1. Evaluation of Velopharyngeal Insufficiency
Melissa Montiel, MS, CCC-SLP
Speech Pathologist

2. Financial Disclosure
Financial Disclosure: I am receiving an honorarium from the South Carolina Speech Language Hearing Association for this presentation and is employed by MUSC.
Non Financial Disclosure: No relevant non-financial relationships to disclose.

3. VPI defined
Velopharyngeal Insufficiency: “An anatomical or structural defect that precludes adequate velopharyngeal closure (the decoupling of the oral and nasal cavities) ”*
Basically, one is unable to appropriately and/or fully close off your oropharynx from the nasopharynx for the purpose of speech/swallowing

4. Common causes/syndromes of VPI
History of cleft palate
Submucous cleft palate
22q11 deletion (VCFS, DiGeorge Syndrome)
Pierre Robin Sequence
Treacher Collins
Neurological impairment (CP,dysarthria)
Adenoid removal
Severe sensorineural hearing loss, especially congenital
Idiopathic-sometimes these children may have no significant medical hx.
Cervical spine anomalies (excessive nasopharyngeal depth)

5. Common signs of VPI Poor feeding/sucking as an infant
Liquid coming through the nose
Severe articulation deficits, specifically weak pressure consonants.

6. Signs Con’t
Difficulty blowing bubbles/birthday candles/sucking through a straw
Nasal “snorting” or turbulence consistent throughout connected speech
Speech sounds as if there is too much sound in the nose (hypernasality)

7. Voice vs. resonance
Voice describes phonation and is a function of the larynx
Terms may be “harsh, weak,hoarse, breathy”
Associated with nodules, cysts, polyps and other laryngeal pathology

8. Resonance
Resonance is a function of the velopharyngeal mechanism and is a property of vowels
Associated terms: hypernasality, hyponasality, mixed or “cul-de-sac”

9. Voice Vs. Resonance

10. Resonance: Hypernasality-too much
Term associated with VPI
Hypernasality is too much energy resonating in the nasal cavity.
Nasality describes energy. Vowels are energy. We are using the term hypernasal to describe a vowel.

11. Resonance: What about the consonant?
Most consonants have pressure, so you are listening for a nasal air emission (NAE), which sounds like snorting
Can also perceive weak pressure on phonemes (m/b, n/d)

12. Resonance: Sounds like VPI
Hypernasality
Nasal air emissions
Weak pressure consonants
Nasal grimacing

13. Resonance: Hyponasality
Not used to describe VPI
Hyponasality is not enough energy resonating in the nasal cavity. (Ex, enlarged adenoids, allergies). The patient may sound as if they are “stuffed up” or have a cold
Hyponasality is perceived on nasal phonemes (/m,n,ing/)
“Mamma made muffins”

14. Resonance: mixed or “cul-da-sac”
A pt with VPI and enlarged tonsils/adenoids
Large adenoids preventing proper closure
VPI with anterior blockage
Behavioral

15. Perceptual effects on resonance of a high pitched voice
Voice Meet Resonance
Perceptual effects on resonance of a high pitched voice
Hyponasality and “deep voice”
Low vocal volume and VPI

16. Hypernasality-good artic

17. Hypernasality-good artic

18. Hypernasal-good articulation

19. Hyponasal

20. Hyponasality

21. VPI assessment- What’s the Purpose
Structure vs Function

22. VPI Assessment
Perceptual
Manometry
Nasendoscopy

23. VPI Assessment-Perceptual
Perceptual evaluation:
Speech production (articulation)
Resonance
Nasal air emissions

24. VPI Assessment Nasometry Measures resonant energy
Microphone measures nasal vs. oral energy
Objective findings are compared against normative data

25. Nasometry

26. Testing example Prolonged Sounds Norms S.D. Score (mean) Range
Prolonged /a/ 6 3 Text Entry Text Entry
Prolonged /i/ Text Entry Text Entry
Prolonged /s/ 0 0 Text Entry Text Entry
Prolonged /m/ Text Entry Text Entry
Oral Passages Norms S.D. Score (mean) Range
Bilabial Plosives Text Entry Text Entry
Alveolar Plosives Text Entry Text Entry
Velar Plosives Text Entry Text Entry
Sibilant Fricatives Text Entry Text Entry

27. Actual test sample
Prolonged Sounds Norms S.D. Score (mean) Standard Deviation from Mean
Prolonged /a/
Prolonged /i/
Prolonged /s/
Prolonged /m/
Oral Passages Norms S.D. Score (mean) Standard Deviation from Mean
Bilabial Plosives
Lingual-Alv Plosives
Velar Plosives
Sibilant Fricatives

28. Oral Passages Bilabial Plosives
-Pick up a book, pick up a pie, pick up a baby
Lingual-Alveolar Plosives
-Take a tire, take a turtle, take a teddy
Velar Plosives
-Go get a cookie, go get a car, go get a cake
Sibilant Fricatives
-Susie sees the dress, Susie sees the scissors, Susie sees the horse

29. -Mama made muffins, mama made mittens, mama made lemonade
Oral Passage cont’d
Nasals
-Mama made muffins, mama made mittens, mama made lemonade

30. Pt. example-PSNAE /s/ phoneme
Oral Passages Norms S.D. Score (mean) Standard Deviation from Mean
Bilabial Plosives
Lingual-Alv Plosives
Velar Plosives
Sibilant Fricatives

31. Phoneme Specific Nasal Air Emission
Deficit in which the patient is able to achieve complete closure of VP port, however s/he has developed production of specific phonemes with nasal rather than oral pressure/flow/turbulence
Deficit is an error in articulation, not the VP mechanism
Generally occurs with sibilants and affricates.
Can be very misleading to the lay listener

32. VPI Assessment Perci Sar Provide pressure/flow information
Estimates the area of the VP gap during pressure consonant production

33. PERCI-SAR

34. VPI Assessment-Nasendoscopy
Direct visualization of the VP mechanism during speech
Provide information regarding closure pattern
Assessment of related areas – tonsils, adenoids, and vocal cords

35. Closure patterns Coronal: Palatal, front to back movement (A)
Sagittal: Lateral wall closure (B)
Circular: Combination of coronal and sagittal (C)
Circular with Passavant’s ridge: Lateral wall, posterior and anterior movement (D)

36. Movement

37. Normal closure

38. Normal closure

39. VPI

40. Lateral gap

41. Hypernasality more pervasive during production of /i/ than /a/

42. Scoping-ears can be deceiving

43. Scoping-ears can be deceiving

44. Roll of an anterior fistula Wide VPI vs small gap and perceptual
Side notes
Roll of an anterior fistula
Wide VPI vs small gap and perceptual

45. VPI correction
Adenoidectomy, Palatoplasty, sphincter pharyngoplasty, pharyngeal flap, combos
-Dental appliances

46. Adenoidectomy- but why?
Prepares surgery site- MUSC paper
Irregularities in the adenoids
Bulky adenoids
If sleep apnea, tonsils may go too

47. Irregular adenoids

48. Palatoplasty Conversion from a straight-line repair Submucous cleft
Create bulk

49. Palatoplasty

50. Sphincter pharyngoplasty
MUSC main choice
This is a dynamic surgery that addresses lateral leaking
Leaves central hole for breathing
Should be surgical choice for 22q11
Still allows for a reduced overall diameter re: A-P closure

51. Sphincter Pharyngoplasty

52. Pharyngeal Flap Band of tissue that extends posteriory into phayrnx
Not dynamic
Will not address lateral leaks
Arguably higher chance for sleep apnea
My experience

53. Pharyngeal Flap

54. Dental appliances
Palatal lift
Obturator

55. Therapy vs Surgery? Speech therapy can not correct a true VPI
Speech therapy is recommended to acquire phonemes or eliminate erred speech (glottal stopping)
Speech therapy is often recommended after surgery to facilitate oral pressure vs. nasal pressure now that mechanism is functioning properly
Side note: when not to refer

56. Clinician VPI bedside Medical hx, including therapy history
Phrase list- remember to leave nasals out!
Nasal mirror
Consistency is key

57. VPI bedside- what to do if concerned
The importance of the team approach

58. M.A
Hx:
Pt saw me at age 3 for lateral “lisp.” Excellent language. Missing depressor angularis muscle on R side. Only noticeable when smiling. R sided fluid and inconsistently failed hearing screens on R side.
Therapy for ~3-6 months, then d/c.
Returned 3 years later with complaints that speech problems returned.

59. M.A. cont’d- perceptual eval
Evaluation revealed mild lateral production of affricates and nasal air emissions inconsistently throughout speech most noticeable with affricates.
What changed?- pt surgery

60. Case Study- M.A Results:
Oral + /a/ syllables  Norms  S.D.  Score (mean)  Standard Deviation from Mean 
pa, pa, pa…  6  3  57  46-66 
ta, ta, ta…   7  4  49  42-57 
ka, ka, ka…  7  4  49  40-55 
sa, sa, sa…  7  5  40  33-49 
sha, sha, sha…  7  4  47  44-54 

61. Case Study M.A
Oral + /i/ syllables  Norms  S.D.  Score (mean)  Standard Deviation from Mean 
pi, pi, pi…  17  7  85  79-88 
ti, ti, ti…  17  7  82  73-88 
ki, ki, ki…  18  8  84  80-91 
si, si, si…  17  8  80  72-84 
shi, shi, shi…  16  8  79  73-85 

62. Case Study M.A
Nasal + /a/ syllables  Norms  S.D.  Score (mean)  Standard Deviation from Mean 
ma, ma, ma…  53  13  71  50-97 
na, na, na…  53  11  73  51-98    
Nasal + /i/ syllables  Norms  S.D.  Score (mean)  Standard Deviation from Mean 
mi, mi, mi…  72  13  89  80-98 
ni, ni, ni…  74  11  87  77-98 

63. Cast Study- M.A
Prolonged Sounds  Norms  S.D.  Score (mean)  Standard Deviation from Mean 
Prolonged /a/  6  3  47  43-52 
Prolonged /i/  19  9  77  73-81 
Prolonged /s/  0  0  84  74-89 
Prolonged /m/  93  3  97  87-97 

64. Case Study M.A
Oral Passages  Norms  S.D.  Score (mean)  Standard Deviation from Mean 
Bilabial Plosives  11  5  62  27-97 
Lingual-Alveolar Plosives  11  5  62  31-97 
Velar Plosives  13  6  59  31-96 
Sibilant Fricatives  12  5  72  38-85    
Nasal Passage  Norm  S.D.  Score (mean)  Standard Deviation from Mean 
Nasals  54  9  76  48-98 

65. Case Study- M.A

66. Case Study- M.A

67. M.A Cont’d: Recs
Speech therapy to correct articulation and to see if she was teachable
Return to VPI clinic in 9 mos
Follow up: Family came back ~3 years later, same results. Parents opted out of surgery.

68. Case Study- C.T
Cleft lip and palate, repaired at Nationwide Children's in Ohio. Lip repair at 7 mos. Palate repaired around 14 months. Born term.  Unspecified heart problem per mom report. He has seen genetics, however, a diagnosis was not specified. He has sleep apnea, does not wear a mask. Mom wants to get rechecked. Mom states that he has "extra space in his brain", but could not name a specific cranial/neuro deficit. No nasal regurgitation when eating

69. Case Study- C.T

70. Case Study-C.T

71. Case Study- C.T

72. Case Study- T.C
Perceptual
What did we find?

73. Standard Deviation from Mean
Case Study T.C
Oral + /a/ syllables 
Norms 
S.D. 
Score (mean) 
Standard Deviation from Mean 
pa, pa, pa…  6  3  8
1-23
ta, ta, ta…   7  4  13
6-39
ka, ka, ka… 
6-10
sa, sa, sa…  5  18
6-31
sha, sha, sha…  15
5-32

74. Standard Deviation from Mean
Case Study- T.C
Oral + /i/ syllables 
Norms 
S.D. 
Score (mean) 
Standard Deviation from Mean 
pi, pi, pi… 
17  7  20
3-54
ti, ti, ti… 
2-39
ki, ki, ki… 
18  8  22
12-88
si, si, si…  45
16-74
shi, shi, shi… 
16  33
21-66

75. Standard Deviation from Mean Standard Deviation from Mean
Case Study- C.T
Nasal + /a/ syllables 
Norms 
S.D. 
Score (mean) 
Standard Deviation from Mean 
ma, ma, ma… 
53 
13  77
44-95
na, na, na… 
11  49
29-92   
Nasal + /i/ syllables 
Norms 
S.D. 
Score (mean) 
Standard Deviation from Mean 
mi, mi, mi… 
72 
13  73
61-92
ni, ni, ni… 
74 
11  76
51-93

76. Standard Deviation from Mean
Case Study- C.T
Prolonged Sounds 
Norms 
S.D. 
Score (mean) 
Standard Deviation from Mean 
Prolonged /a/  6  3  15
7-24
Prolonged /i/ 
19  9  77
47-98
Prolonged /s/  0 
100-0
Prolonged /m/ 
93  92
90-95

77. Case Study-T.C 16 4-65 31 8-92 18 7-67 37 11-74 55 21-94 Oral Passages
Norms 
S.D. 
Score (mean) 
Standard Deviation from Mean 
Bilabial Plosives 
11  5  16
4-65
Lingual-Alveolar Plosives  31
8-92
Velar Plosives 
13  6  18
7-67
Sibilant Fricatives 
12  37
11-74   
Nasal Passage 
Norm 
S.D. 
Score (mean) 
Standard Deviation from Mean 
Nasals 
54  9  55
21-94

78. Case Study-C.T. Intraoral, then “puppy”

79. Case Study C.T. “ta” and “cookie”

80. Case Study- C.T What did we recommend? Why? Trial of S.T
Return in 6 months
Differential: Why? Numbers, perceptual

81. Case Study- A.M
She has a hearing loss (severe on LEFT side and RIGHT side is moderate. Hearing loss is progressive.  Diagnosed around age 2. Normal pregnancy and birth. She has sleep apnea and had her adenoids removed 1.5 years ago. Mom states hypernasality became worse after this.

82. Case Study- A.M

83. Case Study- A.M

84. Case Study- A.M
-Perceptual- What did we find?

85. Case Study- A.M
Oral + /a/ syllables   Norms   S.D.   Score (mean)   Standard Deviation from Mean  
pa, pa, pa…   6   3   39  3-91 
ta, ta, ta…    7   4   32  3-94 
ka, ka, ka…   7   4   35  4-90 
sa, sa, sa…   7   5   42  7-93 
sha, sha, sha…   7   4   33  5-89 

86. Case Study- A.M.
Oral + /i/ syllables   Norms   S.D.   Score (mean)   Standard Deviation from Mean  
pi, pi, pi…   17   7   67  49-96 
ti, ti, ti…   17   7   61  59-95 
ki, ki, ki…   18   8   77  63-95 
si, si, si…   17   8   56  31-89 
shi, shi, shi…   16   8   54  39-78    

87. Case Study- A.M
Nasal + /a/ syllables   Norms   S.D.   Score (mean)   Standard Deviation from Mean  
ma, ma, ma…   53   13   52  30-96 
na, na, na…   53   11   47  22-96    
Nasal + /i/ syllables   Norms   S.D.   Score (mean)   Standard Deviation from Mean  
mi, mi, mi…   72   13   67  42-96 
ni, ni, ni…   74   11   78  67-97 

88. Case Study- A.M
Nasal + /a/ syllables   Norms   S.D.   Score (mean)   Standard Deviation from Mean  
ma, ma, ma…   53   13   52  30-96 
na, na, na…   53   11   47  22-96 
Nasal + /i/ syllables   Norms   S.D.   Score (mean)   Standard Deviation from Mean  
mi, mi, mi…   72   13   67  42-96 
ni, ni, ni…   74   11   78  67-97 

89. Case Study –A.M
Prolonged Sounds   Norms   S.D.   Score (mean)   Standard Deviation from Mean  
Prolonged /a/   6   3   27  22-32 
Prolonged /i/   19   9   64  58-72 
Prolonged /s/   0   0   0  100-0 
Prolonged /m/   93   3   94  89-95    

90. Case Study –A.M
Oral Passages   Norms   S.D.   Score (mean)   Standard Deviation from Mean  
Bilabial Plosives   11   5   57  23-96 
Lingual-Alveolar Plosives  11   5   56  14-96 
Velar Plosives   13   6   57  32-95 
Sibilant Fricatives   12   5   56  17-94 
 Nasal Passage   Norm   S.D.   Score (mean)   Standard Deviation from Mean  
Nasals   54   9   76  40-98 

91. Case Study- A.M (prolonged /sh/)

92. Case Study- A.M. (soupy, teddy)

93. References
Kummer, A.W. (2001). Cleft palate and craniofacial anomalies: the effects on speech and resonance. San Dieago, CA: Singular. *
Peterson-Falzone, S.J., Harding-Jones, M.A, & Karnell, M.P. (2001). Cleft palate speech. St. Louis, MO: Mosby.
Biavati, M.J., Sie, K., Wiet, G.J., & Rocha-Worley, G. (2009, July 06). Velopharyngeal insufficiency. Retrieved from
The impact of adenoid size on rate of revision sphincter pharyngoplasty. O'Connell BP1, Dobbie AM, Oyer SL, Montiel M, Hufnagle K, Patel KG, Discolo CM, Nguyen SA, White DR.

94. Melissa Montiel, MS, CCC-SLP