Velopharyngeal Insufficiency

Question

Answer

There are two other questions which must be answered first. "Why does he have VPI?" and, "Can he actually do anything about it?" The first question is merely a stepping stone to the second, more important question. Without the answer to these questions, any intervention efforts on your part may be a waste of time (at best), cause the child great discouragement as you are asking him to do the impossible, or cause actual physical damage such as vocal fold hyperfunctioning.

The first question asks that you not calmly accept the diagnosis of "unknown origin," but become a bit of a detective. What other diagnoses does the child carry? Does he have artic/phono problems, cognitive or language problems? Does he show signs of apraxia? How is his other motor coordination? What's his overall muscle tone? What is his health like? Does he have frequent colds? Have his tonsils/adenoids been removed? All of these issues could contribute to his hypernasality. Continue your detective work with a case history. Find out about early feeding issues (food/drink coming out his nose), early speech development and family history of cleft palate, VPI, or neurological difficulties. These, too, have a positive correlation with VPI.

Now do a good oral periph. You can't do a good oral periph by looking in his mouth once. It will take several "looks." Note dental structures and the height and width of the palate in general. Note any unusual markings of the palate. Excessively large tonsils can have a detrimental effect on nasal resonance. Look at the soft palate for mass, movement and length. "Mass" refers to the bulkiness of the palate. Does it appear thick and bulky, or thin and weak? Sometimes, if the palate is very thin, the bony ridge of the hard palate becomes visible when the palate is fully elevated. "Movement" looks at the ability of the palate to elevate. If he opens wide and says "ah" chances are the palate is already elevated and you won't see movement. So ask him to say "ung-ah," several times. Note the symmetry, speed and strength of the movement. "Length" asks you to estimate if the palate is long enough to make contact with the posterior pharyngeal wall. You will need to estimate both the length of the palate and the depth of the oral pharynx. Make an educated guess: does it look like his palate can "do the job?" It will help if you look inside the mouths of many people who do have normal resonance.

You can also feel for the presence of a posterior nasal spine, or, conversely, a notch in the bony hard palate by running a gloved finger down the center of his palate. The edge of the bony hard palate should be roughly in the vicinity of the back molars. A notched "v" extending toward the front teeth is a sure sign of a sub-mucus cleft. Watch that your knuckle doesn't touch the back of the tongue and you shouldn't trigger a gag reflex. You may want to leave this to the Cleft Palate Team.

Finally, get the opinion of your local Cleft Palate Team. Most states have one or more teams which can be found either through the American Cleft Palate Craniofacial Association, or a state agency such as Children's Special Health Services. Be sure to give the Cleft Palate Team the results of your evaluation thus far. I am always pleased when the local SLP comes to the Cleft Palate Team Evaluation. In addition to your assessment, the team may be able to perform an endoscopic evaluation of the VP mechanisms. Where as you looked at the length and estimated, "Can it do the job?" this procedure offers a far more definitive answer. A very small camera will be suspended in the nasal pharynx, just above the VP port and project the image to a computer screen. The professionals will be able to actually see when, if, and how the velum is coming into contact with the pharyngeal walls. The team may also ask for a videoflouroscopic study. This is an x-ray procedure similar to a video-swallow study. The child is x-rayed from various views while speaking. Palatal and pharyngeal wall movement is observed by reviewing the video x-ray.

The expertise of the Cleft Palate Team is essential in answering the most important question, that is, "Is it possible for him to make VP closure?" If it's not possible, then all the intervention in the world won't help and you're "beating a dead horse." Unfortunately, this "horse" is an impressionable 6-year-old child who will be subjected to a long series of failures if you attempt to teach closure when the physical mechanism renders closure impossible. Simply put, you cannot teach a child to grow an adequate mechanism.

If the child is not physically capable of making VP closure then two alternatives are considered. First, a prosthesis may be considered. The team may recommend either a palatal lift or a "speech bulb." Second, and more common these days, a surgical procedure may be considered. The most common procedure is a pharyngeal flap, in which a bit of tissue connects the palate and posterior pharyngeal wall (leaving lateral spaces for air passage).

If the child is capable of making closure a variety of speech based activities may be used to strengthen the mechanism. I am hesitant to describe these now, as I really want to encourage you to answer the first questions first (and I've already gone on for pages).

Dr. Cheryl B. Gerard is a professor at Minot State University, where she has engaged in research, taught classes in Cleft Palate and served on the local Cleft Palate Team for over twelve years.