The main objective of primary palatoplasty is to achieve adequate velopharyngeal (VP) function and normal oral-nasal resonance. Many children, however, who undergo cleft palate repair fail to develop normal VP function. Symptoms of velopharyngeal insufficiency (VPI), such as hypernasality and audible nasal air emission, may have a variety of causes, which underscores the need for comprehensive evaluation. This article focuses on the problem of VPI and emphasizes the need for differential diagnosis at the most critical step in management planning. The challenge of the future is to implement the team approach, integrating the expertise of speech scientists and plastic surgeons, so that differential diagnosis can and will lead to differential management.