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Pharyngoplasty in speech
PHARYNGOPLASTY
By J. P.
REIDY,
IN
SPEECH 1
F.R.C.S.
London
THE operation of pharyngoplasty in speech production has for its primary object the narrowing of the nasopharynx. The end result which is sought (in those cases where it is employed) is that the palate will thus be at a better mechanical advantage to enable the patient to close the nose from the mouth. T y p e of Pharyngoplasty.--(I) Passavant in I869 was the first to comment on the poor speech results following repair of the cleft palate by the methods then in use. These methods involved single layer closure with some shortening of the soft palate, and therefore there was nasopharyngeal incompetence. Passavant sutured the posterior edge of the palate to the posterior pharyngeal wall (Fig. I). (2) Rosenthal in I924 advocated Sch6nborn's rectangular flap, which was turned from the posterior pharyngeal wall and sutured to the soft palate. It reduces the nasopharyngeal opening into two smaller passages, and when such a flap is based upwards it is useful in holding up an immobile or paralysed soft palate, thus placing the palate in a better mechanical advantage. Webster and others have proposed a system of classification for the posterior pharyngeal flap (Fig. 2). (3) In I928 Wardill discussed the repair of cleft palates, and stated that there is an increase in the diameter of the nasopharynx, and thus a need to bring the posterior pharyngeal wall forwards. He described his new operation" The Wardill Pharyngoplasty," which could be performed one week prior to the Langenbeck palate repair, or the Gillies-Fry procedure. He said this operation ofpharyngoplasty could be applied to infants, as well as to adults with a palate already scarred (Fig. 3). Wardill's pharyngoplasty consisted of a transverse incision on the posterior pharyngeal wall at the level of the arch of the arias, and this was sutured vertically (like a reverse pyloroplasty) to give a narrowing of the nasopharyngeal opening. This operation was frequently performed, as I have said, by my senior colleagues at the time of primary palate repair, which was done at one year. Eventually the effectiveness of Veau's V-Y retroposition with two layer closure led Professor Kilner to abandon the pharyngoplasty at the time of the primary palate repair. (4) Hynes in I95O published a description of his pharyngoplasty by using muscle transplants from the lateral sides of the pharynx to a transverse position on the posterior pharyngeal wall. The effect of this procedure is to narrow the diameter of the pharynx and at the same time to produce a transverse ridge on the posterior pharyngeal wall, which at times shows muscular movement. Another effect of this pharyngoplasty is to raise the pitch of the voice by several notes. This is an interesting finding when considered with Negus's description of nasopharyngeal development (Fig. 4)Hynes (personal communication, I963) stresses that " whole thickness of the lateral pharyngeal muscles must be used in the lateral pharyngeal flaps down to the pharyngeal aponeurosis." 1 Presented in the Cleft Lip and Palate Panel at the International Meeting, Washington D.C., I963. 389
BRITISH
390
JOURNAL
OF
PLASTIC
SURGERY
\
,
! FIG. I
FIG. 2
\/ Fig. I.--Posterior pharyngeal wall flap of Passavant (i863). ~
j
Fig. 2.--Posterior pharyngeal wall flap of Rosenthal. Fig. 3.--Pharyngoplasty Wardill.
Fro. 3
r
J
@
Outline of Hjnes P~ar~,~goni~tJ. C[ap3now horlzonta/. l~/I.~ ~'~
T
'I" FIG. 4 Pharyngoplasty of Hynes.
~l ~]
~'~,.~\,
I:%,
of
PHARYNGOPLASTY
IN SPEECH
39 I
Of all these pharyngoplasties I give preference to that of Hynes, in that it is more physiological and in practice it gives greater efficiency than any other procedure. General P r o c e d u r e in Palate R e p a i r . - - I f as a general rule primary repair of the cleft palate takes place on or about the first birthday, and if this repair is on the lines of Veau's V-Y retroposition, then in my experience there is now no place for a pharyngoplasty as a primary operation in infants, either alone or accompanied by the V-Y operation on the palate. Hynes does not agree with this and his viewpoint will be discussed later (Fig. 5).
i \
~"// /'
FIG. 5 Retroposition of palate by V-Y operation in contrast to the Langenbeck closure (above).
As a result of the straightforward V-Y retroposition of the palate, the speech results show a high percentage of normal speakers. Pharyngoplasty has not been regularly employed (Table In). However, about 2o per cent. of the remainder of these primary cases fail to satisfy the speech requirements, and need further investigation, and indeed treatment. In addition, there are certain cases operated upon elsewhere, in addition to some of my own, which show nasopharyngeal incompetence. This group of 20 per cent. has been investigated and reported elsewhere, and shows defects of speech due to mental retardation and to physical defects of the palate. Of these cases which came to review some responded to speech therapy and some required Hynes pharyngoplasty. As a result the overall speech results of this series showed an improvement (Table IB).
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TABLE IA Palate Repair : Speech Results--Comparisons B.
A.
T y p e of Operation 1927. G r e y T u r n e r I927. N i t c h . I927 . V e a u Veau 1933. V e a n 1933. Wardill[
Ritchie. Vaughan Bentley and Watkins I95I. H o l d s w o r t h . I949. Oldfield 1957. R e i d y
.
Total
Langenbeck Langenbcck Langenbeck Veau Technique Veau V-Y Langenbeck Gillies F r y Veau V-Y + pharyngoplasty
V-Y V-Y V-Y V-Y
'
D,
Bad/Unintelligible
Normal
Fair
Poor
P e r cent.
Per cent. 38.8
P e r cent. 27 "7 48 .6 15 .o 60 .o
P e r cent. 18.8 I4"3 6o-o
23 '0
15 "o 16.o
9°
II'O
35 4~
37"I
IOO
40 .o
IOO
62 .o 84 .o
25 .o
38
V-Y primary secondary primary secondary
C.
85 113 7o I93 51
4 2 "0
43 -o
43 .o 51 .o
26-0
47 .o
43 "o 32 "8 6O '0
27 "0
61 '0 25 "7
20 '2
77"2 39"2
58 .8
"6-2 14.8 2"0
0'5 I' 9
T A B L E IB
Revised Speech Results : Groups n and In, Primary Number [ 1957 P r i m a r y , ] G r o u p s II a n d I I I
Grade Result
A B
I49 39 (1) (4)
C D C o r r e c t e d total
.
Percentage
I96O
] A f t e r investiga- ( tion a n d / o r 41 j treatment ([ 3 Less mentally f defective
I49 + I4 25
I88
I88
86 "7 13 "3
I63 25
IO0"O
Revised Speech Results : Groups II and III, Secondary Grade Result
i957 Secondary, G r o u p s II a n d I I I
A
2O
B
3o i m e n t a l l y backward
C
I96O
j
After investiga-( tion a n d / o r j treatment (
Percentage
20 + 5 23
5°
50
D C o r r e c t e d total
50
50
IO0
PHARYNGOPLASTY IN SPEECH
393
TABLE I I
Speech (Post-op.) Group A - - N o r m a l Speech No faults Minor faults of'articulation (Lateral S. substitution and incorrect tongue position) Major faults and dyslalias .
I 2 3
Group B--Articulation correct but Nasal Escape of Air Minimal nasal escape (normal or excellent speech) Medium nasal escape Gross nasal escape
4 5 6
Group C--Articulation incorrect and Nasal Escape of Air Minor faults of articulation Major faults of articulation
7 8
Group D - - U n f o r m e d or Unintelligible Speech Unformed speech of infants . • • Unintelligible speech in conversation £nd reading Unintelligible speech even of words in isolation
9 o x
In passing, it will be noted that in the classification of lip and palate clefts, that of Ritchie and Staige Davis (I922) is used. From the clinical point of view this is straightforward and simple. The physical shortcomings of speech can be investigated by speech checks (Table II) and by lateral X-rays of the palatal movements using barium to outline the palate (Fig. 6).
FIG. 6 Lateral palatal X-rays. Tracing of X-rays.
Those cases that fall short of normal speech reveal an inability on the part of the patient to close the nasopharyngeal aperture on saying " ee" and blowing, and show a definite gap between the posterior edge of the soft palate and the posterior pharyngeal wall. 4E
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The causes of mechanical disadvantage of the palate or of this nasal escape are as follows : I. A palate that is too short absolutely. 2. A capacious nasopharynx. 3- A palate that is immobile and short by reason of scarring from previous treatment. Since the checking of speech is something that is accurate only when the child reaches the age of 4 or 5 years, and only when such a child is co-operative in the matter of X-rays (Fig. 7), it is only then that the need for further treatment to the
FIG. 7 Lateral palatal X-rays. Above, A f t e r V - Y repair, nasal escape on " ee " a n d Below, After H y n e s p h a r y n g o p l a s t y , n a s o p h a r y n g e a l closure. blowing. Note t r a n s v e r s e ridge.
palate or to the pharynx can be estimated. Unless it is possible to improve the palate under cause 3 by further palatal surgery (for example, secondary V-Y repair) all causes (i, 2 and 3) qualify for pharyngoplasty, which in my hands thus becomes a supportive operation to be used only when required. In my opinion, therefore, indications for pharyngoplasty arise from 5 years onwards (Fig. 8). There is, however, a group of patients where pharyngoplasty is indicated as a primary procedure. Where a patient has reached an age in excess of 5 or 6 years onwards, with an untreated cleft of palate, there is usually a capacious nasopharynx. In addition, the palatal tissues are thicker than in infancy, and thus there is a limit to the degree ofretroposition by surgery. In this group a pharyngoplasty is desirable at the time of the palate repair. As already stated, Hynes does not agree with my statement that " there is no
P H A R Y N G O P L A S T Y IN
SPEECH
395
place for a pharyngoplasty as a primary operation in infants either alone or accompanied by repair of the palate." In fact, for several years Hynes has modified his approach to palate repair as follows : - I . He advocates the V-Y repair for patients with a reasonable amount of palatal tissue. 2. He prefers his " t w o - i n - o n e " operation : (a) For the cleft of soft palate only. (b) For the longer and wider cleft of palate with little tissue present to work with, using development of thc uvula as a guide to bulk.
FIG. 8 Lateral palatal X-rays. A, After V-Y repair, incomplete closure. B, Speech therapy, normal closure. C, C. P., 26 years of age, pre-operative. D, After V-Y repair, normal closure. E, C. P., 2o years of age, pre-operative. F, After V-Y repair, capacious pharynx, needs Hynes pharyngoplasty. T h e " t w o - i n - o n e " operation consists of simple paring and suturing of the soft palate edges combined with his pharyngoplasty. Unfortunately there are no foUow-ups recorded to show whether the " t w o - i n - o n e " operation is superior to the ordinary V-Y repair in the production of normal speech. It is true to say that up to about I94 o my teacher, Professor Kilner, frequently performed a pharyngoplasty at the time of palate repair at I year of age. After that
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date the operation of a Wardill pharyngoplasty at the time for primary palate repair largely disappeared. The indications therefore for pharyngoplasty in my view fall under the following headings : m I. For congenital short palate. 2. For congenital absence of part of the palate. 3. For a palate scarred by previous treatment. 4. For an abnormally capacious nasopharynx. 5. Combined with the primary palate repair from say 5 years to adult life. 6. Combined with the secondary repair of the palate. 7. Combined with palate repair in infancy (up to 194o). 8. Paresis of soft palate from diphtheria ; from poliomyelitis. 9. Deterioration of speech after adenoidectomy (after palate repair with normal speech). All the case notes of cleft palate repair, primary and secondary, which have passed through Stoke Mandeville since 194° have been checked with a view to noting where pharyngoplasty has been required and at what stage it has been performed. The results shown in the following tables relate to the findings noted up to August 1963, and are those of several surgeons, all of the Kilner School. a t one y e a r
RESULTS
One thousand and seventy-five cases of cleft lip and palate were investigated, of which 944 were the subject of cleft palate repair ; of these cases of palate repair 171 required a pharyngoplasty. Table III shows the ratio of the sexes, and also the number of pharyngoplasties for each type of cleft (using the classification of Ritchie and Staige Davis). TABLE I I I
Pharyngoplasty Series. Sex Ratio. Type of Cleft (Ritchie and Staige Davis) Sex-Males Females . Not stated
87 74 Io Total
171
Type of C l e f t - G.P. II G.P. III.I G.P. III.3
59 69 43 Total
171
Table IV shows a breakdown of cases in relation to the indications for pharyngoplasty. In item 7, palate repair took place at about 1 year, with a Wardill. pharyngoplasty. Items 3 and 4 (separately and together) give the largest number ( 2 3 + 2 5 + 2 6 - 7 4 ) where pharyngoplasty has been used as a " s u p p o r t i v e " operation, where palate repair alone has been inadequate to provide normal speech. Table V indicates the type of pharyngoplasty. It will be remembered that the majority of the Wardill pharyngoplasties were performed at about i year with the palate repair. It will also be noted that the Hynes pharyngoplasty becomes more popular from I95O onwards. Table VI shows a large number of pharyngoplasties at I year with palate repair. These are of the Wardill type and are mainly from Professor Kilner's cases.
PHARYNGOPLASTY
397
IN SPEECH
TABLE I V
Type of Cleft Indications for Pharyngoplasty i. Congenital short palate 2. Congenital absence part palate 3. Scarred palate . 4. Capacious nasopharynx 5. + Primary palate repair in adult ' 6. + Secondary palate repair in adult 7. + Primary palate repair in infancy Both I and 4 above Both 3 and 4 above Both 3 and 6 above Not stated
II
I III.I
2
2
.,.
U------8 II
i
15 15
17
• .-
I
I
ii
6
2
9 I 2
59
69
43
4
23 25
5 4 7
I0
[
8
Total
Total
111.3
22
29 36
2
2
26 I
5
I
I7I
TABLE V Type of Pharyngoplasty-Wardill. Rosenthal Hynes . Not stated Implant
Second Pharyngoplasty-Wardill . Rosenthal Hynes . Not stated
98 7 56 8
I
4 IO I56
2
Total Total
17I
171
Type of Pharyngoplasty Surgeon
Wardill
Rosenthal
Hynes
Professor K i l n e r .
- -
66
i
5
M r Reidy .
]
i2
3
26
Others
[
2i
3
24
Total
99
55
None
Not stated
2
3
... 5 2
Total
_. 47716 48
8
From io years onwards there is a rise in the incidence of pharyngoplasty (and these figures could include the operations of Wardi11, Rosenthal, and Hynes), applied as a " supportive" operation alone, or combined with secondary repair of palate or combined with primary repair of palate in an adult (i.e., a patient over 5 years of age) (Table VI). Table VII shows the improvements in the speech groups where pharyngoplasty has been applied alone or combined with palate repair.
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TABLE V I Ages of Secondary Palate Repair. I to 5 years 5 to 6 years 6 to 7 years 7 to 8 years 8 to 9 years 9 to IO years IO to I5 years I5 to 20 years 20 to 25 years 25 to 3 ° years 3oX . 3oY . None
Ages of Pharyngoplasty. I tO 5 y e a r s
30
5 to 6 years 6 to 7 years 7 to 8 years 8 to 9 years 9 to io years io to 15 years I5 to 2o years 20 to 25 years 25 to 3o years 3° years and over N o t stated
I0
6 4 3 4 16 28 35 II 20
4 Total
2
8 2
4 3 I
3 IO
23 5 7 I 102
I71
Total
171
TABLE VII T y p e of Cleft Speech before Pharyngoplasty Group A Group B Group C Group D N o t stated Total
II
III.I
111.3
I5 35
II 32
12
32 79
7
26
25
58
59
69
43
171
6
2
Total
2
T y p e of Cleft Speech after Pharyngoplasty Group A Group B Group C Group D N o t stated Total
II
III.i
III.3
Total
18 24 7
25 23 9
29 14
62 61
6
22
IO
I2
4
26
59
69
43
171
CONCLUSIONS
I. Where adequate palate repair is undertaken at I year there is n o indication for pharyngoplasty as well at that age. 2. Pharyngoplasty is indicated as a " supportive" operation only when the result of the palate repair can be assessed (5 years plus), and where the speech result proves disappointing.
PHARYNGOPLASTY
IN
SPEECH
399
3. T h e figure o f 171 p h a r y n g o p l a s t i e s i n 944 cases applies to t h e k n o w n speech results u p to A p r i l I963. I t follows t h a t with f o l l o w - u p o f t h e m o r e r e c e n t p r i m a r y cases p h a r y n g o p l a s t y m a y well b e necessary i n some. 4. T h e H y n e s p h a r y n g o p l a s t y has p r o v e d to b e the m o s t satisfactory.
M y thanks are due to my colleagues Professor T. P. Kilner, M r R. P. Osborne, M r Peet, and M r Thompson for permission to use the data from their case notes. I am deeply indebted to M r Barr and M r GoIding of the Oxford Regional Hospital Board for their patience in compiling the statistics. Reproductions were made by Miss Janet Plested of the Photographic Department, Stoke Mandeville Hospital. REFERENCES
FOGH-ANDERSEN,P. (1953). Acta chir. scand., xos, I. HYNES, W. (195o). Brit. ft. plast. Surg., 3, 128. - - (1953). Ann. R. Coll. Surg. Engl., x3, I. KILNER, T. P. (1937 a). St Thomas's Hosp. Rep., 2, 127. -(1937 b). Brit. ft. Surg., 9, 33. NEGUS, V. E. (1929). " Mechanism of Larynx." London : Heinemann. - (1949). " Comparative Anatomy and Physiology of Larynx." London : Heinemann. PASSAVANT,G. (1869). Virchows Arch., vol. 46. REIDY, J. P. (1958). Ann. R. Coll. Surg. Engl., 23, 341. - - (1959). Brit. ft. plast. Surg., I2, 215. - - (1962). Brit. ft. plast. Surg., xS, 261. SULLIVAN,D. E. (1951). Blast. reconstr. Surg., 27, I. WARDILL,W. E. M. (1928). Brit. J. Surg., 16, 127. - - (1933). Brit. J. Surg., 21, 347. WEBSTER,R. C., COFFE¥,R. J'., RUSSELL,]'. A., and QUIGLEY,L. F. (1956). Plast. reconstr. Surg., i8, 474.
By J. P.
REIDY,
IN
SPEECH 1
F.R.C.S.
London
THE operation of pharyngoplasty in speech production has for its primary object the narrowing of the nasopharynx. The end result which is sought (in those cases where it is employed) is that the palate will thus be at a better mechanical advantage to enable the patient to close the nose from the mouth. T y p e of Pharyngoplasty.--(I) Passavant in I869 was the first to comment on the poor speech results following repair of the cleft palate by the methods then in use. These methods involved single layer closure with some shortening of the soft palate, and therefore there was nasopharyngeal incompetence. Passavant sutured the posterior edge of the palate to the posterior pharyngeal wall (Fig. I). (2) Rosenthal in I924 advocated Sch6nborn's rectangular flap, which was turned from the posterior pharyngeal wall and sutured to the soft palate. It reduces the nasopharyngeal opening into two smaller passages, and when such a flap is based upwards it is useful in holding up an immobile or paralysed soft palate, thus placing the palate in a better mechanical advantage. Webster and others have proposed a system of classification for the posterior pharyngeal flap (Fig. 2). (3) In I928 Wardill discussed the repair of cleft palates, and stated that there is an increase in the diameter of the nasopharynx, and thus a need to bring the posterior pharyngeal wall forwards. He described his new operation" The Wardill Pharyngoplasty," which could be performed one week prior to the Langenbeck palate repair, or the Gillies-Fry procedure. He said this operation ofpharyngoplasty could be applied to infants, as well as to adults with a palate already scarred (Fig. 3). Wardill's pharyngoplasty consisted of a transverse incision on the posterior pharyngeal wall at the level of the arch of the arias, and this was sutured vertically (like a reverse pyloroplasty) to give a narrowing of the nasopharyngeal opening. This operation was frequently performed, as I have said, by my senior colleagues at the time of primary palate repair, which was done at one year. Eventually the effectiveness of Veau's V-Y retroposition with two layer closure led Professor Kilner to abandon the pharyngoplasty at the time of the primary palate repair. (4) Hynes in I95O published a description of his pharyngoplasty by using muscle transplants from the lateral sides of the pharynx to a transverse position on the posterior pharyngeal wall. The effect of this procedure is to narrow the diameter of the pharynx and at the same time to produce a transverse ridge on the posterior pharyngeal wall, which at times shows muscular movement. Another effect of this pharyngoplasty is to raise the pitch of the voice by several notes. This is an interesting finding when considered with Negus's description of nasopharyngeal development (Fig. 4)Hynes (personal communication, I963) stresses that " whole thickness of the lateral pharyngeal muscles must be used in the lateral pharyngeal flaps down to the pharyngeal aponeurosis." 1 Presented in the Cleft Lip and Palate Panel at the International Meeting, Washington D.C., I963. 389
BRITISH
390
JOURNAL
OF
PLASTIC
SURGERY
\
,
! FIG. I
FIG. 2
\/ Fig. I.--Posterior pharyngeal wall flap of Passavant (i863). ~
j
Fig. 2.--Posterior pharyngeal wall flap of Rosenthal. Fig. 3.--Pharyngoplasty Wardill.
Fro. 3
r
J
@
Outline of Hjnes P~ar~,~goni~tJ. C[ap3now horlzonta/. l~/I.~ ~'~
T
'I" FIG. 4 Pharyngoplasty of Hynes.
~l ~]
~'~,.~\,
I:%,
of
PHARYNGOPLASTY
IN SPEECH
39 I
Of all these pharyngoplasties I give preference to that of Hynes, in that it is more physiological and in practice it gives greater efficiency than any other procedure. General P r o c e d u r e in Palate R e p a i r . - - I f as a general rule primary repair of the cleft palate takes place on or about the first birthday, and if this repair is on the lines of Veau's V-Y retroposition, then in my experience there is now no place for a pharyngoplasty as a primary operation in infants, either alone or accompanied by the V-Y operation on the palate. Hynes does not agree with this and his viewpoint will be discussed later (Fig. 5).
i \
~"// /'
FIG. 5 Retroposition of palate by V-Y operation in contrast to the Langenbeck closure (above).
As a result of the straightforward V-Y retroposition of the palate, the speech results show a high percentage of normal speakers. Pharyngoplasty has not been regularly employed (Table In). However, about 2o per cent. of the remainder of these primary cases fail to satisfy the speech requirements, and need further investigation, and indeed treatment. In addition, there are certain cases operated upon elsewhere, in addition to some of my own, which show nasopharyngeal incompetence. This group of 20 per cent. has been investigated and reported elsewhere, and shows defects of speech due to mental retardation and to physical defects of the palate. Of these cases which came to review some responded to speech therapy and some required Hynes pharyngoplasty. As a result the overall speech results of this series showed an improvement (Table IB).
BRITISH
392
JOURNAL
OF
PLASTIC
SURGERY
TABLE IA Palate Repair : Speech Results--Comparisons B.
A.
T y p e of Operation 1927. G r e y T u r n e r I927. N i t c h . I927 . V e a u Veau 1933. V e a n 1933. Wardill[
Ritchie. Vaughan Bentley and Watkins I95I. H o l d s w o r t h . I949. Oldfield 1957. R e i d y
.
Total
Langenbeck Langenbcck Langenbeck Veau Technique Veau V-Y Langenbeck Gillies F r y Veau V-Y + pharyngoplasty
V-Y V-Y V-Y V-Y
'
D,
Bad/Unintelligible
Normal
Fair
Poor
P e r cent.
Per cent. 38.8
P e r cent. 27 "7 48 .6 15 .o 60 .o
P e r cent. 18.8 I4"3 6o-o
23 '0
15 "o 16.o
9°
II'O
35 4~
37"I
IOO
40 .o
IOO
62 .o 84 .o
25 .o
38
V-Y primary secondary primary secondary
C.
85 113 7o I93 51
4 2 "0
43 -o
43 .o 51 .o
26-0
47 .o
43 "o 32 "8 6O '0
27 "0
61 '0 25 "7
20 '2
77"2 39"2
58 .8
"6-2 14.8 2"0
0'5 I' 9
T A B L E IB
Revised Speech Results : Groups n and In, Primary Number [ 1957 P r i m a r y , ] G r o u p s II a n d I I I
Grade Result
A B
I49 39 (1) (4)
C D C o r r e c t e d total
.
Percentage
I96O
] A f t e r investiga- ( tion a n d / o r 41 j treatment ([ 3 Less mentally f defective
I49 + I4 25
I88
I88
86 "7 13 "3
I63 25
IO0"O
Revised Speech Results : Groups II and III, Secondary Grade Result
i957 Secondary, G r o u p s II a n d I I I
A
2O
B
3o i m e n t a l l y backward
C
I96O
j
After investiga-( tion a n d / o r j treatment (
Percentage
20 + 5 23
5°
50
D C o r r e c t e d total
50
50
IO0
PHARYNGOPLASTY IN SPEECH
393
TABLE I I
Speech (Post-op.) Group A - - N o r m a l Speech No faults Minor faults of'articulation (Lateral S. substitution and incorrect tongue position) Major faults and dyslalias .
I 2 3
Group B--Articulation correct but Nasal Escape of Air Minimal nasal escape (normal or excellent speech) Medium nasal escape Gross nasal escape
4 5 6
Group C--Articulation incorrect and Nasal Escape of Air Minor faults of articulation Major faults of articulation
7 8
Group D - - U n f o r m e d or Unintelligible Speech Unformed speech of infants . • • Unintelligible speech in conversation £nd reading Unintelligible speech even of words in isolation
9 o x
In passing, it will be noted that in the classification of lip and palate clefts, that of Ritchie and Staige Davis (I922) is used. From the clinical point of view this is straightforward and simple. The physical shortcomings of speech can be investigated by speech checks (Table II) and by lateral X-rays of the palatal movements using barium to outline the palate (Fig. 6).
FIG. 6 Lateral palatal X-rays. Tracing of X-rays.
Those cases that fall short of normal speech reveal an inability on the part of the patient to close the nasopharyngeal aperture on saying " ee" and blowing, and show a definite gap between the posterior edge of the soft palate and the posterior pharyngeal wall. 4E
394
BRITISH
JOURNAL
OF
PLASTIC
SURGERY
The causes of mechanical disadvantage of the palate or of this nasal escape are as follows : I. A palate that is too short absolutely. 2. A capacious nasopharynx. 3- A palate that is immobile and short by reason of scarring from previous treatment. Since the checking of speech is something that is accurate only when the child reaches the age of 4 or 5 years, and only when such a child is co-operative in the matter of X-rays (Fig. 7), it is only then that the need for further treatment to the
FIG. 7 Lateral palatal X-rays. Above, A f t e r V - Y repair, nasal escape on " ee " a n d Below, After H y n e s p h a r y n g o p l a s t y , n a s o p h a r y n g e a l closure. blowing. Note t r a n s v e r s e ridge.
palate or to the pharynx can be estimated. Unless it is possible to improve the palate under cause 3 by further palatal surgery (for example, secondary V-Y repair) all causes (i, 2 and 3) qualify for pharyngoplasty, which in my hands thus becomes a supportive operation to be used only when required. In my opinion, therefore, indications for pharyngoplasty arise from 5 years onwards (Fig. 8). There is, however, a group of patients where pharyngoplasty is indicated as a primary procedure. Where a patient has reached an age in excess of 5 or 6 years onwards, with an untreated cleft of palate, there is usually a capacious nasopharynx. In addition, the palatal tissues are thicker than in infancy, and thus there is a limit to the degree ofretroposition by surgery. In this group a pharyngoplasty is desirable at the time of the palate repair. As already stated, Hynes does not agree with my statement that " there is no
P H A R Y N G O P L A S T Y IN
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395
place for a pharyngoplasty as a primary operation in infants either alone or accompanied by repair of the palate." In fact, for several years Hynes has modified his approach to palate repair as follows : - I . He advocates the V-Y repair for patients with a reasonable amount of palatal tissue. 2. He prefers his " t w o - i n - o n e " operation : (a) For the cleft of soft palate only. (b) For the longer and wider cleft of palate with little tissue present to work with, using development of thc uvula as a guide to bulk.
FIG. 8 Lateral palatal X-rays. A, After V-Y repair, incomplete closure. B, Speech therapy, normal closure. C, C. P., 26 years of age, pre-operative. D, After V-Y repair, normal closure. E, C. P., 2o years of age, pre-operative. F, After V-Y repair, capacious pharynx, needs Hynes pharyngoplasty. T h e " t w o - i n - o n e " operation consists of simple paring and suturing of the soft palate edges combined with his pharyngoplasty. Unfortunately there are no foUow-ups recorded to show whether the " t w o - i n - o n e " operation is superior to the ordinary V-Y repair in the production of normal speech. It is true to say that up to about I94 o my teacher, Professor Kilner, frequently performed a pharyngoplasty at the time of palate repair at I year of age. After that
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date the operation of a Wardill pharyngoplasty at the time for primary palate repair largely disappeared. The indications therefore for pharyngoplasty in my view fall under the following headings : m I. For congenital short palate. 2. For congenital absence of part of the palate. 3. For a palate scarred by previous treatment. 4. For an abnormally capacious nasopharynx. 5. Combined with the primary palate repair from say 5 years to adult life. 6. Combined with the secondary repair of the palate. 7. Combined with palate repair in infancy (up to 194o). 8. Paresis of soft palate from diphtheria ; from poliomyelitis. 9. Deterioration of speech after adenoidectomy (after palate repair with normal speech). All the case notes of cleft palate repair, primary and secondary, which have passed through Stoke Mandeville since 194° have been checked with a view to noting where pharyngoplasty has been required and at what stage it has been performed. The results shown in the following tables relate to the findings noted up to August 1963, and are those of several surgeons, all of the Kilner School. a t one y e a r
RESULTS
One thousand and seventy-five cases of cleft lip and palate were investigated, of which 944 were the subject of cleft palate repair ; of these cases of palate repair 171 required a pharyngoplasty. Table III shows the ratio of the sexes, and also the number of pharyngoplasties for each type of cleft (using the classification of Ritchie and Staige Davis). TABLE I I I
Pharyngoplasty Series. Sex Ratio. Type of Cleft (Ritchie and Staige Davis) Sex-Males Females . Not stated
87 74 Io Total
171
Type of C l e f t - G.P. II G.P. III.I G.P. III.3
59 69 43 Total
171
Table IV shows a breakdown of cases in relation to the indications for pharyngoplasty. In item 7, palate repair took place at about 1 year, with a Wardill. pharyngoplasty. Items 3 and 4 (separately and together) give the largest number ( 2 3 + 2 5 + 2 6 - 7 4 ) where pharyngoplasty has been used as a " s u p p o r t i v e " operation, where palate repair alone has been inadequate to provide normal speech. Table V indicates the type of pharyngoplasty. It will be remembered that the majority of the Wardill pharyngoplasties were performed at about i year with the palate repair. It will also be noted that the Hynes pharyngoplasty becomes more popular from I95O onwards. Table VI shows a large number of pharyngoplasties at I year with palate repair. These are of the Wardill type and are mainly from Professor Kilner's cases.
PHARYNGOPLASTY
397
IN SPEECH
TABLE I V
Type of Cleft Indications for Pharyngoplasty i. Congenital short palate 2. Congenital absence part palate 3. Scarred palate . 4. Capacious nasopharynx 5. + Primary palate repair in adult ' 6. + Secondary palate repair in adult 7. + Primary palate repair in infancy Both I and 4 above Both 3 and 4 above Both 3 and 6 above Not stated
II
I III.I
2
2
.,.
U------8 II
i
15 15
17
• .-
I
I
ii
6
2
9 I 2
59
69
43
4
23 25
5 4 7
I0
[
8
Total
Total
111.3
22
29 36
2
2
26 I
5
I
I7I
TABLE V Type of Pharyngoplasty-Wardill. Rosenthal Hynes . Not stated Implant
Second Pharyngoplasty-Wardill . Rosenthal Hynes . Not stated
98 7 56 8
I
4 IO I56
2
Total Total
17I
171
Type of Pharyngoplasty Surgeon
Wardill
Rosenthal
Hynes
Professor K i l n e r .
- -
66
i
5
M r Reidy .
]
i2
3
26
Others
[
2i
3
24
Total
99
55
None
Not stated
2
3
... 5 2
Total
_. 47716 48
8
From io years onwards there is a rise in the incidence of pharyngoplasty (and these figures could include the operations of Wardi11, Rosenthal, and Hynes), applied as a " supportive" operation alone, or combined with secondary repair of palate or combined with primary repair of palate in an adult (i.e., a patient over 5 years of age) (Table VI). Table VII shows the improvements in the speech groups where pharyngoplasty has been applied alone or combined with palate repair.
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TABLE V I Ages of Secondary Palate Repair. I to 5 years 5 to 6 years 6 to 7 years 7 to 8 years 8 to 9 years 9 to IO years IO to I5 years I5 to 20 years 20 to 25 years 25 to 3 ° years 3oX . 3oY . None
Ages of Pharyngoplasty. I tO 5 y e a r s
30
5 to 6 years 6 to 7 years 7 to 8 years 8 to 9 years 9 to io years io to 15 years I5 to 2o years 20 to 25 years 25 to 3o years 3° years and over N o t stated
I0
6 4 3 4 16 28 35 II 20
4 Total
2
8 2
4 3 I
3 IO
23 5 7 I 102
I71
Total
171
TABLE VII T y p e of Cleft Speech before Pharyngoplasty Group A Group B Group C Group D N o t stated Total
II
III.I
111.3
I5 35
II 32
12
32 79
7
26
25
58
59
69
43
171
6
2
Total
2
T y p e of Cleft Speech after Pharyngoplasty Group A Group B Group C Group D N o t stated Total
II
III.i
III.3
Total
18 24 7
25 23 9
29 14
62 61
6
22
IO
I2
4
26
59
69
43
171
CONCLUSIONS
I. Where adequate palate repair is undertaken at I year there is n o indication for pharyngoplasty as well at that age. 2. Pharyngoplasty is indicated as a " supportive" operation only when the result of the palate repair can be assessed (5 years plus), and where the speech result proves disappointing.
PHARYNGOPLASTY
IN
SPEECH
399
3. T h e figure o f 171 p h a r y n g o p l a s t i e s i n 944 cases applies to t h e k n o w n speech results u p to A p r i l I963. I t follows t h a t with f o l l o w - u p o f t h e m o r e r e c e n t p r i m a r y cases p h a r y n g o p l a s t y m a y well b e necessary i n some. 4. T h e H y n e s p h a r y n g o p l a s t y has p r o v e d to b e the m o s t satisfactory.
M y thanks are due to my colleagues Professor T. P. Kilner, M r R. P. Osborne, M r Peet, and M r Thompson for permission to use the data from their case notes. I am deeply indebted to M r Barr and M r GoIding of the Oxford Regional Hospital Board for their patience in compiling the statistics. Reproductions were made by Miss Janet Plested of the Photographic Department, Stoke Mandeville Hospital. REFERENCES
FOGH-ANDERSEN,P. (1953). Acta chir. scand., xos, I. HYNES, W. (195o). Brit. ft. plast. Surg., 3, 128. - - (1953). Ann. R. Coll. Surg. Engl., x3, I. KILNER, T. P. (1937 a). St Thomas's Hosp. Rep., 2, 127. -(1937 b). Brit. ft. Surg., 9, 33. NEGUS, V. E. (1929). " Mechanism of Larynx." London : Heinemann. - (1949). " Comparative Anatomy and Physiology of Larynx." London : Heinemann. PASSAVANT,G. (1869). Virchows Arch., vol. 46. REIDY, J. P. (1958). Ann. R. Coll. Surg. Engl., 23, 341. - - (1959). Brit. ft. plast. Surg., I2, 215. - - (1962). Brit. ft. plast. Surg., xS, 261. SULLIVAN,D. E. (1951). Blast. reconstr. Surg., 27, I. WARDILL,W. E. M. (1928). Brit. J. Surg., 16, 127. - - (1933). Brit. J. Surg., 21, 347. WEBSTER,R. C., COFFE¥,R. J'., RUSSELL,]'. A., and QUIGLEY,L. F. (1956). Plast. reconstr. Surg., i8, 474.