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Video Nasal Endoscopy for Velopharyngeal Insufficiency

by , last modified on 1/5/19.


Patients are often referred from the INOVA Fairfax Craniofacial Clinic as well as other regional craniofacial clinics to our office in order to obtain video nasal endoscopy. We are the only clinic in the DC/VA region to perform this type of specialized exam where video AND audio is both obtained during the examination.

This webpage is to make sure you and your child understands what is going to happen and what we are looking for during this exam. The exam provides important information helpful to the Craniofacial Team especially when deciding on surgery.

The examination itself is performed using a special fiberoptic scope hooked to a video camera to record the entire exam. It is most important to obtain both video AND audio recordings so one can correlate what one sees with what one hears. Here is a YouTube video of a 6 year old child undergoing this exam in our clinic. If you feel helpful, watch this video with your child. Click here to get a larger screen view within YouTube.

The key questions that are being answered are:

Real-time MRI scan can also be used to assess veloopharyngeal function. More info here.

Obviously, the plastic surgeon will find this info quite useful in planning what type of surgery as well as how large a flap to create. If too big a flap is created, nasal obstruction with hypo-nasal speech will result. If the flap is too small, hypernasal speech will persist. The perfect outcome is the perfectly sized flap placed exactly where the hole is allowing for proper speech and adequate nasal breathing.

Watch Video on 4 Ways to Surgically Treat VPI

For more information regarding nasal speech in general, click here.

Normal Example

Once the fiberoptic scope is placed in the back of the nose called the nastopharynx, recording begins and the patient is requested to state specific words. A NORMAL examination is shown here. Note that the palate (which is moving up and down with talking) makes a tight closure with the back wall preventing any air escape.


Example 1: Uncoordinated Velopharyngeal Closure

Note the nasal sounding speech. On exam, the palate does not move in coordination with speech. However, at other times, it does move properly. With good speech therapy, this should improve over time. Of note, the lumpy mass coming down from the ceiling is the adenoids.


Example 2: After Cleft Palate Repair with Small Central Velopharyngeal Insufficiency

Note the nasal sounding speech (hypernasal), especially with plosives /p/, /b/ (pah, bah) and the sibilant 'sh'. Note the air escape demonstrated by bubbles. Also, the palate never really makes a tight seal with the back wall centrally known as velopharyngeal insufficiency. However, there is a lateral squeeze present. Surgical procedures to correct this velopharyngeal insufficiency focus on closing this central gap without affecting the lateral aspects. Such procedures include posterior pharyngeal flap (see example 6 below) or posterior pharyngoplasty (injection or graft). In this child, the tonsils and adenoids aid in speech and removal may result in worsening of speech quality. This small opening can be easily resolved by injection nasopharyngoplasty.


Example 3: After Cleft Palate Repair with Large Central Velopharyngeal Insufficiency

Compared to the prior example, this child who is also after cleft palate repair has nasal speech due to a very large central velopharyngeal insufficiency. There is some degree of palate elevation as well as lateral squeeze, but not enough to provide complete closure which is always present. In the distance, you can see the child's epiglottis.



Example 4: Right Lateral Velopharyngeal Insufficiency

The prior examples were all due to central velopharyngeal insufficiency. However, lateral velopharyngeal insufficiency also exists, but is more rare. This example shows a child without any history of cleft palate who has a small insufficiency on the right side. Note the bubbles that emanate from this small opening. There is a nice tight closure elsewhere.

It seemed that the child had a temporary mild right soft palate paralysis that resolved spontaneously along with resolution of the velopharyngeal insufficiency after about 1 month.



Example 5: Resolved Central Velopharyngeal Insufficiency After Pharyngeal Flap Surgery

This adult patient underwent pharyngeal flap surgery to correct a central velopharyngeal insufficiency after cleft palate repair as a child. Note the bridge of mucosa from the soft palate to the posterior wall which is the flap. When relaxed, there is an opening on either side of the flap (called "lateral ports") to allow for nasal breathing. When talking, the lateral ports close to prevent air escape.

The risks with the procedure include creating too small a flap which would result in persistent hyper-nasal speech (see next example) or too large a flap which would result in nasal obstruction and a hypo-nasal speech. A skilled plastic surgeon is able to create the perfect sized flap that's not too large or too small as in this case.



Example 6: Failed Pharyngeal Flap Surgery With Persistent Left VPI

This patient underwent pharyngeal flap surgery to correct a velopharyngeal insufficiency after cleft palate repair several years prior. However, unlike the prior example which was a perfect outcome, there is a persistent large opening on the left side resulting in a large left velopharyngeal insufficiency causing hypernasal speech. Also, the pharyngeal flap is shifted right of midline instead of being perfectly in the middle.

This patient's pharyngeal flap failed in 2 aspects resuling in VPI. First, the flap was created right of midline resulting in no lateral port on the right and a very large left lateral port. Second, the flap was made too small so even if the flap was perfectly in the midline, most likely VPI would still have occurred.


failed flap

Example 7: UN-Resolved Velopharyngeal Insufficiency After Pharyngeal Flap Surgery and Obturator Use

This adult patient underwent pharyngeal flap surgery to correct a central velopharyngeal insufficiency after cleft palate repair. Unlike the prior example where there was complete closure of the lateral ports with phonation, this unfortunate patient has a small VPI on both sides (note the bubbles).

In order to resolve this VPI, the patient used an obturator in order to completely close the lateral ports thereby eliminating his hypernasal speech. However, use of an obturator resulted in near-complete nasal obstruction.

Watch the video which shows a small VPI without the obturator as well as VPI resolution with obturator (along with nasal obstruction).


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