Velopharyngeal insufficiency (VPI) is a relatively uncommon diagnosis and requires an understanding not only by the otolaryngologist but also by primary care physicians who are often the first to recognize its presence. An appreciation of the speech pathology that occurs in VPI assists in the often challenging diagnosis. Although VPI is more commonly seen in the pediatric population, there are multiple causes for its presence in adults and children. We review the anatomy of the velopharynx and the etiology of VPI, as well as the evaluation and the management of these patients.