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Velopharyngeal mislearning — Clinical Guidelines

Overview

Velopharyngeal insufficiency (VPI) is a condition characterized by inadequate closure of the velopharyngeal port during speech, leading to hypernasality, nasal emission, and articulation disorders. 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 32 33 34 35 36 37 38 39

Diagnosis

Key Diagnostic Criteria: Hypernasality, nasal air emission, articulation errors, and speech intelligibility issues.

Recommended Tests: Nasometry, videofluoroscopy, endoscopy (e.g., nasopharyngoscopy), and instrumental assessments like SNORS.

Grading Systems: Golding-Kushner scale (GKS) for endoscopic assessment 8.

Additional Assessments: Aerodynamic studies and levator veli palatini muscle activity analysis 23.

Management

First-Line Treatments:

- Speech Therapy: Essential component, often combined with surgical interventions 1 3 15 29 32. - Surgical Interventions: Furlow palatoplasty, sphincter pharyngoplasty, and augmentation techniques using autologous materials (e.g., fat, tragal cartilage) 1 5 18 20.

Adjunctive Treatments:

- Speech Aid Prosthesis (SAP): Used in conjunction with speech therapy for persistent VPI 4 14. - Conscious Sedation: For pediatric patients undergoing nasendoscopy 17.

Special Populations

Pediatrics: Speech therapy is foundational, with surgical interventions considered for refractory cases 1 3 15 29 32.

Comorbidities: Patients with submucous cleft palate may benefit from combined surgical and therapeutic approaches 3.

Post-Adenoidectomy VPI: Requires careful assessment and management, often involving surgical correction if persistent 18 22 34.

Key Recommendations

Initiate Comprehensive Speech Therapy Early: Essential for all patients with VPI to address articulation and resonance issues (Evidence: Strong 1 3 15 29 32).

Consider Surgical Interventions for Refractory Cases: Autologous fat grafting, Furlow palatoplasty, and sphincter pharyngoplasty can be effective when conservative measures fail (Evidence: Moderate 1 5 18 20).

Use Combined Approaches for Persistent VPI: Integrate speech therapy with prosthetic devices like SAP for optimal outcomes in adults (Evidence: Moderate 4 14).

Endoscopic Assessment with Standardized Tools: Utilize validated tools like the GKS for consistent evaluation of velopharyngeal function (Evidence: Moderate 8).

Evaluate Nasal Airway Resistance: Consider aerodynamic assessments to guide prosthetic adjustments in patients with VPI (Evidence: Weak 28).

References

1 Hassan MM, Gelaney AE, Ahmed ME, Hassanyn MA, Bakry S, Elsherbiny A. Speech Outcome Following Autologous Fat Grafting in Soft Palate for Velopharyngeal Insufficiency. The Cleft palate-craniofacial journal : official publication of the American Cleft Palate-Craniofacial Association 2026. link 2 Chee-Williams JL, Bunton K, Alvarez-Montoya E, Cordero KN, Perry JL, Philp J et al.. Does Successful Surgical Treatment of Velopharyngeal Insufficiency Aid in the Remediation of Compensatory Misarticulation Errors?. American journal of speech-language pathology 2025. link 3 Ritzen TFP, Wijnants N, Verbeek MJM, Caenen-Drummen SAD, van Kuijk SMJ, Booi DI et al.. Speech therapy only versus speech therapy combined with Furlow palatoplasty for the treatment of velopharyngeal insufficiency in submucous cleft palate: A systematic review and meta-analysis. Journal of plastic, reconstructive & aesthetic surgery : JPRAS 2025. link 4 Wadhwa B, Selvaraj U, Bhandari S, Sharma A, Singh SP. Influence of speech aid prosthesis with speech therapy on speech outcomes in adult patients with persisting velopharyngeal insufficiency: A retrospective analysis. The Journal of prosthetic dentistry 2024. link 5 Khafagy AG, Kassamy H, Mohamed AA. Augmentation of the posterior pharyngeal wall with autologous tragal cartilage for management of velopharyngeal valve insufficiency in adults. Auris, nasus, larynx 2021. link 6 Poff C, Horton J, Boerner R, Marston AP, Nguyen SA, White DR. Publishing trends in velopharyngeal insufficiency. International journal of pediatric otorhinolaryngology 2020. link 7 Johns A, Tanner A, Gingrich M, Urata M. Velopharyngeal Insufficiency Impact and Nasopharngoscopy Discomfort and Cooperation: Patient, Parent, and Provider Perspectives. The Journal of craniofacial surgery 2020. link 8 Miller C, Bly R, Cofer S, Dahl JP, de Serres L, Goudy S et al.. Multicenter Interrater Reliability in the Endoscopic Assessment of Velopharyngeal Function Using a Video Instruction Tool. Otolaryngology--head and neck surgery : official journal of American Academy of Otolaryngology-Head and Neck Surgery 2019. link 9 Samoy K, Hens G, Verdonck A, Schoenaers J, Dormaar T, Breuls M et al.. Surgery for velopharyngeal insufficiency: The outcomes of the University Hospitals Leuven. International journal of pediatric otorhinolaryngology 2015. link 10 Bliss M, Muntz H. Nasal endoscopy: new tools and technology for accurate assessment. Advances in oto-rhino-laryngology 2015. link 11 Skirko JR, Sie KC. Validated patient-reported outcome instruments for velopharyngeal insufficiency. Advances in oto-rhino-laryngology 2015. link 12 de Stadler M, Hersh C. Nasometry, videofluoroscopy, and the speech pathologist's evaluation and treatment. Advances in oto-rhino-laryngology 2015. link 13 Tsunoda K, Sasaki T, Tsunoda A, Kobayashi R, Ueha R, Shoji S. Undiagnosed submucous cleft palate interfering with inhalation therapy and a solution. The Journal of allergy and clinical immunology 2013. link 14 Uphadhyay M, Jain D, Kumar S, Uppal S. Speech aid prosthesis. BMJ case reports 2013. link 15 Bispo NH, Whitaker ME, Aferri HC, Neves JD, Dutka Jde C, Pegoraro-Krook MI. Speech therapy for compensatory articulations and velopharyngeal function: a case report. Journal of applied oral science : revista FOB 2011. link 16 Anandakrishna GN, Gali S. Management of velopharyngeal disorders. A case series. Journal of prosthodontics : official journal of the American College of Prosthodontists 2010. link 17 Heman-Ackah SE, Sidman J, Lui M. Conscious sedation in pediatric speech endoscopy. International journal of pediatric otorhinolaryngology 2009. link 18 Abdel-Aziz M, Dewidar H, El-Hoshy H, Aziz AA. Treatment of persistent post-adenoidectomy velopharyngeal insufficiency by sphincter pharyngoplasty. International journal of pediatric otorhinolaryngology 2009. link 19 Shprintzen RJ, Marrinan E. Velopharyngeal insufficiency: diagnosis and management. Current opinion in otolaryngology & head and neck surgery 2009. link 20 Ragab A. Cerclage sphincter pharyngoplasty: a new technique for velopharyngeal insufficiency. International journal of pediatric otorhinolaryngology 2007. link 21 Goffart Y. Side effects and complications of velopharyngeal surgery. Acta oto-rhino-laryngologica Belgica 2002. link 22 Stewart KJ, Ahmad T, Razzell RE, Watson AC. Altered speech following adenoidectomy: a 20 year experience. British journal of plastic surgery 2002. link 23 Tachimura T, Nohara K, Fujita Y, Hara H, Wada T. Change in levator veli palatini muscle activity of normal speakers in association with elevation of the velum using an experimental palatal lift prosthesis. The Cleft palate-craniofacial journal : official publication of the American Cleft Palate-Craniofacial Association 2001. link 24 Main A, Kelly S, Manley G. Instrumental assessment and treatment of hypernasality, following maxillofacial surgery, using SNORS: a single case study. International journal of language & communication disorders 1999. link 25 James NK, Twist M, Turner MM, Milward TM. An audit of velopharyngeal incompetence treated by the Orticochea pharyngoplasty. British journal of plastic surgery 1996. link90050-8) 26 Motta S, Cesari U. Aerodynamic study of velopharyngeal insufficiency before and after logopedic treatment. Folia phoniatrica et logopaedica : official organ of the International Association of Logopedics and Phoniatrics (IALP) 1996. link 27 Haapanen ML, Ignatius J, Rihkanen H, Ertama L. Velopharyngeal insufficiency following palatine tonsillectomy. European archives of oto-rhino-laryngology : official journal of the European Federation of Oto-Rhino-Laryngological Societies (EUFOS) : affiliated with the German Society for Oto-Rhino-Laryngology - Head and Neck Surgery 1994. link 28 Leeper HA, Janzen V, Sills PS, Ahmad D. Technique for assessing nasal airway resistance in patients treated prosthetically. The Journal of prosthetic dentistry 1994. link90082-5) 29 Broen PA, Doyle SS, Bacon CK. The velopharyngeally inadequate child: phonologic change with intervention. The Cleft palate-craniofacial journal : official publication of the American Cleft Palate-Craniofacial Association 1993. link 30 Hutters B, Brøndsted K. A simple nasal anemometer for clinical purposes. European journal of disorders of communication : the journal of the College of Speech and Language Therapists, London 1992. link 31 Moller KT. An approach to evaluation of velopharyngeal adequacy for speech. Clinics in communication disorders 1991. link 32 Pannbacker M, Lass NJ, Stout BM. Speech-language pathologists' opinions on the management of velopharyngeal insufficiency. The Cleft palate journal 1990. link027<0068:spootm>2.3.co;2) 33 Riski JE, Hoke JA, Dolan EA. The role of pressure flow and endoscopic assessment in successful palatal obturator revision. The Cleft palate journal 1989. link 34 Witzel MA, Rich RH, Margar-Bacal F, Cox C. Velopharyngeal insufficiency after adenoidectomy: an 8-year review. International journal of pediatric otorhinolaryngology 1986. link80023-4) 35 Gallagher B. Prosthesis in velopharyngeal insufficiency: effect on nasal resonance. Journal of communication disorders 1982. link90020-x) 36 Marsh JL, Wray RC. Speech prosthesis versus pharyngeal flap: a randomized evaluation of the management of velopharyngeal incompetency. Plastic and reconstructive surgery 1980. link 37 Shapiro RS. Velopharyngeal insufficiency starting at puberty without adenoidectomy. International journal of pediatric otorhinolaryngology 1980. link90051-8) 38 Shelton RL, Beaumont K, Trier WC, Furr ML. Videoendoscopic feedback in training velopharyngeal closure. The Cleft palate journal 1978. link 39 Shelton RL, Trier WC. Issues involved in the evaluation of velopharyngeal closure. The Cleft palate journal 1976. link 40 Demark RV, Kuehn DP, Tharp RF. Prediction of velopharyngeal competency. The Cleft palate journal 1975. link

Velopharyngeal mislearning