Dominic Stone
Velopharyngeal closure (VPC) is an important part of speech and swallowing, requiring the coordination of a diverse group of muscles along the upper aerodigestive tract. The velopharyngeal mechanism is a muscular valve that extends from the posterior surface of the hard palate (roof of the mouth) to the posterior pharyngeal wall. It comprises the velum (soft palate), lateral pharyngeal walls, and the posterior pharyngeal wall. The function of the velopharyngeal mechanism is to create a tight seal between the oral and nasal cavities, preventing air from escaping through the nose during consonant production. Inadequate velopharyngeal closure can lead to hypernasal speech and articulation difficulties. Structural defects, such as cleft palate, and neuromuscular problems can contribute to velopharyngeal insufficiency. Treatments include speech therapy, surgery, and continuous positive airway pressure (CPAP) therapy to strengthen the palate and improve velopharyngeal function.
| Characteristics | Values |
|---|---|
| Velopharyngeal closure | A seal between the nasal and oral cavities |
| A voluntary action controlled by the motor cortex | |
| The soft palate is the dominant mobile element in VP closure | |
| Coronal closure is the most common type of VP closure | |
| Velar component movement is created primarily by the action of the levator veli palatini muscle | |
| Palatoglossus and palatopharyngeus muscles control the fine-tuning of velar position | |
| Musculus uvulae help in velar stretch and in filling the gap between the velum and PPW | |
| Velopharyngeal incompetence may occur as a result of neurogenic causes, such as a functional problem with the oral motor mechanism | |
| Velopharyngeal incompetence may result from skull base surgery, tumors involving the jugular foramen, or central nervous system impairment from brainstem stroke | |
| Velopharyngeal dysfunction (VPD) may be caused by tonsil hypertrophy that prevents the palate from moving superiorly during attempted velopharyngeal closure | |
| VPD may be caused by other neurologic diseases, such as muscular dystrophy, multiple sclerosis, amyotrophic lateral sclerosis (ALS), or Parkinson's disease | |
| Continuous positive airway pressure (CPAP) therapy may be beneficial for patients with VPD related to oral motor issues or velar weakness |
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What You'll Learn
The levator veli palatini muscle
The superior part originates from the inferior surface of the petrous part of the temporal bone, anteriorly to the inferior opening of the carotid canal, and posteriorly to the origin of the tensor tympani muscle. The inferior part of the muscle originates from the inferior part of the medial lamina of the cartilage of the auditory (Eustachian) tube and from the vaginal process of the sphenoid bone. From these origin sites, the muscle fibres course inferomedially towards the soft palate. After passing through a narrow space between the two layers of the palatopharyngeus muscle, the levator veli palatini muscle inserts onto the superior aspect of the palatine aponeurosis, where it interlaces with the fibres of its contralateral counterpart.
The primary action of the levator veli palatini muscle is to elevate and draw posteriorly the nearly vertical posterior portion of the soft palate, bringing the soft palate into contact with the posterior wall of the pharynx. This action creates a barrier between the nasopharynx and oropharynx, facilitating the act of swallowing and preventing food from passing into the nasopharynx. The levator veli palatini muscle is considered the primary muscle responsible for velar elevation, and it functions to elevate the velum to create closure between the oral and nasal cavities.
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Muscles involved: musculus uvulae, superior pharyngeal constrictor, palatopharyngeus, palatoglossus, and salpingopharyngeus
Velopharyngeal closure is an important part of speech and the process of swallowing. The muscles involved in supporting velopharyngeal closure include the musculus uvulae, superior pharyngeal constrictor, palatopharyngeus, palatoglossus, and salpingopharyngeus.
The musculus uvulae is a muscle that, when contracted bilaterally, shortens and elevates the uvula. This muscle assists the levator veli palatini in separating the oral cavity and the oropharynx.
The superior pharyngeal constrictor is one of three pharyngeal constrictor muscles that facilitate the process of deglutition (swallowing). This muscle has a complex structure, consisting of four parts: the pterygopharyngeal, buccopharyngeal, mylopharyngeal, and glossopharyngeal. It is located anterior to the prevertebral muscles and bounds important features of the neck compartment, such as the peritonsillar and parapharyngeal spaces.
The palatopharyngeus is a small, long muscle in the roof of the mouth. It arises from the soft palate and, by contracting, pulls the pharynx upward, preventing food from passing into the nasopharynx.
The palatoglossus elevates the root of the tongue and separates the oral cavity and the oropharynx. It is the only muscle of the tongue not innervated by the hypoglossal nerve.
The salpingopharyngeus is involved in raising the pharynx and larynx during swallowing. It opens the pharyngeal orifice of the Eustachian tube, allowing for pressure equalization. It is absent in about 40% of individuals.
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Velopharyngeal incompetence
The velopharyngeal sphincter is a ring of muscle that separates the nasal and oral cavities during certain activities such as speech, swallowing, vomiting, blowing, and sucking. During speech, the velopharyngeal sphincter must close to prevent air from escaping through the nose, ensuring the production of clear and intelligible speech.
When velopharyngeal incompetence occurs, the soft palate and pharyngeal walls cannot form an effective seal. This results in an abnormal connection between the nasal and oral cavities, causing a range of symptoms, including hypernasal speech, increased nasal resonance, regurgitation, nasal emission, and decreased intraoral pressure during speech. These symptoms can lead to reduced speech intelligibility and significant functional and social impairment.
The treatment for velopharyngeal incompetence typically involves a multidisciplinary approach, including speech-language pathology, otolaryngology, and plastic surgery. Speech therapy can help individuals adjust their speech to reduce the sounds associated with velopharyngeal incompetence. Surgery may also be required to create a better seal between the nasal and oral cavities without blocking the airway. Surgical approaches vary depending on the specific structural problems involved.
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Velopharyngeal insufficiency
The soft palate muscle in the mouth moves up and down and touches the back of the throat during normal speech. To produce oral consonants (letters such as p, w, and x), the soft palate closes against the back of the throat. When the muscle does not close tightly, air comes out of the nose (characterized by hypernasality and/or nasal air emission) during speech. This can cause speech that is difficult to understand.
The most common cause of VPI is a cleft palate or a submucous cleft palate. About 20% of children who have a repaired cleft palate will have persistent VPI. Adenoidectomies (removal of adenoids – lymphoid tissue in the back of the nose) can occasionally result in VPI by creating more space between the soft palate and the back of the throat. Children with velocardiofacial syndrome (DiGeorge syndrome) can have VPI even without an obvious cleft palate. Traumatic brain injuries or neurological disorders can also result in velopharyngeal incompetence due to muscle weakness or difficulty with muscle coordination of the palate. In some cases, VPI results from an unknown cause.
VPI is diagnosed using a nasoendoscopy, which involves inserting a small flexible fiberoptic scope into the child’s nose to observe how the palate moves during speech. Treatment usually involves speech therapy and surgery. Speech therapy can help a child adjust the way they speak to reduce the sounds of VPI. Surgery aims to create a better seal between the nasal and oral cavities without blocking the airway. The type of surgery depends on the structural problems involved.
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Velopharyngeal dysfunction treatment
Velopharyngeal dysfunction (VPD) is the inadequate separation of the oral and nasal cavities during speech and/or swallowing. It is caused by structural and/or functional abnormalities of the soft palate and pharyngeal muscles. The condition can cause hypernasal speech, abnormal articulation, decreased intelligibility, and even regurgitation of food and liquid through the nose.
If VPD is suspected, a child will typically undergo a speech evaluation and meet with a team of specialists, including a speech-language pathologist and a surgeon, to determine the best course of treatment. This team may include otolaryngologists (ear, nose, and throat doctors), plastic surgeons, and nurses. The specialists will evaluate the child's medical history, perform a physical examination of the mouth, and may recommend imaging procedures such as nasopharyngoscopy, videofluoroscopy, MRI, or genetic testing to confirm the diagnosis.
Treatment options for VPD may include speech therapy, surgery, or both. Speech therapy can help individuals adjust their speech to reduce the sounds of VPD and improve articulation. Surgery is typically the first-line treatment and aims to improve speech by creating a better seal between the nasal and oral cavities. Surgical approaches vary depending on the specific structural problems but may include changing the shape of the soft palate, expanding the pharyngeal wall, lengthening or readjusting the palate muscles, or using fat injections to help close the palate. In some cases, a speech prosthesis may be recommended.
It is important to seek early treatment for VPD to prevent the development of long-term habits that can be harder to break. With proper evaluation and treatment, individuals with VPD can improve their speech and overall quality of life.
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Frequently asked questions
The velopharyngeal mechanism creates a tight seal between the velum and pharyngeal walls to separate the oral and nasal cavities for various purposes, including speech.
The muscles that support velopharyngeal closure include the levator veli palatini, musculus uvulae, superior pharyngeal constrictor, palatopharyngeus, palatoglossus, and salpingopharyngeus.
The levator veli palatini muscle is primarily responsible for creating velar component movement, which is essential for achieving velopharyngeal closure during speech.
