30 Proc. roy. Soc. Med. Volume 69 January 1976 haps doubtfully successful, surgical procedures should not be embarked upon to correct 'acceptable speech faults'. I think our surgical endeavours should be directed to those unfortunate patients with bad faults which render speech unintelligible or difficult to understand when unfamiliar topics are being discussed.
X-ray studies of the palate (Calnan 1956) have been for a long time the only way to observe palatal function and the state of the palatopharyngeal isthmus, and in most centres they are the only available means of observing and recording the action of the soft palate. I have found them to be of the greatest help. Cineradiography while the patient engages in conversational speech is particularly helpful, but still films, with the tongue, palate and pharynx in static positions, provide a record which can be kept in the patient's folder and which is, therefore, immediately available when the patient attends for follow-up examination.
Helpful though the X-rays of the soft palate are, there is nothing so convincing as seeing for one's self what is happening. Direct observation of the palatopharyngeal isthmus is now possible by nasendoscopy. Ingenious techniques have been perfected so that simultaneous recording of speech, of the cineradiography of the palatopharyngeal sphincter, and of the action of the soft palate and pharynx as seen from above through the nasendoscope is possible. These marvellous advances are as yet practised in one or two centres only. If and when they become available to all who are interested in this very difficult branch of surgery, they will surely increase our understanding 6 the failures of the speech mechanism and thereby lead to improvement in the management of our patients.
My own interest in the speech mechanism was stimulated and developed during my training under the late Professor T P Kilner and the late Mr Eric Peet. I learned much from my mentors, and from their colleagues, especially Professor James Calnan, al4out the management of cleft lip and palate deformities and about the 'speech problems which are due to incomplete closure of the palatopharyngeal isthmus. I gratefully acknowledge my debt to them. REFERENCES Calnan J (1956) British Journal ofPlastic Surgery 8, 265 Hynes W (1950) British Journal ofPlastic Surgery 3, 128 Kilner T P (1937) St Thiomas's Hospital Reports 2, 127 Millard D R (1963) Surgery, Gynecology and Obstetrics with International Abstracts of Surgery 116, 297 Skoog T (1965) British Journal ofPlastic Surgery 18, 265 Wardill W E M (1937) British Journal of Surgery 25, 117
4
Dr M J Gibson and Mr R W Pigott (Departments of Radiology andPlastic & Jaw Surgery, Frenchay Hospital, Bristol) A Technique of Investigation of the Function of the Palatopharyngeal Isthmus in Speech Dr Gibson pointed out that the standard lateral X-ray of the pharynx provided only the anteroposterior dimension of the isthmus and that a second plane of view was essential to complete the assessment. For the past eighteen months he and Mr Pigott had been obtaining videotape recording of the lateral pharyngeal view using an image intensifier mounted on a C-arm and endoscopic view using a Storz Hopkins nasopharyngoscope recorded by television camera, the two images being combined on videotape using a screen splitter unit (Gibson, Makepeace & Pigott, in preparation). In addition he showed the value of the basal X-ray recommended by Skolnick (1970). With the patient's head hyperextended the X-ray beam was passed on a line at right angles to a plane from the external auditory meatus to the angle of the mouth. This technique required barium coating and gave the same en face view of the isthmus as endoscopy. It was -particularly valuable in small children when endoscopy proved difficult or impossible. Mr Pigott showed the cine film of videotapes and emphasized the value to the surgeon of knowing precisely which speech muscles were active and how local tissue might best be used to supplement them. The investigation was of special value in reassessing the failed operation and revising the procedure. The investigation had enabled him to eradicate palatopharyngeal incompetence in two-thirds of his patients, as judged by a speech therapist, and reduce the incompetence in the majority of the remainder (Pigott et al. 1969, Pigott 1974).
He had observed that the intelligibility of patients with a completely successful pharyngoplasty was improved only to a very limited extent. Where gross articulation faults existed prior to surgery, a very guarded prognosis should be given to parents and patients and emphasis placed on the function of the operation to prepare the ground for intensive retraining. REFERENCES Pigott R W (1974) Scandinavian Journal ofPlastic and Reconstructive Surgery 8, 148-152 Pigott R W, Bensen J F & White F D (I1969) Plastic and Reconstructive Surgery and The Transplantation Bulletin 43, 141-147 Skolnick M L (1970) Cleft Palate Journal 7, 803-816
X-ray studies of the palate (Calnan 1956) have been for a long time the only way to observe palatal function and the state of the palatopharyngeal isthmus, and in most centres they are the only available means of observing and recording the action of the soft palate. I have found them to be of the greatest help. Cineradiography while the patient engages in conversational speech is particularly helpful, but still films, with the tongue, palate and pharynx in static positions, provide a record which can be kept in the patient's folder and which is, therefore, immediately available when the patient attends for follow-up examination.
Helpful though the X-rays of the soft palate are, there is nothing so convincing as seeing for one's self what is happening. Direct observation of the palatopharyngeal isthmus is now possible by nasendoscopy. Ingenious techniques have been perfected so that simultaneous recording of speech, of the cineradiography of the palatopharyngeal sphincter, and of the action of the soft palate and pharynx as seen from above through the nasendoscope is possible. These marvellous advances are as yet practised in one or two centres only. If and when they become available to all who are interested in this very difficult branch of surgery, they will surely increase our understanding 6 the failures of the speech mechanism and thereby lead to improvement in the management of our patients.
My own interest in the speech mechanism was stimulated and developed during my training under the late Professor T P Kilner and the late Mr Eric Peet. I learned much from my mentors, and from their colleagues, especially Professor James Calnan, al4out the management of cleft lip and palate deformities and about the 'speech problems which are due to incomplete closure of the palatopharyngeal isthmus. I gratefully acknowledge my debt to them. REFERENCES Calnan J (1956) British Journal ofPlastic Surgery 8, 265 Hynes W (1950) British Journal ofPlastic Surgery 3, 128 Kilner T P (1937) St Thiomas's Hospital Reports 2, 127 Millard D R (1963) Surgery, Gynecology and Obstetrics with International Abstracts of Surgery 116, 297 Skoog T (1965) British Journal ofPlastic Surgery 18, 265 Wardill W E M (1937) British Journal of Surgery 25, 117
4
Dr M J Gibson and Mr R W Pigott (Departments of Radiology andPlastic & Jaw Surgery, Frenchay Hospital, Bristol) A Technique of Investigation of the Function of the Palatopharyngeal Isthmus in Speech Dr Gibson pointed out that the standard lateral X-ray of the pharynx provided only the anteroposterior dimension of the isthmus and that a second plane of view was essential to complete the assessment. For the past eighteen months he and Mr Pigott had been obtaining videotape recording of the lateral pharyngeal view using an image intensifier mounted on a C-arm and endoscopic view using a Storz Hopkins nasopharyngoscope recorded by television camera, the two images being combined on videotape using a screen splitter unit (Gibson, Makepeace & Pigott, in preparation). In addition he showed the value of the basal X-ray recommended by Skolnick (1970). With the patient's head hyperextended the X-ray beam was passed on a line at right angles to a plane from the external auditory meatus to the angle of the mouth. This technique required barium coating and gave the same en face view of the isthmus as endoscopy. It was -particularly valuable in small children when endoscopy proved difficult or impossible. Mr Pigott showed the cine film of videotapes and emphasized the value to the surgeon of knowing precisely which speech muscles were active and how local tissue might best be used to supplement them. The investigation was of special value in reassessing the failed operation and revising the procedure. The investigation had enabled him to eradicate palatopharyngeal incompetence in two-thirds of his patients, as judged by a speech therapist, and reduce the incompetence in the majority of the remainder (Pigott et al. 1969, Pigott 1974).
He had observed that the intelligibility of patients with a completely successful pharyngoplasty was improved only to a very limited extent. Where gross articulation faults existed prior to surgery, a very guarded prognosis should be given to parents and patients and emphasis placed on the function of the operation to prepare the ground for intensive retraining. REFERENCES Pigott R W (1974) Scandinavian Journal ofPlastic and Reconstructive Surgery 8, 148-152 Pigott R W, Bensen J F & White F D (I1969) Plastic and Reconstructive Surgery and The Transplantation Bulletin 43, 141-147 Skolnick M L (1970) Cleft Palate Journal 7, 803-816
