Children's Hospital Colorado

Velopharyngeal Insufficiency

What is velopharyngeal insufficiency?

Velopharyngeal insufficiency (VPI) occurs when the back part of the roof of the mouth (soft palate) and the pharynx (throat) don't work together to make a good seal when your child is talking. This is often caused by a soft palate that is too short or muscles of the palate that do not work well. Air leaks through the nose and gives their speech a nasal quality. It's often hard to understand a child with VPI, and the child must work very hard to speak and be understood.

What causes velopharyngeal insufficiency?

There are several conditions that can cause VPI. The following are some of the conditions that can cause VPI:

Cleft palate

The most common cause of VPI is a cleft palate or submucosal cleft palate (cleft covered by the lining or mucous membrane of the roof of the mouth). About10 to 40% of children who have a cleft palate with or without a cleft lip will have persistent VPI after their cleft palate repair. About 25% of children with a submucosal cleft palate will also have VPI.

Velar dysplasia

Velar dysplasia can be a cause of VPI. Velar dysplasia refers to an abnormality in the growth or development of the velum. The velum is the soft flexible area located toward the back of the roof of the mouth. VPI is common in many craniofacial syndromes, particularly in hemifacial microsomia and related conditions. Related conditions include Goldenhar syndrome, oculo-auriculo-vertebral (OAV) spectrum and facio-auriculo-vertebral (FAV) spectrum.

Cervical spine anomalies

Some patients with craniofacial conditions have a cervical spine (neck bones) that curves backward, causing their throat to be abnormally deep. When this occurs, the velum may not be long enough to contact the back wall of the throat during speech production and cause velopharyngeal insufficiency. Some conditions, such as Klippel–Feil syndrome and Down syndrome, are also associated with cervical spine anomalies that can also cause a deep pharynx.

Adenoid and tonsil problems

Sometimes VPI develops after an adenoidectomy. An adenoidectomy is a surgical procedure to remove adenoids or lymphoid tissue in the back of the nose.

A child's tonsils can become so big that they intrude into the throat. Tonsils are lymphoid tissue that are located on both sides of the back of the throat. They can restrict the movement of the side walls of the throat and prevent the velum from achieving an adequate velopharyngeal seal during speech.


Surgical removal of tumors in the mouth can affect velopharyngeal closure.

What are the symptoms of velopharyngeal insufficiency?

  • Hypernasal speech (speech that has a high nasal quality)
  • Increased nasal resonance (sound energy traveling through the nose and mouth)
  • Nasal regurgitation (food comes out of the nose)
  • Nasal emission during speech (air escapes through the nose during speech)

What tests are used to diagnose velopharyngeal insufficiency?

VPI is diagnosed during a thorough evaluation at our VPI Clinic. A typical visit at our VPI clinic includes the following:

  • Caregiver interview: The team nurse and speech-language pathologist will ask questions about your child's medical history and speech-language development.
  • Speech and resonance evaluation: The speech-language pathologist will do an evaluation of your child's speech sounds, oral and nasal resonance and nasal emission (air escape through the nose) during speech.
  • Nasometer: The speech-language pathologist will do an evaluation with a nasometer. A nasometer is a computer-based tool that measures sound energy coming from the nose and mouth. Your child will wear a special headset during this portion of the evaluation.
  • Physical exam: The doctor will look in your child's ears, nose and mouth.
  • Endoscopy: The doctor may do a brief endoscopy procedure. An endoscopy is done to evaluate how the palate and the structures around it move during speech. An endoscope is a flexible, narrow tube attached to a bright light and a camera. The endoscope allows us to view the speech structures inside the nose and throat.
    • The tube goes a short distance into the nose. While the tube is in place, the speech-language pathologist will ask the child to say some words and sentences. The child and caregiver can observe the procedure as it is happening on a screen. The procedure lasts from less than a minute to approximately two to three minutes.

VPI evaluation results are shared with the parent/caregiver and child (if developmentally appropriate) at the end of the visit. A longer report is sent in the mail within one to two weeks of the visit. If needed, the team speech-language pathologist is available to discuss the results of the evaluation with your child's home speech-language pathologist.

What can we expect from velopharyngeal insufficiency testing?

Testing will take about one hour. Many caregivers have questions about whether their child will tolerate the endoscopy portion of the VPI evaluation. Our team makes a significant effort to ensure that this part of the evaluation is as comfortable as possible for your child. Numbing medicine is sprayed inside the nose before the evaluation to help decrease any discomfort.

The endoscope is a small scope designed for use with children. This portion of the visit may be uncomfortable, but will not be painful. It often lasts just a few minutes. Most children do cry some. This is normal and expected.

If you feel that your child will not tolerate this procedure well, please contact our scheduler in advance. We can connect you and your child to a child life specialist who can provide suggestions to make this procedure easier.

Why choose Children's Hospital Colorado for velopharyngeal insufficiency testing?

We have extensive experience performing tests used to diagnose VPI and have excellent reliability. We use a multidisciplinary approach to evaluate, diagnose and treat your child. We use equipment that is designed for children, which helps to minimize discomfort. Our care team members only work with children and understand how to meet the unique needs of children.

How is velopharyngeal insufficiency treated?

Treatment depends on your child's condition. Your child's treatment may include any of the following:

  • Speech therapy: Treatment of VPI often initially involves a course of speech therapy for three to six months before we consider surgery.
  • Surgery: There are three main surgeries that are done to manage VPI. The best surgery for your child depends on your child's condition. Each of these surgeries is done to lower the amount of air escaping from the mouth into the nose.
    • Furlow palatoplasty: This surgery is done to repair the soft palate. The muscles of the palate are realigned and the palate is lengthened.
    • Pharyngeal flap: Tissue from the back of the throat is attached to the soft palate, making a physical barrier in the back of the throat. This surgery is done when there is good movement in the sidewalls of the throat. The size of the flap is determined by the size of the opening as well as the sidewall movement.
    • Sphincter pharyngoplasty: Muscles are attached from the side of the throat to the back of the throat. This surgery is usually done when there is good movement of the palate. The size of the muscle flaps used is determined by the size of the opening.

Why choose Children's Colorado for your child's velopharyngeal insufficiency treatment?

Our multidisciplinary team works together to understand the cause of your child's speech difficulties and provide recommendations to improve your child's ability to communicate and be understood. Both the speech-language therapist and the surgeon who perform evaluations and treatment are trained in and focused on pediatric care. We have state-of-the-art equipment, which enables us to provide high-quality, comprehensive care to your child.

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