Preoperative Evaluation for Velopharyngeal Insufficiency Before Adenoidectomy
All patients should undergo a thorough palatal examination by a cleft/craniofacial specialist or experienced otolaryngologist before adenoidectomy to identify anatomical risk factors for velopharyngeal insufficiency (VPI). 1
Clinical History Assessment
Obtain specific history focusing on VPI risk factors:
- Low birth weight 2
- Family history of hypernasality or speech problems 2
- Current speech problems or nasal regurgitation 2
- History of speech delay or articulation disorders 2
Physical Examination
Perform detailed oral and palatal examination looking for:
- Submucous cleft palate (SMCP) - identified in approximately 12% of post-adenoidectomy VPI cases 3
- Occult submucous cleft palate - found in 14% of VPI cases after adenoidectomy 3
- Poor palate mobility or short palate 2
- Deep pharynx - present in 37% of post-adenoidectomy VPI patients 4
- Bifid uvula or zona pellucida (signs of SMCP) 3
- Palpable notch in posterior hard palate 3
Speech and Language Assessment
Baseline speech evaluation by a speech-language pathologist is essential before adenoidectomy in any child with speech concerns or identified anatomical risk factors. 1, 4
Key speech parameters to document:
- Resonance quality (presence or absence of hypernasality) 4
- Nasal air emission during speech 4
- Articulation patterns 4
- Speech intelligibility 4
This baseline assessment allows comparison if VPI develops postoperatively, as 72.5% of post-adenoidectomy VPI cases have an identifiable anatomical cause 4.
High-Risk Populations Requiring Enhanced Screening
Children with 22q11.2 deletion syndrome require mandatory preoperative VPI assessment, as approximately two-thirds have palatal abnormalities and velopharyngeal dysfunction. 1, 5
Additional high-risk groups:
- Children with known cleft palate or repaired cleft - adenoidectomy is contraindicated 1
- Children with existing velopharyngeal dysfunction - adenoidectomy is contraindicated 1
- Children with neurologic conditions affecting palatal function 3, 2
- Children with bleeding disorders (relative contraindication) 1
Instrumental Evaluation (When Indicated)
Velopharyngeal imaging with nasendoscopy or videofluoroscopy should be performed preoperatively in children with suspected VPD or anatomical abnormalities, once adequate speech is present. 1
These studies assess:
- Velopharyngeal closure pattern 4
- Size of velopharyngeal gap 4
- Palatal mobility and excursion 4
- Pharyngeal depth and dimensions 4
Risk Stratification and Decision-Making
Low-risk patients (normal palate, no speech concerns, no risk factors):
- Proceed with standard adenoidectomy 1
Moderate-risk patients (deep pharynx, long palate, mild speech concerns):
- Consider partial/superior adenoidectomy to preserve tissue 2
- Ensure detailed preoperative counseling about VPI risk 4
High-risk patients (SMCP, poor palatal mobility, existing speech problems):
Common Pitfalls to Avoid
- Failing to examine the palate preoperatively - clinical examination prevents some but not all VPI cases 3
- Dismissing parental concerns about speech or nasal regurgitation - these are significant risk factors 2
- Proceeding with adenoidectomy in children with undiagnosed SMCP - accounts for 26% of post-adenoidectomy VPI 3
- Inadequate preoperative counseling - VPI occurs in approximately 1 in 1,200 adenoidectomies but has significant impact on communication and quality of life 3, 4
Documentation Requirements
Document in the medical record:
- Results of palatal examination 1
- Presence or absence of VPI risk factors 2
- Baseline speech characteristics 4
- Discussion of VPI risk with family 4
The incidence of persistent post-adenoidectomy VPI is rare (1 in 1,200 procedures), but when it occurs, it requires intensive multidisciplinary treatment with an average of 4.9 clinic visits over 38 months, and 86.9% of patients require either prolonged speech therapy or surgical intervention. 3, 4