Velopharyngeal insufficiency
 Velopharyngeal insufficiency refers to the inability of the velopharyngeal sphincter
to close completely during production of the oral (nonnasal) sounds of speech.
 The primary effects of velopharyngeal insufficiency are nasal air escape and
hypernasality.
Incidence
 Satisfactory speech results occur in about 80% of pts after primary palatoplasty
 Further 15 % achieve normal speech with speech therapy
 5% require further management with due to insufficient secondary palate closure
 In this 5% air escapes through the nasopharynx when attempting to produce certain
sounds precludes normal speech
 Important to realize that the presence of abnormal speech is not an indication for
surgery and thorough assessment of the defect is need
Normal speech production
1. Sphinter remains open
a. Nasal sounds – M N
b. Useful to test for overcorrection post surgery – Mamma made some mittens
2. Complete closure required
a. Plosive consonants – K T P – Pick up the book
b. Fricative consonants – F S - Suzy sees the scissors
 Voice requires quality, richness and carrying power
 Also clear, precise consonants
Classification based on aetiology
1) velopharyngeal insufficiency(VPI) - structural origin and includes structural
problems associated with the velum or the side walls at the level of the
nasopharynx with insufficient tissue to accomplish adequate closure
2) velopharyngeal incompetence(VP incompetence) – neurogenic origin
3) velopharyngeal mislearning -mislearning or functional origin
Velopharyngeal dysfunction – all encompassing term for the above and does not imply a
specific etiology
Pathophysiology
 Previously thought that VP closure resulted from a short velum. And thus the push
back procedures were used with little success. Now known that the closure of the VP
is a complex mechanism and thus need accurate Ix
 Four closure patterns (Skolnick)
1.
2.
3.
4.
Coronal - mostly palate (most common)
Sagittal - mostly lateral wall (least common)
Circular - both palatal and lateral wall
Circular with Pasavants ridge – posterior, palatal and lateral walls
Aetiology
Cleft
1. unrepaired
2. repaired
3. submucous cleft
4. fistula
NonCleft
1. anatomic
2. neuromuscular
3. behavioral/functional
Cleft palate
1.
2.
3.
4.

poor muscle sling
poor elevation
short palate
immobile scarred palate
subclinical disease may manifest later due to:
i. adenoidal involution at the time of puberty
ii. adenoidectomy
iii. Orthognatic (LeFort) advancement – controversial.
1. Mr Baker says this does not occur
Noncleft
Anatomic
> congenitally short palate
> reduced palatal bulk
> deep/enlarged pharynx
>adenoidectomy
> maxillary advancement
> tumour resection
Neuromuscular
> cerebral palsy
> head injury
> cva
> neuromuscular disorder – amyotrophic lateral sclerosis
combined
velocardiofacial syndrome (shprintzen syndrome)
• square nose, narrow ala base
• long face, retruded chin
• hypotonia
• cardiac defects
• intellectual impairment or learning disabilities(50%)
CLINICAL
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hypernasality
nasal emission
nasal turbulence
nasal substitution
compensatory articular patterns (distortions, substitutions, and omissions).
weak omitted consonants
nasal/facial grimace
hoarseness
low volume voice
monotonous voice
breathiness
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unusual pitch variations
nasal fluid regurgitation
utterances or sentences are short and their speech tends to take on a choppy
pattern because of the leak
DIAGNOSIS
Oral examination
• size
• movement
• symmetry
• elevation on phonation
• dentition
• occlusion
• fistula
• nasal air escape using mirror
Perceptual evaluation – the most important
• attempts to define characteristic speech of vpi and quantify severity
• consult speech therapist
Investigations
information on :
1. type of closure
2. size of vp gap
3. evidence of fatigue
4. consistency of performance
Videofluroscopy
• video recorded radiograph
• barium paste nasally
• lateral and frontal views
• Townes view (30 head down, mouth wide open)
• info on size of gap, pattern of closure and degree of palate elevation
Method
• barium paste instilled intranasally which coats the surface of the oropharynx and
then the pt is asked to duplicate certain sounds while the fluoroscopic images are
taken with the lateral , frontal and submental views being the most important
• when the adenoids are enlarged the Townes view demonstrates the VP orifice
better than the basal views
Nasendoscopy
• direct visualization of the velopharyngeal mechanism
• recommended in conjunction with video fluoroscopy giving mainly quantitative
information and the nasendoscopy giving mainly qualitative information
• fine flexible scope
• rigid scope
• type and degree of closure
• not successful in young children
• useful adjunct to vf in difficult cases
• some use routinely
Nasometer
• Nasalance is a ratio of the nasal acoustic output relative to oral plus nasal acoustic
output and is expressed as a percentage.
• sensitivity and specificity of nasometry in correctly identifying subjects with more than
mild hypernasality in their speech - 89% and 95%, respectively.
other
1. accelermeter
2. aeromechanics
CT and MRI angiography
 useful in picking up abnormal medial displacement of the carotid artery
 abnormality of the internal carotid is common in VCF syndrome
 10% found to be located just under the pharyngeal mucous membrane and thus can
be endangered in raising pharyngeal flap
 Sommerlad (Cleft Palate Craniofac J. 2004 Jul) - Examination and palpation of the
pharyngeal walls after the patient is positioned for surgery appear to be reliable in
detecting abnormal pulsations and allow accurate surgical planning. Routine vascular
imaging, even in patients with pulsations on preoperative nasendoscopy is not
essential and may not always be reliable, as shown by the variation in endoscopic,
MRA, and intraoperative findings.
Management
Nonoperative treatment
 Speech therapy
o generally not enough in itself for structural problems related to VPI.
o It is, however, valuable for small gaps or inconsistent closure
o very valuable either before or after surgery, or both, in order to eliminate
compensatory strategies that patients develop over time.
 Prosthesis
o Poorly tolerated in children. Mainly
indicated where surgical risks are
prohibitive.
1. obturators (speech bulb) - provides
a bulky apparatus for the pharynx
against which the lateral walls and
the palate can close during speech
2. Palatal lifts - attaches to the
patient’s teeth and roof of the
mouth. Reserved for patients with
adequate tissue to effect closure
but there is poor control or
coordination. May also be used as
a preoperative trial to see if VP closure alone will improve the speech disturbance.
Elevates the palate towards the pharyngeal walls during speech and the residual
palate motion does the rest. Used mainly in amyotrophic lateral sclerosis
Operative treatment
Main treatment methods
1) pharyngeal flap surgery
 benefit patients with sagittal closure patterns.
2) sphincter pharygoplasty
 those with circular and coronal closure patterns as it does not interfere with the
posterior motion of the palate.
3) Furlow palatoplasty
4) Others
 Intravelar veloplasty – if not already performed
 post pharyngeal wall augmentation
 prosthetic speech appliances
 most surgeons regard lateral pharyngeal wall motion as the single most
important determinant with regard to surgical planning.
 Armour A, Fisher D; Does Velopharyngeal Closure Pattern Affect the Success of
Pharyngeal Flap Pharyngoplasty? PRS Jan 2005
o pharyngeal flap pharyngoplasty was successful in correcting nasalance in a
significantly greater percentage of patients with noncoronal closure pattern
velopharyngeal insufficiency (57%) than with coronal pattern velopharyngeal
insufficiency (35%)
o Sphincter pharyngoplasty is thus recommended for coronal closure patterns
 Pre-VP management tonsillectomy and/or adenoidectomy are advised if the initial
airway evaluation findings indicate that the lymphoid mass will compromise the
operation or patency of the ports.
Pharyngeal flap pharyngoplasty
 first true pharyngeal flap operation was described by Schoenborn (1875) and was an
inferiorly based flap, he then changed to a superiorly based flap.
 Use of a pharyngeal flap is best when a sagittal closure pattern exists (ie, when the
greatest contribution to velar closure is lateral wall movement).
 May also be used for circular closure patterns
 No additional benefit with intravelar veloplasty
Principle:
 tissue/flap from the post pharyngeal wall is attached to the soft palate creating a
midline obstruction of the oral and nasal cavities with two patent lateral ports that
ideally remain patent during respiration and nasal consonant production
 depth of the flap is down to the prevertebral fascia so it includes the superior
constrictor muscle
Modifications
1) construction of the appropriate width of flap
2) the use of a superiorly or inferiorly based flap
3) whether the flap should be lined to reduce post op contraction of the flap
4) correct width and level of attachment to the flap
Superior based pharyngeal flap
Correct width and level of attachment to the flap
 Width and level of insertion are crucial
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
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The flap must not be too wide that the lateral ports are occluded which will result
in mouth breathing and sleep disturbances as sleep apnoea and snoring and hypo
nasal speech
Lateral port control (introduced by Hogan) –aim for total port size of 10-20mm2
cross sectional area (oropharyngeal air pressure decreases significantly when the
orifice size exceeds 10 mm2, with nasal escape of air obvious above 20 mm2)
Thus 10 mm2 catheters are placed on each side to control the size of the port ( this
does not however account for the effects of flap contraction)
Shprintzen et al. (1979 - Flaps are tailored according to the amount of lateral
pharyngeal wall motion and gap size as based on the preoperative on
videofluoroscopy and nasopharyngoscopy. Narrow, moderately wide, or very
wide flap, depending on whether the preoperative lateral pharyngeal wall motion
was rated as excellent, moderate, or poor, respectively
Flap lining and flap contraction
 Flaps are raised from wide area and the post surface heals by second intention thus
post op contraction is a problem with recurrence of the VPI
 The position of the flap may also have effect on the overall post op state
 Distal insertion of a wide short flap along the free margin of the soft palate may
also lessen the problem of post op contraction
Superior or inferior based flaps
 Superior based flaps may be better as the inferiorly based flaps have a
1. severe length limitation
2. disadvantage of tethering the flap in a inferior direction away from the palatal
plane and in the opposite direction required for palatal closure
 Most studies have not found a difference between the 2 methods in postoperative
speech outcome, hearing, complications, or length of hospital stay.
 Kapetansky (1973) introduced a third design, bilateral transverse flaps. He believed
that basing the flaps laterally would preserve nerve supply, thus maintaining more flap
mass, as well as preserving contractile function. Therefore, he made an S-shaped
incision in the posterior pharyngeal wall and elevated two laterally based flaps, each
15 to 20 mm in width and 30 to 35 mm in length, using one to provide oral lining and
one for nasal lining. However, this design has never become as popular as the
superiorly or inferiorly based flaps.
Outcome
 speech improvement in 95% but up to 35% are overcorrected
Sphincter pharyngoplast)( Hynes and modified by Jackson)
 Hynes(1950) described transposition of bylateral flaps from the lateral pharyngeal
walls to join in the palatal midline anterior to Passavant’s ridge
 Each flap is 3–4-cm long and consists of salpingopharyngeus muscle and its
overlying mucosa.
 67% of the flaps were noted to be contractile on postoperative examination, and 95%
of patients achieved velopharyngeal competence.
bilateral flaps from the lateral pharyngeal walls to
Orticochea modification
 constructed from the posterior tonsillar pillars which are elevated to include the
palatopharyngeus muscle at the top of the tonsillar fossae and are sutured end to end
Jackson modification
 sphincter is constructed from the posterior tonsillar pillars, which are elevated to
include the palatopharyngeus muscles sutured together in the midline and were
attached to the undersurface of a superiorly based posterior pharyngeal flap.
Advocated by many as
1) dynamic sphincter closure as a result of retained neuromusc innervation
2) ease of operation
3) good results
4) low complication rate
5) nonobstruction of the nasal airway and no interference with the velum
Best for those with circular closure patterns with mild nasal resonance
Better results in children under the age of six
Palatal lengthening
 Theoretical advantage of lengthening the palate without damaging the normal VP
mechanism
 The V-Y palatal push back was designed to create a retro displacement of the palatal
mucoperiosteum and the velar musculature during initial palatoplasty
 Double opposing Z plasty (Furlow) now commonly used
 Best used in those with small defects only
Posterior pharyngeal wall augmentation
 a static augmentation of the posterior wall to allow a compromised palate to achieve
contact. It is best with a small gap and with good palate movement, and it has been
especially good with patients who get VPI after adenoidectomy.
 The goal is to achieve Vp closure without altering the function of the velumor the
lateral walls
 Many materials have been used to augment the post pharyngeal wall
 Materials used include paraffin, cartilage, sialastic, fat, Teflon and collagen
 Mostly abandoned due to the unpredictable effect of migration and rejection
 folded superior pharyngeal flap technique is an alternative
Palatal fistulae
Large fistulae may be associated with hypernasality and nasal emission and thus may
benefit from occlusion
Complication (overall incidence 16%)
1) Obstructive sleep apnoea (90%)
i. One of the most common complication of pharyngeal flap surgery
ii. Tonsillectomy recommended preop or intraop if enlarged
iii. Affects most pts early post op - it is usually short lived and last for 1-2 days
2)
3)
4)
5)
6)
7)
8)
9)
iv. other factors such as decreased airway size , presence of tonsils, alteration in
resp pattern and syndromic contributions are more likely to contribute to OSA
than the flap width)
snoring
bleeding(8%)
airway obstruction in the first 24 hrs(9%)
OSA(4%)
i. May require flaps to be taken down or revised
Inadequate correction of the VPI
Overcorrection
flap dehiscence and loss
Inhibition of facial growth due to the tethering effect of the velum that may restrict
maxillary advancement
i. No significant change in facial form noted
Predictive factors of complications included the operating surgeon, presence of
associated medical conditions, concurrent performance of another major procedure, and
leaving the posterior pharyngeal donor site open.
Management of pharyngeal flap with orthognathic advancement
 A nasoendoscope- guided clinical examination by a speech pathologist familiar with
cleft palate and jaw deformities can reliably predict current and expected
velopharyngeal function
 When significant postoperative velopharyngeal deterioration is anticipated, the patient
and family are educated about the sequencing of treatment, and alternatives are
discussed.
 Unusual to need to transect an in-placed pharyngeal flap to achieve the desired
advancement.
Revision for hypernasality
Sandwich technique
Sandwich technique for persistent hypernasality using superiorly based flap. Donor is left
to heal by secondary intention