What is Velopharyngeal (VPI) Insufficiency?

What is Velopharyngeal (VPI) Insufficiency?


Velopharyngeal insufficiency (VPI) is a disorder that can cause speech problems in children with cleft lip or cleft palate.

In normal mouths, the soft palate closes off the nose from the mouth. But for children with VPI, the soft palate does not separate the mouth and nose like it should.

This gap between the mouth and the nose causes air to escape through the nose while your child talks. Sometimes liquid can also escape through the nose when your child drinks. 

Children who have cleft palate (with or without a cleft lip) have a higher chance of developing this problem. 10 to 30 percent of children with cleft palate develop VPI. But other children can also have VPI.

How is VPI Diagnosed?

Speech and language pathologists usually diagnose VPI by analyzing the way your child's voice sounds when they talk and say different phrases. Speech and language pathologists use a type of analysis called perceptual speech analysis to find and document these problems. 

Speech pathologists may also perform a test to compare the amount of air that escapes from the mouth and nose when your child talks. This is called nasometry.

The unique shape of your child’s nose and throat and how the throat tries to close will help surgeons choose the best treatment for your child.

The Scope Exam

During a scope exam, your doctor will insert a small, flexible telescope through your child’s nose. The telescope also has a camera attached to it. This type of procedure is also called an endoscopy. An endoscopy allows your child’s doctor to see the area behind the palate. This area is called the velum. Most children handle an endoscopy very well after they get used to the strange feeling. 

After the camera is inside your child’s nose, speech and language pathologists will ask your child to say certain phrases. As your child talks, the doctor will watch how your child’s throat closes behind their palate. This will help guide your child’s treatment plan.

An endoscopy will also help your doctor find any other problems your child might have in their nose, throat, and voice box.

Treatments & Surgery

Most children with VPI need surgery to prevent air from escaping through their nose. During surgery, surgeons will operate on your child's throat so it closes off the nose from the mouth like normal soft palates do. Surgery will help air escape through your child's nose correctly, but other speech problems will also need to be addressed.

There are several types of surgery to treat VPI. The best surgery for your child will depend on how their palate moves and the way the back of their nose and throat looks. Your pediatric facial plastic surgeon and speech pathologist will review all the information (including the scope exam) to develop the best plan for your child.

Prosthetic Speech Device

Occasionally, children with VPI (also called hypernasality) need treatment, but some children are not a candidate for surgery. VPI in patients with severe airway obstruction—or blockage—can make it difficult for surgeons to choose the best treatment. Airway obstruction can become worse over time and can make surgery more risky.

If your child has airway obstruction, doctors may treat the problem with a prosthetic. A prosthetic is an artificial body part that is shaped like a normal soft palate. The back of the prosthetic clasps to your child’s teeth and blocks air from escaping through the nose.

Parents can remove their child’s prosthetic at night, so the prosthetic won't worsen your child's airway obstruction or sleep apnea.

Furlow Palatoplasty for VPI

If the muscles in your child’s palate are not positioned or shaped normally, your child may need surgery to lengthen their palate and realign their muscles. Some children with VPI may be candidates for a type of surgery called furlow palatoplasty.

Furlow palatoplasty is similar to a type of surgery that closes the soft palate in children who have a cleft palate but not a cleft lip.

Children with cleft palate have muscles that run front to back. Furlow palatoplasty lengthens the soft palate and moves the muscles so they run across the palate in a normal direction instead of running front to back. Furlow palatoplasty is sometimes also called a double z-plasty.

The size of your child’s gap between their mouth and nose, as well as how their muscles are oriented, will help surgeons decide if furlow palatoplasty is the best option.

Sphincter Pharyngoplasty for VPI

Some children have palate muscles that run normally, but their palates are still too short to reach the back of their throat.

Depending on the size and shape of this gap, many of these children can have a type of surgery called sphincter pharyngoplasty. Sphincter pharyngoplasty creates a bump at the back of the throat.

During sphincter pharyngoplasty, surgeons remove a piece of tissue from behind your child's tonsil. Then, surgeons rotate this tissue so it lays across the throat behind your child's palate. Surgeons call these pieces of tissue flaps. Surgeons usually rotate one flap from each side of the throat.

For almost every sphincter pharyngoplasty, surgeons customize flaps so they fit the gap in your child's palate. This includes the size, position on the side of the throat, and height of placement of the flaps.

Customizing the procedure to treat your child's VPI can lower your child's risk of sleep apnea while improving her speech.

Pharyngeal Flap for VPI

For some children with VPI, sphincter pharyngoplasty is not a good option because the gap in their palate is too large or their palate does not move well enough.

For these children, a pharyngeal flap is usually the best type of surgery.

In this procedure, surgeons connect a piece of tissue from the back of the throat to the back of the soft palate. This piece of tissue blocks air that escapes through the nose, but it still allows your child to breathe through their nose easily.

VPI Surgery & Sleep Apnea

One of the risks of performing surgery to correct VPI is that your child may develop breathing problems at night. These problems may include snoring and sleep apnea.

Different types of surgery may give children higher or lower chances of developing sleep apnea. The studies examining this question do not show a clear answer. Still, doctors think that furlow palatoplasty is the least likely to cause sleep apnea.

Two Types of Surgery: Sphincter Pharyngoplasty & Pharyngeal Flap Surgery

Unfortunately, furlow palatoplasty does not help most patients with VPI. Furlow palatoplasty can only help children if their palate muscles run in the wrong direction. If your child’s palate muscles run across their mouth, your child will need:

  • sphincter pharyngoplasty
  • or pharyngeal flap surgery.

When Do We Perform Pharyngeal Flap Surgery?

Children who have pharyngeal flap surgery have a higher chance of developing sleep apnea after their surgery. Because of this risk, we usually perform pharyngeal flap surgery only when a sphincter pharyngoplasty most likely won't correct VPI.

Children who have sleep apnea and VPI add other challenges. For these children, we must fix the problem that is causing the sleep apnea before we can improve speech problems or VPI.

To treat children with both sleep apnea and VPI, we must figure out where your child's airway is collapsing. To do this, we use a camera when we see your child in the clinic. This exam is similar to the evaluation for VPI. We must also perform this exam again when your child is sleeping at the beginning of a surgery.

Potential Problems

The flaps surgeons use in pharyngeal flap surgery can cause problems if they are too big, sit too low, or stop in the wrong place. These problems may make it hard for your child to breathe through their nose, but this is not common.

Your child may also have scarring that blocks the space between their nose and throat. This is called nasopharyngeal stenosis. But this is very rare.

Though it is not common, your child may also develop sleep apnea after the procedure.


Personalized Treatment

Our surgeons customize the size and shape of both pharyngeal and sphincter flaps to fit the gap behind your child’s palate. Our surgeons also make small adjustments to lower your child's chances of developing sleep apnea and scarring.

VELO: A Tool to Measure VPI & Quality of Life

We have developed new tools to help other surgeons and cleft teams measure how VPI affects your child's life. Our tool asks children and families how many problems they are having and whether these problems are severe. Some surgeons forget the reason we are operating is to improve the quality of your child's day-to-day life.

Tests that measure nasal emissions can be helpful. Doctors who look at nasal emissions measure how well your child speaks when they make certain sounds in speech like the "s" or "p" sound. But our tool, called the VELO, focuses more on measuring your child's quality of life over other factors (like speech, for example).

We are passionate about helping your child as well as helping surgeons worldwide provide better care to children just like yours.

Experts in Treating VPI

Some children with cleft lip and palate or VPI have sleep apnea for complex reasons. Our pediatric facial plastic & ENT surgeons have expertise treating children with advanced pediatric sleep apnea. We also have expertise in treating sleep apnea in children who have problems with positive pressure devices (like CPAP). 

Once we correct your child's sleep apnea, we can then focus on your child's speech. Surgeons usually must perform surgery to correct sleep apnea first, and then correct VPI in a later surgery.

What to Expect & Common Questions


It’s normal for parents to have questions about their child’s VPI surgery. Read our list of common questions for VPI and one and two-stage palate surgery.

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