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.)

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

• 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