Management of velopharyngeal dysfunction: differential diagnosis for differential management.

A single surgeon's 20 year experience in one cleft center with differential diagnosis for differential management of velopharyngeal dysfunction (VPD) is reviewed. The specific diagnostic and functional status of each affected individual is determined to select the method of VPD management. Two types of diagnostic evaluation of velopharyngeal function, perceptual and instrumental, are used to make that determination. There are four broad etiologic categories of VPD: anatomic deficiency, myoneural deficiency, anatomic and myoneural deficiency, and neither anatomical nor myoneural deficiency. The type of VPD management is specific for each etiologic category. The management options are between prosthetic appliances (lift, obturator, "liftorator") and operations (intravelar veloplasty, velar Z-plasty, pharyngeal flap, sphincter pharyngoplasty, posterior pharyngeal wall augmentation). The objective of differential management based on differential diagnosis is to optimize the function of the velopharynx for speech tasks while minimizing the morbidity of the intervention on the upper airway. A personal experience, in the context of an interdisciplinary cleft team, with such an approach over the past 20 years validates the assumption that differential management of VPD based on differential diagnosis can achieve this goal.