MRI assessment of velopharyngeal dysfunction: A comprehensive primer for radiologists

Velopharyngeal dysfunction (VPD) is a condition where the velopharyngeal mechanism fails to close properly, resulting in nasal air escape during speech and hypernasal resonance. VPD is common in patients with cleft palate and presents significant challenges, often necessitating advanced imaging techniques for surgical treatment planning. Recent advancements in magnetic resonance imaging (MRI) have enhanced the capability to obtain detailed static images of velopharyngeal structures at rest and during sustained phonation, which are comparable or superior to traditional technologies. MRI is particularly effective at assessing the levator veli palatini muscle, a critical component of the velopharyngeal mechanism. As a non-invasive, radiation-free imaging method with high-resolution capabilities, MRI is becoming increasingly popular for VPD evaluation, especially in the pediatric population. However, understanding the complexities of VPD requires specialized knowledge spanning craniofacial surgery and speech-language pathology, which is often inaccessible in the radiology literature. While technical guides on MRI protocols for VPD exist, foundational knowledge of the velopharyngeal mechanism and its relevance to cleft anatomy remains underrepresented. This primer aims to bridge the gap between radiology and the complex multidisciplinary care of VPD by equipping radiologists with the knowledge necessary to effectively interpret MRI findings and integrate them into diagnostic and therapeutic pathways. By reviewing velopharyngeal and cleft anatomy, relevant VPD terminology, the principles of surgical management, and the role of MRI in velopharyngeal assessment, this paper provides radiologists with the context and tools to collaborate and communicate more effectively with cleft and craniofacial teams that treat this condition.