgery required is determined by the size and shape of a child's velopharyngeal gap. The goal of all VPI procedures is to bridge this gap.
4 common surgical procedures for VPI
- Furlow palatoplasty
- The palate is extended to adequately fill the velopharyngeal gap in this procedure. This operation is appropriate for almost all VPI patients, independent of their initial palatoplasty approach. It can be used to correct a submucosal cleft palate and supplement palatoplasty surgery.
- Typically used as a main palate repair although it can be used as a secondary repair to prolong the velum.
- Appropriate for coronal gaps that are narrow.
- Pharyngeal flap
- This is the most performed VPI procedure.
- It entails removing tissue from the back of the throat and connecting it to the soft palate to prevent air from escaping via the nose during speech.
- To partially close the nasopharynx in the midline, a flap is lifted from the posterior pharyngeal wall and sutured into the velum.
- On either side, lateral apertures are left open for nasal breathing and the creation of nasal noises.
- Excellent for midline or deep (anterior-posterior) gaps.
- Sphincter pharyngoplasty
- This procedure includes moving tissue from the sides of the throat behind the tonsils to the rear of the throat to reduce the size of the child's velopharyngeal gap and prevent air from escaping during speech.
- Posterior wall pharyngeal augmentation
- This surgery involves injecting filler material into the child's velopharyngeal gap.
- The material is injected into the posterior pharyngeal wall.
- Fat, collagen, Radiesse (hydroxyapatite), or Deflux can be used.
- Excellent for filling minor, localized holes or abnormalities in the posterior pharyngeal wall.
The surgery closes the child's velopharyngeal gap, preventing air from escaping through their nose. However, many children will require speech therapy following their treatment to remediate any compensatory articulations that formed due to VPI.
Six weeks after surgery, a speech evaluation is usually performed to determine whether speech therapy is required. Doctors may refer a child to a psychologist if indicated to help them cope with any social challenges related to their condition, such as forming relationships or functioning at school.
What is velopharyngeal insufficiency?
Velopharyngeal insufficiency (VPI) is a condition in which the soft palate does not tightly close against the upper part of the throat. This may result in serious speech impairment due to air escaping into the nose.
VPI is normally discovered and treated in children, but it can occur in adults as a result of central nervous system disease or damage, peripheral nerve injury, or palate surgery for cancer treatment.
- The velopharyngeal valve the muscle that separates the oral and nasal chambers (called the velopharyngeal port) must be able to close adequately to execute basic oral tasks, such as swallowing and speaking.
- When this valve lacks adequate tissue to divide these chambers, air escapes via the nose while speaking, resulting in hypernasal speech. Children with VPI have difficulty pronouncing high-pressure oral consonants including p, b, t, d, k, and g.
5 common symptoms of VPI
- Hypernasality or too much air escaping into the nose during speech
- Reflux of liquids or food into the nose while eating
- Inability to generate pressure for speech sounds
- Inability to form speech sounds correctly
- These speech disorders can significantly interfere with the child’s ability to communicate and impact development and social functioning
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8 common causes of VPI
Velopharyngeal insufficiency (VPI) occurs when the velopharyngeal sphincter or soft palate muscle does not close properly during speaking. If this muscle fails to close properly, air escapes through the nose rather than the mouth.
While speaking, VPI causes a nasal tone to the voice, called hypernasality, as well as a snorting sound when particular letters are pronounced. VPI can be caused by structural, neuromotor, or other functional factors.
VPI can arise alone or in conjunction with other medical or hereditary disorders, such as:
- Cleft palate
- Submucous cleft palate
- Adenoidectomy
- Tonsillectomy
- Congenital VPI
- Nerve or muscle disease
- Weak throat muscles
- Traumatic brain injury
VPI disorders are associated with genetic syndromes, some of which include:
- Down syndrome
- DiGeorge syndrome
- Neurofibromatosis
- Kabuki syndrome
What is the success rate of surgery for VPI?
When palatal anomalies are the cause of velopharyngeal insufficiency, surgery to rectify the deficiency may be performed. The most common type of surgery is pharyngeal flap surgery, also called pharyngoplasty, which involves shifting soft tissues to improve velopharyngeal sphincter function.
- It is not unusual for some people's problems to demand numerous procedures to rectify the defect.
- The success rate of surgery to treat velopharyngeal insufficiency is sometimes considered to be in the 80 to 90 percent range.
- With the inclusion of speech therapy, the patient's condition improves even further.
Children who have VPI surgery frequently stay in the hospital overnight or for many nights (sometimes). Complications are uncommon and are usually connected to breathing blockages during sleep, which cause snoring and in some cases, sleep apnea.
Children with VPI may need therapy for laryngeal anomalies, sleep apnea, voice difficulties, hearing loss or ear illness, and tonsil and adenoidal problems.