Velopharyngeal insufficiency: current concepts in diagnosis and management

To discuss principles of evaluation and treatment of children with velopharyngeal insufficiency, and to review recent reports of surgical outcomes.

Velopharyngeal insufficiency significantly impacts both quality-of-life and speech intelligibility in children. Diagnosis is made through history and physical, perceptual speech assessment, and instrumental measures including nasendoscopy and radiographic multiplanar videofluoroscopy. Treatment options for velopharyngeal insufficiency consist of prosthetic management or surgery, supplemented with speech therapy when appropriate. Surgical interventions are palatal, palatopharyngeal or pharyngeal in nature. Despite some controversy, most recent reports identify no significant difference in outcomes following pharyngeal flap or sphincter pharyngoplasty. Complications of surgical therapy relate to postoperative obstructive breathing or persistent velopharyngeal insufficiency.

Although there is no universally accepted measure to assess velopharyngeal insufficiency severity, nasendoscopy and multiplanar videofluoroscopy are most commonly used for clinical diagnosis. A speech pathologist is an integral member of the velopharyngeal insufficiency team, and momentum toward a standardized reporting system of perceptual speech measurements is increasing. Treatment of velopharyngeal insufficiency should be tailored to the specific needs of the child and family. Surgical therapy may improve velopharyngeal function but may negatively impact upper airway patency and respiration during sleep. The otolaryngologist should be familiar with strengths and limitations of different surgical options for velopharyngeal insufficiency.