In a small percentage of cases, some children, in spite of cleft palate repair, will continue to exhibit hyper-nasal speech. This defect can be diagnosed by physical examination, speech pathologist evaluation, cine-fluoroscopy and nasal endoscopy. This condition, known as velopharyngeal insufficiency (VPI) or velopharyngeal dysfunction (VPD), may occur after the patient has undergone cleft palate surgery or after adenoidal tissue develops as the child grows. In some patients who have undergone palate repair, short sentences may sound relatively normal. Long, sustained speech, however, may deteriorate, resulting in increasing hyper-nasality as the palate tires.
Surgical procedures for correction of VPI include the creation of pharyngeal flaps. Surgeons elevate the posterior pharyngeal wall and suture it to the soft palate, reducing the gap between the short or poorly functioning soft palate. Other surgical approaches involve some alteration of the anatomy surrounding the soft palate and posterior pharyngeal wall (described as a "pharyngoplasty").
Patients undergo this surgery at a variety of ages, from pre-school into the teens. Good speech therapy early in life can help the patient maximize use of the soft palate and delay surgery. Surgical repair of the soft palate is considered when speech therapy no longer can help the patient correct speech patterns and sounds.