Marsh Jeffrey L
Kids Plastic Surgery, St. Louis, MO 63110, USA.
J Craniofac Surg. 2003 Sep;14(5):621-8; discussion 629. doi: 10.1097/00001665-200309000-00004.
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.
本文回顾了一位外科医生在一个腭裂治疗中心20年的经验，内容涉及对腭咽功能障碍（VPD）进行鉴别诊断以实施差异化管理。根据每个患者的具体诊断和功能状态来选择VPD的治疗方法。腭咽功能的诊断评估分为两种类型，即直观评估和仪器评估，通过这两种评估来做出治疗决策。VPD主要有四大病因类别：解剖结构缺陷、肌神经缺陷、解剖结构与肌神经均有缺陷、解剖结构与肌神经均无缺陷。针对每种病因类别的VPD，其治疗方式各有不同。治疗方案包括使用修复器械（提升器、阻塞器、“提升阻塞器”）和手术（咽内腭成形术、腭部Z成形术、咽瓣手术、括约肌咽成形术、咽后壁增高术）。基于鉴别诊断进行差异化管理的目的是，在尽量减少对上呼吸道干预所带来的并发症的同时，优化腭咽功能以完成言语任务。在过去20年里，在跨学科腭裂治疗团队的背景下，个人的这种经验验证了基于鉴别诊断对VPD进行差异化管理能够实现这一目标的假设。
