Management of velopharyngeal insufficiency: development of a protocol and modifications of sphincter pharyngoplasty

Velopharyngeal closure is required for normal speech production. Incomplete velopharyngeal closure manifests as resonance disorders and nasal air escape. Management of velopharyngeal insufficiency requires a general knowledge of speech production as well as a more detailed understanding of the velopharyngeal mechanism. Comprehensive evaluation by a velopharyngeal insufficiency team includes medical assessment focusing on airway obstructive symptoms, perceptual speech analysis, and instrumental assessment, which is utilized to characterize the velopharyngeal gap. Options for intervention include speech therapy, intraoral prosthetic devices, and surgery. Surgical interventions can be categorized as palatal, palatopharyngeal, or pharyngeal procedures. The therapeutic challenge lies in achieving velopharyngeal closure during speech production while maintaining patency of the upper airway. We present our protocol for evaluation of velopharyngeal function with a focus on indications for palatoplasty and pharyngoplasty. We also discuss surgical modifications of sphincter pharyngoplasty.