Plastic and Jaw Department, United Sheffield Hospitals

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1 THE EXAMINATION OF IMPERFECT SPEECH FOLLOWING CLEFT-PALATE OPERATIONS By WILFRED HYNES, F.R.C.S Plastic and Jaw Department, United Sheffield Hospitals THE results of cleft-palate operations can be difficult to predict in that, in some cases, a good anatomical result can be associated with poor speech while, in others, excellent speech may follow an indifferent palate repair. The anatomical defect in a cleft-palate patient is widespread ; it is not confined to the palate but involves the pharynx, the tongue, the jaws, and, if there is also a hare-lip deformity, it also affects the lips, the teeth in the incisor region, and the nose. All these structures are also concerned with speech. An operation, if confined to the palato-pharyngeal region, can therefore result in imperfect or even incomprehensible speech, and the operation, though perfectly adequate in itself, is apt to be regarded as unsatisfactory. A cleft-palate patient attempts to compensate by using some structures to overcome faults in adjacent ones. While compensation can be most effective in correcting some anatomical defects it can be quite ineffective in others ; and attempts at compensation may even produce speech faults on their own account. The factors concerned with speech production are therefore extremely complicated and matters are made more difficult by the fact that there is no simple standard method of testing speech results after cleft-palate operations. The object of this paper is to describe such a method which has the following advantages :-- i. It is quick and simple and requires no detailed knowledge of speech therapy and no special apparatus ; it can therefore be used by the surgeon himself in his follow-up clinic. 2. It provides a standard so that results from one clinic can be compared with those from another. 3- It not only demonstrates speech faults but also locates the structures responsible for them. In the following discussion the expression "palato-pharyngeal sphincter" is used as a convenient term for the mechanism involved when the palato-pharyngeal space is occluded. The writer is aware that a difference of opinion exists as to the exact nature of this mechanism. PRINCIPLES OF THE TEST Many words used in assessing speech are far less simple than they appear to be. The word Peter, for example, comprises four sounds (P, Ee, T, and Er) and at least five structures are involved in its production--the lips, the tip of the tongue, the hard palate, the back of the tongue, and the palato-pharyngeal sphincter. If this word is badly pronounced it can therefore be quite difficult to say exactly what is wrong with it and to determine which anatomical structures i14

The vowel Ah can be described as an unspecialised vowel as its production does not require the use of any specialised movement but involves only a simple depression of the tongue to the floor of the

2 IMPERFECT SPEECH FOLLOWING CLEFT-PALATE OPERATIONS II 5 are responsible. Even a single syllable such as Tee or Dee requires at least three structures for its production and, if articulated badly, gives rise to a similar difficulty. The vowel Ah can be described as an unspecialised vowel as its production does not require the use of any specialised movement but involves only a simple depression of the tongue to the floor of the mouth. It is therefore articulated normally by cleft-palate patients however inadequate the soft palate may be (Fig. i). If the different consonants are combined with the vowel Ah, a series of monosyllables result (e.g., Tah, Dah, Gah, Kah, etc.), and these are used to test the speech of cleft-palate patients for the following reasons :-- I. If the test syllable (e.g., Tah) is faulty, the fault cannot be due to the vowel Ah, which, as stated above, is always normal ; it must therefore lie in the production of the consonant T, and the same holds with other test syllables-- Lah, Dah, Gah, etc. The method therefore tests each consonant uncomplicated by any other accompanying sound, and this makes it quite easy for the examiner to detect if each individual consonant is normal or otherwise. 2. If the patient says the syllable " Tah," for example, he must open his mouth for the vowel Ah, and this enables FIG. the surgeon to see what is happening A cleft-palate patient saying " Ah." The inside the oral cavity, particularly to the tongue is simply depressed. tongue. Abnormal tongue movements are the commonest causes of bad speech and are easily detected in this way (Fig. 3, A and B). It may be objected that the examination of speech by using single syllables (Tah, Dah, Gah, etc.) as test sounds is of little practical value; the fact that a patient can produce a certain consonant in isolation does not mean that he will be able to produce the same consonant in continuous speech. The correct production of a particular consonant in isolation, however, does show that the patient possesses the apparatus to produce that sound and that speech therapy is worth while. On the other hand, inability to articulate a given consonant in isolation ~ndicates that the patient does not possess the necessary apparatus for that sound; if we can then locate the fault to the responsible structure or structures, we are in a position to correct them. COMPENSATION IN CLEFT-PALATE PATIENTS As already stated, a cleft-palate patient possesses a series of faulty structures lying between the pharynx behind and the lips in front and he will endeavour to use some of them to overcome faults in others, It is important to discuss these

--Abnormal movements of the tongue during articulation in a cleft palate patient with almost unintelligible speech.

3 II6 BRITISH JOURNAL OF PLASTIC SURGERY FIGS, 2 and 3 Fig. 2.--Normal movements of the tongue during articulation. A, A patient saying " Lah." The tip of the tongue rises. B, A patient saying " Kah." The back of the tongue rises. Fig. 3.--Abnormal movements of the tongue during articulation in a cleft palate patient with almost unintelligible speech. A, The patient has been asked to say " Lah." The whole of the tongue, including the tip, is strongly depressed (compare with Fig. 2, A). B, The patient has been asked to say " Kah." The whole of the tongue, including the base, is strongly depressed (compare with Fig. 2, B).

IMPERFECT SPEECH FOLLOWING CLEFT-PALATE OPERATIONS [I 7 efforts at compensation at this stage because they exert a considerable influence on speech.

4 IMPERFECT SPEECH FOLLOWING CLEFT-PALATE OPERATIONS [I 7 efforts at compensation at this stage because they exert a considerable influence on speech. In many cases compensation is highly successful, but in others it may not only fail in its purpose but may produce faulty speech on its own account Compensation is effected by moving one or more structures either locally or from one place to another in order to close gaps or to alter the abnormal size and shape of cavities. Four common causes of imperfect speech after cleft-palate operations will now be considered and the methods of compensation used in each will be discussed--they are palato-pharyngeal incompetence, dental faults in the incisor region, faults of the upper lip, and faulty tongue movements. I. Compensation for Palato-pharyngeal Incompetence.--Compensation is attempted by the pharynx, the tongue, the nostrils, and the glottis. A. The Pharynx.--An oropharynx with actively contracting walls can so reduce its diameters, especially in a lateral direction, that it makes a considerable contribution to the closure of the palato-pharyngeal space in cases where the soft palate is short or moves badly. Unfortunately, the oropharynx in many failed cleft-palate cases is so large and its walls show so little movement that the pharynx contributes little or nothing to palato-pharyngeal closure (Hynes, I952). B. The Tongue.--The behaviour of the tongue in failed cleft-palate cases varies enormously. (I) The tongue may move normally, rising at the tip to produce L, T, and D, and at the base to produce K, G, and the vowels Ee, Ay, and I (Fig. 2, A and B). (2) In cases with a large residual cleft the tongue may rise excessively during speech so that the tip of the tongue enters the palatal cleft and closes it. This explains those remarkable cases where a widely cleft palate can be associated with near-normal speech (Fig. 4, A and B). (3) In other failed cleft-palate cases the tongue, instead of rising, is pulled firmly downwards and backwards when the patient attempts to say K, G, L, T, D and certain vowels, particularly Ee (see Fig. 3). The writer considers that this active depression of the tongue accompanies closure of the glottis when glottal stops are used to overcome palato-pharyngeal incompetence--just as depression of the tongue accompanies closure of the glottis during normal swallowing. Unfortunately, in many of these patients this abnormal tongue movement persists during speech after the palato-pharyngeal sphincter has been made competent by operation ; and, as a rising tongue is necessary for the correct articulation of many consonants and vowels, these patients remain almost unintelligible even after a satisfactory palate repair. C. The nostrils help to compensate for palato-pharyngeal incompetence by contracting, producing the well-known nasal grimace during speech. D. The glottis attempts to compensate for inadequate palato-pharyngeal closure by closing and, as stated above, this is accompanied by the descent of the tongue. By these means air is imprisoned momentarily in the larynx and when it is released a glottal stop is produced. The results of compensation can be highly successful in some cases of palato-~haryngeal incompetence and normal, or near-normal, speech can be achieved. As a general rule, however, compensation is inadequate and typical nasal speech accompanied by nasal escape is present ; if such a patient attempts compensation by depressing his tongue during speech~ he becomes almost unintelligible.

II8 BRITISH JOURNAL OF PLASTIC SURGERY 2. Dental Faults in the Incisor Region.

Compensation is attempted by the tongue, by overclosure of the mandible, and by the lips. A FIG. 4

" The tip of the tongue has moved vertically upwards to close the cleft to produce T and has just started to leave that position on its way down to lie on the floor of the mouth to

5 II8 BRITISH JOURNAL OF PLASTIC SURGERY 2. Dental Faults in the Incisor Region.--These take the tbrm of absence, irregularity, or retrusion of the upper teeth, and it would be expected that Th, S and Z, F and V would be very imperfectly articulated. Compensation is attempted by the tongue, by overclosure of the mandible, and by the lips. A FIG. 4 B Fig. 4.--Movement of the tongue with a residual cleft of the palate associated with near-normal speech. A, The residual cleft. B, The patient saying " Tah." The tip of the tongue has moved vertically upwards to close the cleft to produce T and has just started to leave that position on its way down to lie on the floor of the mouth to produce Ah. Fig. 5.--A large lower lip compensating tbr a short, immobile upper lip. FIG. 5 A. The Tongue.--By protruding the tongue excessively, the patient so narrows the gap between the upper and lower alveolus in the incisor region that he is able to produce a very reasonable Th. B. Overclosure of the mandible similarly narrows the alveolar gap in the incisor region so that the patient can produce a reasonab!e S and Z.

6 IMPERFECT SPEECH FOLLOWING CLEFT-PALATE OPERATIONS li 9 C. The Lips.--By sucking in the lower lip until it lies inside the upper~ and then releasing it, the patient can articulate an excellent F and V. Defects in the incisor region can therefore be adequately compensated and are never the cause of really bad speech after cleft-palate operations. 3. Faults of the Upper Lip.--These take the form of shortness in the vertical or transverse diameters, retrusion, lack of normal mobility, or combinations of these ; difficulty in articulating P, B, and W might be expected. In most cases, however, these sounds are quite reasonably produced, and this is due to the fact that a large lower lip can compensate for an inadequate upper lip. A patient with a short, immobile upper lip, for example, merely holds his large lower lip at a higher level so that the lip margins lie in contact. This gives the patient an aggressive appearance behind which, however, often lies a pleasant and co-operative disposition (Fig. 5). Defects of the upper lip can therefore generally be adequately compensated and are never the cause of poor speech after hare-lip and cleft-palate operations. 4. Tongue Faults.--As the tongue is a highly specialised organ, a cleft-palate patient, whose tongue fails to rise during speech, cannot compensate for this fault. In these cases speech can be unintelligible as a rising tongue is normally responsible for as many as eighteen vowel sounds (including diphthongs and triphthongs) and fourteen consonants. It can be concluded that compensation can largely remedy speech defects due to faults in the upper lip, dental faults in the incisor region, and some cases of palato-pharyngeal incompetence ; but that it is ineffective if there are faulty tongue movements and in most cases showing imperfect palato-pharyngeal closure. It follows, therefore, that if a patient speaks badly after a cleft-palate operation the cause must lie in the tongue or in the palato-pharyngeal region, provided of course that the patient has reasonable intelligence. THE EXAMINATION OF IMPERFECT SPEECH AFTER CLEFT-PALATE OPERATIONS The examination is conducted according to the following plan :-- I. Examination of the palato-pharyngeal region. z. Examination of the tongue movements. 3- Examination of the intelligence, hearing, and Vision. I. Examination of the Palato-pharyngeal Region. A. Inspection as the patient says " Ah " will demonstrate the length, mobility, and condition of the palate and the size and mobility of the oropharynx. Severe abnormalities of these strfictures will be obvious but the examiner must be cautious in his assessment of less severe defects. B. Nasal escape (and nasal grimace) varies in degree with the different consonants but is most marked when saying " S." The patient is therefore asked to say "~Sing a Song of Sixpence," which will demonstrate nasal escape if it is present. C. Nasal speech is due to nasalised vowels and is most obvious in the vowel " Ee." The patient is therefore asked to say " Peter paid a green fee," which will demonstrate nasal tone if it is present.

120 BRITISH JOURNAL OF PLASTIC SURGERY D. Special Tests : (I) The Carnival Blower Test; (2) the Mirror Test; (3) nip the nostrils between finger and thumb to see if this improves speech. 2.

7 120 BRITISH JOURNAL OF PLASTIC SURGERY D. Special Tests : (I) The Carnival Blower Test; (2) the Mirror Test; (3) nip the nostrils between finger and thumb to see if this improves speech. 2. Examination of the Tongue.---The tongue is involved in the production of eighteen vowel sounds and fourteen consonants and it produces these by rising at its tip, in its central third, or at its base. For practical purposes the writer tests only the base and the tip of the tongue, using the sounds Kah, Gab, and Ah-ay-ah to see if the base rises correctly, and Lah, Tah, and Dah to see if the tip rises correctly. There is a tendency for patients to close the mouth for the initial consonant of each test syllable and this can make it difficult for the surgeon to watch the movement of the tongue. It is quite easy, however, to articulate the syllables Lah, Tah, Dah, Kah, and Gah with the mouth widely open, and patients should be asked to do this ; an excellent view of the movement of the tongue is then obtained. In many failed cleft-palate cases the tip and base of the tongue rise normally during speech (see Fig. 2) ; in others, as already described, both the tip and the base fall (see Fig. 3) and, in these patients, speech is almost unintelligible. Between these two extremes is an intermediate group of patients in whom the tip of the tongue rises normally when saying Lah, Tah, and Dah, but the base falls for Kah and Gab; and there are patients who show the reverse condition in which the base of the tongue rises correctly for Kah and Gah, but the tip fails to rise for Lah, Tah, and Dah. Patients in this intermediate group show corresponding faults in continuous speech. It should be noted that faults in the palato-pharyngeal region and faulty tongue movements may occur together or separately. It is therefore possible to have a cleft-palate patient with an excellent palato-pharyngeal sphincter, following a satisfactory palate repair, who yet speaks very badly because his tongue movements are abnormal. 3. Examination of the Intelligence, Hearing, and Vision.--The writer considers that mental retardation as the cause of defective speech after cleft-palate operations has been overstressed and that many patients have been labelled mentally dull whose imperfect speech is really due to a tongue that moves incorrectly. In a similar way, undetected deafness or visual disturbance can cause behaviour and speech which are considered to be the result of stupidity. Detection and treatment of these disturbances followed by intelligent speech therapy can produce an unexpected improvement in the speech of these patients. CONCLUSION Though the above method of examining cleft-palate speech requires a lengthy description and therefore, perhaps, appears complicated and difficult, it is really a very simple procedure which occupies only a few minutes of the surgeon's time in the out-patient clinic. The method is summarised below. I. Examination of the Palato-pharyngeal Region. A. Inspection of the Palato-pharyngeal Region as the patient says "Ah." B. Nasal Escape.--Demonstrated when the patient says " Sing a song of sixpence."

--The patient says " Lab, Tah, Dah," with the mouth widely open. B. Base of the Tongue.--jThe patient says " Kah, Gah, Ah-ay-ah," with the mouth widely open. 3.

8 IMPERFECT SPEECH FOLLOWING CLEFT-PALATE OPERATIONS I2I C. Nasality.--Demonstrated when patient says " Peter paid a green fee." D. Special Tests: (I) Carnival blower Test; (2) Mirror Test; (3) nip the nostrils. 2. Inspection of the Tongue Movements. A. Tip of the Tongue.--The patient says " Lab, Tah, Dah," with the mouth widely open. B. Base of the Tongue.--jThe patient says " Kah, Gah, Ah-ay-ah," with the mouth widely open. 3. Examination of the Intelligence, Hearing, and Vision. A METHOD OF HELPING THE SPEECH THERAPIST TO CORRECT ABNORMAL TONGUE MOVEMENTS If a cleft-palate patient speaks badly because his tongue falls during speech, the speech therapist may find considerable difficulty in teaching him to raise the A B C FI~. 6 The dental training plate. A, The uniformly thick plate. B, The plate thickened at its anterior end. C, The plate thickened at its posterior end. tongue to produce consonants such as L, T, D, K, G and vowels such as Ay, Ee, or I. Speech therapy can be facilitated by fitting the patient with a temporary training palate--a thickened upper dental plate which artificially lowers the roof of the mouth to a position where it almost touches the dorsum of the tongue. The slightest effort on the patient's part will then enable his tongue to come into contact with the plate immediately above it so that the patient acquires the " feel" of his tongue touching something overhead. The plate is progressively thinned as progress is made until it ca R finally be discarded (Fig. 6, A). If failure of the tongue to rise is confined to its tip, the dental plate is thickened only at its anterior end (Fig. 6, B); if only the base of the tongue shows faulty movement, the plate is thickened only at its posterior end (Fig. 6, c). ] wish to t.hank Miss K. Noton, Head Speech Therapist to the United Sheffield Hospitals, fo~ considerable help and advice. 2D REFERENCE HYNES, W. (~952). Ann. R. Coll. Surg. Engl., x3, ~7.

By JAMES CALNAN, F.R.C.S. 1 Plastic Surgeon, University of Oxford

BLOWING TESTS AND SPEECH By JAMES CALNAN, F.R.C.S. 1 Plastic Surgeon, University of Oxford and CATHERINE E. RENFREW, F.C.S.T. Chief Speech Therapist, United Oxford Hospitals " Is the mechanism competent?