27/12/2025
Velopharyngeal Insufficiency (VPI)
Definition
Failure of velopharyngeal closure during speech and swallowing → abnormal nasal airflow.
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When to Suspect VPI (Clinical Clues)
Hypernasal speech (key complaint)
Nasal air escape during speech
Weak pressure consonants (ب، ت، ك، س)
Nasal regurgitation of fluids (especially in children)
History of:
Cleft palate (even repaired)
Adenoidectomy
Neurological disease
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Examination
Oral cavity:
Short soft palate
Bifid uvula (suggests submucous cleft)
Palatal scar
Speech assessment:
Ask patient to say pressure words (e.g. “Papa”, “Kaka”)
Look for nasal fogging / audible nasal emission
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Confirmatory Investigations
Nasopharyngoscopy (gold standard)
→ Direct visualization of palatal closure
Videofluoroscopy (dynamic assessment)
Nasometry (objective nasalance score)
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Common Causes (Clinically Important)
Structural: cleft palate, short palate, post-adenoidectomy
Neuromuscular: CN IX/X palsy, stroke, cerebral palsy
Mislearning: abnormal articulation without defect
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Management (Practical Approach)
Speech therapy
Mild VPI
Mislearning
Post-surgery support
Surgery (structural defect)
Pharyngeal flap
Sphincter pharyngoplasty
Prosthesis
Palatal lift (neuromuscular cause)
Speech bulb
