Velo-pharyngeal insufficiency (VPI) is the inability to close the gap behind the nose or palate region to achieve certain sounds. VPI causes a speech impediment with words such as sixty, hamper and others. In order to diagnose this condition, a nasal endoscopy is needed in which a small spaghetti-like scope is passed to the back of the nose. While in position the child is asked to repeat various sounds while we directly visualize this area. We perform the study with a pediatric speech therapist as well. The results allow us to plan for treatment. Treatment usually begins with speech therapy. If no improvement is noted in 6 –12 months, then surgical correction is considered. Surgery consists of various types of flaps of tissue moved around in the back of the throat in attempt to close the gap that is present.