Velopharyngeal Dysfunction

Velopharyngeal insufficiency (VPI) occurs when there is not enough (“insufficient”) tissue in the palate or throat to let the palate contact the back of the throat during speech.

Velopharyngeal mislearning (VPM) happens when a child learns wrong ways to make sounds. Some children develop unusual speech patterns that do not use the palate even though their palate works properly.

Other children use unusual speech patterns to make up for problems with the structure of their mouth or throat. They learn to make sounds without moving their soft palate to the back of their throat.

Velopharyngeal incompetence (VP incompetence) means there is a problem in how the soft palate moves to make speech sounds.

It is possible to have more than one type of VPD. A speech and language pathologist (SLP) specializing in VPD will help determine what types your child has.

The 2 main speech symptoms of VPI are: 

• Nasal speech (hypernasality)
• Nasal air escape 

Both symptoms happen because the palate does not touch the back of the throat during speech.

Nasal speech

In English, the sounds m, n and ng are the only sounds that should sound nasal. Nasal speech happens when other sounds resonate through the nose. This is called “hypernasality” or “hypernasal resonance.” It can be mild or severe.

You can hear nasal speech when a child is saying vowels or sounds such as w, y, l or r.

Nasal air escape

When air escapes through the nose as your child makes pressure consonants, this is called “nasal air escape” or “nasal air emission.”

In English, the pressure consonants are p, b, t, d, k, g, s, z, f, v, sh, zh, ch, dj and th.

They are called pressure consonants because pressure builds up in the mouth when the palate closes and seals off the mouth from the nose.

When a child has VPI, pressure cannot build up in the mouth. Air escaping through the nose can sound like puffs, squeaks or snorts. Your child’s speech may be very soft.

To learn more, see Early Sound Development in Children with a Cleft Palate (PDF) (Spanish).

Sometimes children learn the wrong way to make sounds. During speech their soft palate does not close to the back of their throat. These sounds are called “compensatory misarticulations.” They include: 

• Stopping air with the vocal cords (as when saying “uh oh”). This sound is called a glottal stop.
• Using the tongue or palate to stop or restrict air in the mouth or throat in unusual ways.
• Holding the palate open and pushing air through the nose

Symptoms of VP incompetence vary widely. They are caused by a problem with how the soft palate moves to make speech sounds. The timing of palate movement or the amount the palate moves may be wrong.

Speech therapy may be part of your child’s treatment even if they have a structural problem that will also require surgery or a speech appliance. 

• For children with VPM, speech therapy can help them learn how to control air flow and use their tongue, lips and jaw correctly to make sounds.
• With VP incompetence, the specific goals of speech therapy depend on your child’s needs. After assessing your child, the SLP will determine which sounds and skills to focus on.

For some children with VPI or VP incompetence, treatment will include a speech appliance called an obturator.

An obturator is like a modified dental retainer with a “speech bulb” attached to the back. It can help your child sound less nasal and keep air from escaping out of their nose when they talk.

The obturator is custom shaped to fit your child’s muscle movements. Your child will have several visits to the Dental Clinic so the dentist can make the appliance.

A speech and language pathologist helps fit the obturator and check how effective it is. Your child wears it during the day and takes it out at night for sleep. It can be worn while eating.

An obturator can be a short- or long-term option. It can be used before or instead of surgery for VPI. Some children start with an obturator and have surgery when they are older. Some continue to use an obturator as adults

Most children with VPI need surgery because they don’t have enough (“insufficient”) tissue in the palate or throat. Sometimes children with VP incompetence also need surgery.

If your child could benefit from surgery, your surgeon and SLP will talk with you about the type of surgery and when to have it.

The most common speech surgeries for VPI are called Furlow palatoplasty and sphincter pharyngoplasty.

The Furlow palatoplasty brings the muscles of the palate into a more normal position. This lengthens the palate.

Sphincter pharyngoplasty moves tissue from the side of the throat to create a “speed bump” at the back of the throat. With this change, the soft palate can touch the back of the throat when your child talks.

After VPI surgery, the soft palate can touch the back of the throat to close off the nose during speech.

Surgical procedures are performed inside the mouth under general anesthesia. Most times, your child will need to stay in the hospital overnight.

Your child will have a follow-up speech evaluation 3 to 4 months after surgery.

Your child’s treatment team is likely to include: 

• A speech and language pathologist (SLP) who specializes in identifying traits of VPD speech. SLPs also are skilled at telling VPD apart from other speech problems.
• An ear, nose and throat doctor (ENT or otolaryngologist). Our experienced ENTs do special tests to check velopharyngeal function in children and perform surgery if needed.
• A surgeon skilled in doing surgeries on the throat and palate to help correct speech issues. Depending on your child’s needs, this may be an ENT surgeon or a plastic surgeon.
• An orthodontist who makes custom speech appliances for children who need them. 

If your child’s VPD is related to a craniofacial condition, they will also receive care from other experts in our Craniofacial Center. These 50 specialists work together to diagnose and create a personalized plan of care for each child. A craniofacial pediatrician, nurse and social worker will work closely with your family. They help coordinate care and make sure all your questions are answered.

An SLP starts working with you and your baby during their first year of life. Even before they learn to talk, babies are making pre-speech sounds.

Babies with cleft palate often are finding ways to make sounds that do not require their palate to touch the back of their throat.

Our speech and language pathologists monitor your child closely for development of VP mislearning. We can help you encourage your child to develop correct speech patterns even before their palate is repaired.

Families may face many challenges when their child has VPD. Often, a child already has been treated for cleft palate or other medical conditions. It can be hard to choose among the possible treatments.

We take time to explain your child’s condition and answer all your questions. We help you fully understand your treatment options and make choices that are right for your family.

Our SLPs and social workers help you deal with the challenges and find resources in your community.