Velopharyngeal insufficiency is the inability to separate the oropharyngeal and nasopharyngeal compartments due to inadequate length or poor elevation of the velum (soft palate), poor contraction of the lateral and posterior pharyngeal musculature, or other neurogenic or structural abnormalities (i.e., oronasal fistula). Often encountered in patients with unrepaired or repaired cleft palates, VPI presents with nasal air emissions, nasal regurgitation, hypernasality, and speech misarticulations. Diagnosis can be made via speech evaluation or other diagnostic methods such as nasoendoscopy. Management includes speech therapy in addition to various surgical techniques depending on the cause of VPI. Inadequate palatal length or posterior excursion can be treated with palatal lengthening or posterior pharyngeal flap, while VPI secondary to inadequate lateral pharyngeal wall motion can be addressed with sphincter pharyngoplasty.