First Assistant, Professional Unit, Nuffield Department of Plastic Surgery, University of Oxford

Transcription

1 DIAGNOSIS, PROGNOSIS, AND TREATMENT OF " PALATO- PHARYNGEAL INCOMPETENCE," WITH SPECIAL REFERENCE TO RADIOGRAPHIC INVESTIGATIONS I By JAMES CALNAN, F.R.C.S. First Assistant, Professional Unit, Nuffield Department of Plastic Surgery, University of Oxford INTRODUCTION DORRANCE (I933) defined palatal insufficiency as the condition in " which the velum, assisted by the superior constrictor muscle of the pharynx, fails to produce a sphincter-like closure between the nasopharynx and the oropharynx, a condition essential to the production of normal speech." Vaughan (I94o) considers it a condition where the " soft palate is short and, when acting with the superior constrictor of the pharynx, fails to produce complete velopharyngeal closure." We prefer to use the term " palato-pharyngeal incompetence" and no longer believe that the superior constrictor plays an important part in speech. Nor do we consider the closure to be "-sphincter-like." Palato-pharyngeal incompetence may be defined as the condition in which the soft palate fails to meet the posterior pharyngeal wall. Whether the incompetence is manifest during rapid conversational speech, careful speech in isolation, on effort or on swallowing, may indicate the degree of failure. The cause of incompetence may be intrinsic or extrinsic ; the fault may be in the palatal muscles or their nerve supply (be it central or peripheral), the conformation and size of the pharynx, or a combination of these. The clinical appraisement of disease in man is customarily based upon inquiries into personal and family history and environment ; the patient's account, both voluntarily and elicited, of his own subjective discomforts; an estimate of his physical type and psychological endowments; and a routine examination of his various systems. In cases of doubt or difficulty we may further employ certain instrumental devices such as the electrocardiograph or invoke the aid of the radiologist, the chemist, or the bacteriologist. The surgeon who investigates a patient with palato-pharyngeal incompetence finds himself at a curious disadvantage: the history is of little help; if the palate is cleft the diagnosis wili already have been made; if there is no cleft it will be the relatives who will proclaim the symptoms. If the patient suffers from a congenital speech abnormality he will only rarely believe that it differs from normal, even though he may be quite unintelligible in conversation. A routine examination of the various systems is seldom of value. The detailed examination of the mouth, palate, and pharynx frequently leaves doubts which until recently were unanswerable. In consequence surgical opinion based on a theoretical and ill-understood pathology of this condition has lacked uniformity. Radiography as an aid in the diagnosis of palato-pharyngeal incompetence is not new. Veau (I943) recommended fluoroscopy to sift out those adult patients i Paper read at a meeting of the British Association of Plastic Surgeons at Oxford, July I

2 266 BRITISH JOURNAL OF PLASTIC SURGERY who were unlikely to benefit from palate repair. Mme Borel-Maisonny (1947, 195o), his speech therapist, worked out the various tongue positions in speech, using this method. Podvinec and Mark (1951) preferred tomography. Radiographic investigations of the speech mechanism have been made by Trevino and Parmenter (1932), Harrington (I944), Oldfield (1947), Ricketts (1954), Hagerty and Hoffmeister (1954), and in certain theses by Wolfe (1942), Kaltenborn (1948), Hixon (1949), and Norris (1949). Subtelny (1954) used tomography to estimate the width of the pharynx. Since 1952 lateral X-ray films of the soft palate and pharynx have been used at Oxford routinely as an adjunct in the assessment of patients with speech disorders. This paper attempts to show how these investigations have helped in the diagnosis, treatment, and prognosis of our patients. In a plastic surgery department the commonest cause of palato-pharyngeal incompetence is " cleft palate," closely followed in frequency by " surgical intervention." It is not our intention to describe in detail the a:tiology of this condition but to use such examples of various abnormalities as will illustrate the scope of the radiographic method. In the course of these investigations our horizon of knowledge and understanding has been broadened, a constant reminder that many patients suffer from diseases not found in the textbooks. A METHOD OF REPRODUCING INTELLIGIBLE RADIOGRAPHS The normal function of the soft palate and pharynx as seen on an X-ray film differs somewhat from that described in standard works on the subject. The inherent difficulties in demonstrating particular features on prints of X-ray films are well known ; the value of most radiographic prints in current publications is entirely lost by the lack of detail of the point to be illustrated and the confusion of surrounding shadows. To overcome this problem Professor Kilner directed my attention to a device used by Victor Veau (1938). In the introduction to his monograph on cleft lip, Veau describes the method he used to obtain line drawings from photographs, commenting that tracings cost much less to print. Briefly the procedure is as follows : Fig. 1 shows the print of a lateral X-ray film of the skull of a normal male aged 30 saying "Ah... " (~). On this print the outline of essential landmarks is overdrawn using waterproof Indian ink (Fig. 2). For clarity the soft palate has been cross-hatched, the tongue outline given a little frill, and the main bony mass of the skull and spine hatched; the outline of the arch of the atlas can be seen well in profile. This print is immersed in Lugol's iodine (5 per cent. free iodine in IO per cent. potassium iodide) until it turns quite black ; it is washed in running water and then cleared in a saturated solution of sodium thiosulphate (photographer's " hypo ") until the Indian-ink outline can be seen on a perfectly white background. In this way an accurate and intelligible reproduction of an X-ray film can be obtained (Fig. 3). Teehnique of Lateral X-rays.--Three films are taken of each patient, sitting upright with the left side of his face to the X-ray tube of a Schonander- Lysholm skull table. The tube, which is fixed, is about 18 in. from the patient and the exposures used in adults are 0"4 sec., 90 to 95 kv., and 80 ma. The first film is taken with the mouth and palate at rest during quiet nasal breathing. A notched metal rod is held between the teeth in the midline of the

3 DIAGNOSIS~ PROGNOSIS~ AND TREATMENT OF " PALATO-PHARYNGEAL INCOMPETENCE " 267 Fig. i.--normal male aged 30 saying " Ah..." (phonetically ~). Direct contact print of a lateral X-ray of the skull. Barium solution has been used to coat the nasal surface of the soft palate and pharynx. FIG. I Fig. 2.--The same lateral skull view as in Fig. i but essential structures have been outlined in Indian ink.!~i! ~ FIG. 2

4 268 BRITISH JOURNAL OF PLASTIC SURGERY mouth, providing an accurate scale for any measurements that one may wish to make from the films later. The patient is then asked to say " EE..." during the exposure for the second film. During the third exposure he blows out a carnival blower (a toy now seen only during fairs and f6tes). The X-ray tube is centred a little in front of the neck of the mandible, a point corresponding fairly accurately to the midpoint of the elevated soft palate. The films are true laterals and from the exposures used produce soft tissue films. J FIG. 3 Same view as in Figs. I and 2. The photographic printing has been faded out by Veau's method. With air alone used as the contrast medium it is difficult to discern the outline of the soft palate and even more difficult to identify accurately the posterior pharyngeal wall, hence the use of some form of contrast medium on these structures is essential if they are to be of more than academic interest. Iodised oils do not flow easily over mucous membranes and the outline they give on X-ray films is usually irregular and untidy. Barium is the obvious choice for an opaque medium, but when mixed with water alone the solid matter is precipitated too readily. Mr W. Trillwood, Chief Pharmacist to the United Oxford Hospitals, suggested that if a " water-wettable substance " such as pectin were

5 DIAGNOSIS, PROGNOSIS, AND TREATMENT OF " PALATO-PHARYNGEAL INCOMPETENCE " 269 added to a solution of finely precipitated barium the resulting mixture would flow evenly and smoothly over mucous surfaces. The barium suspension is made by adding just sufficient pectin mucilage to barium sulphate to produce a thick suspension that is not pourable. The formula for the pectin mucilage is as follows :- Pectin. 3 drachms Glycerin. I½ ft. oz. Sodium benzoate. 4o gr. Boiling water to I pint. "Mix the glycerin with the pectin, add the boiling water to which the sodium benzoate has been dissolved. Boil the product with constant stirring for two minutes." For palatal radiography the barium mixture is diluted with water until it is of the consistence of thin cream. About 3 to 4 ml. of this suspension is gently injected down each nostril : the patient is lying down for this and then requested to cough with the mouth closed while the nose is lightly pinched to occlude the ~OS~RyNG~AL ALL I"/" A RCH S FIG. 4 Artist's drawing to show the position and relations of the soft palate on saying " IEE... " (i). nasal airway. This " explosive cough " will spray barium over the roof and posterior wall of the nasopharynx. A drink of about I oz. of the same material is given in order to coat the dorsum of the tongue. The X-ray films are then taken as described above. While most of our radiographs have been taken with this particular barium suspension, "Micropaque" (Damancy & Co.) has also been used satisfactorily and more recently "Fotogel" (Evans & Co.). The normal anatomy differs somewhat from that described in textbooks, and the essential points of this are shown in Fig. 4. DIAGNOSIS John Ryle, a former physician at Oxford, wrote that the three main tasks of the clinician, be he physician, surgeon, or specialist, are diagnosis, prognosis, and treatment. Of these, diagnosis is by far the most important, for upon it the success

6 270 BRITISH JOURNAL OF PLASTIC SURGERY of the other two depends. These remarks are particularly apposite to-day when so many have become bemused by "procedures," techniques, and animal experimentation as a basis for clinical practice. In the past one has been left FIG. 5 Length and mobility of the soft palate. All films show patients saying " EE... " (i). A, Normal palate : Female, aged 35. B, Normal elevation and closure of the isthmus in a boy aged 9, eight years after repair of cleft palate. Normal speech. C, Girl, aged 8, submucous cleft. Soft palate of adequate length but not elevating to the level of the hard palate, one year after repair of the submucous cleft palate. Speech shows nasal escape of air. D, Adequate soft palate but very little mobility in a boy aged 8 with congenital supranuclear bulbar paresis. Almost unintelligible speech and gross nasal escape. with the impression that diagnostic infallibility was more often the aspiration than the achievement of any surgeon. Radiography will assist to :-- I. Confirm the clinical findings concerning the length and mobility of the soft palate (Fig. 5). 2. Confirm clinical suspicions regarding the size and shape of the naso-

7 DIAGNOSIS, PROGNOSIS~ AND TREATMENT OF " PALATO-PHARYNGEAL INCOMPETENCE ~' 271 pharynx ; the competence of the palato-pharyngeal closure ; the presence of an adenoid pad and its importance to the individual concerned (Fig. 6). 3- Indicate the need for further treatment, be it surgical or therapeutic (Fig. 7). FIG. 6 The size and shape of the nasopharynx (at rest). A, Normal patient, aged 20. Narrow nasopharyngeal isthmus and long soft palate. B, Very deep pharynx in a patient who had his cleft palate repaired two years ago at the age of 32. C, Man, aged 26. Cleft palate repaired six years ago. Posterior pharyngeal wall angled forwards at about 45 degrees. The soft palate is of adequate length for competent closure of the isthmus. D, Man, aged 28. Cleft palate repair in infancy. The soft palate is the same length as patient in C but the posterior pharyngeal wall is almost vertical. In order to obtain the maximum information from these films--and it may be necessary to obtain further views during other speech sounds--a palatopharyngeal analysis should be made.

8 272 BRITISH JOURNAL OF PLASTIC SURGERY Problems in diagnosis. FIG. 7 All patients are phonating " EE... " (i). A and B. Girl, aged x I when cleft palate first repaired. A, Six months after operation. An incompetent soft palate with little mobility and an ill-defined levator eminence. Needs speech therapy. B, One year later after speech therapy. Normal speech. Competent closure of the nasopharyngeal isthmus. C and D. Cleft palate repair in female, aged 26, who had worn an obturator for the past twenty years. Speech showed normal articulation except for F.V.G.K. but nasal escape. C, Before operation: V-Y retroposition of the palate should produce a good result. D, Three weeks after operation : competent closure and no nasal escape in speech. E and F. Wide post-alveolar cleft palate in female, aged 2o. E, Before operation. Mobile soft palate more than r cm. from the posterior pharyngeal wall. F, One year after V-Y retroposition of the palate and speech therapy. The soft palate elevated to the level of the hard palate but failed to reach the posterior pharyngeal wall by 0. 4 cm. Speech shows nasal escape but normal articulation. This patient needs a pharyngoplasty (Fig. I4).

9 DIAGNOSIS~ PROGNOSIS~ AND TREATMENT OF " PALATO-PHARYNGEAL INCOMPETENCE " 273 PALATO-PHARYNGEAL ANALYSIS This may be tabulated briefly under various headings :-- i. Soft Palate.--(a) Length: Normally about four-fifths of the length of the hard palate. Actual measurements vary from 2. 5 to 4 cm. (b) Thickness : Normally 6 to 15 mm. (c) Site of the levator eminence. This is the most active part of the soft palate and normally lies near the junction of the anterior two-thirds and posterior third of its nasal surface. That portion of tissue from the posterior nasal spine FIG. 8 The levator eminence. All these patients have incompetent palato-pharyngeal closure. All are saying " EE... " (i). All present nasal escape in speech. A, Man, aged 3 2. Well-marked levator eminence of a repaired cleft palate, but the pharynx is enormous. B, Boy, aged I I. Repaired cleft palate. Ill-defined levator eminence with a convenient pad of adenoids only I mm. away. C, Boy, aged 15. Long soft palate, well-defined levator eminence which is well back, but the pharynx is too deep. No cleft palate or submucous cleft : diagnosis probably " congenital large pharynx." D, Girl, aged II. Reasonably long soft palate in a deep pharynx. The levator eminence is ill-defined and appears to be too far forwards. No evidence of submucous cleft palate and the diagnosis is probably " congenital short soft palate " (q.s.).

10 274 BRITISH JOURNAL OF PLASTIC SURGERY to the levator eminence functions as the effective valve in closure of the nasopharyngeal port during speech. It is this tissue which should be in mind when reference is made to the " length of the soft palate." In palato-pharyngeal incompetence the levator eminence is frequently too far forwards so that the effective length of the soft palate is short, even though the actual length of the organ may fall within normal limits (Fig. 8). (d) Mobility : Normally the soft palate elevates to a level above that of the hard palate for most speech sounds and will rise even higher on effort, on blowing, and on gagging. Inability to do so may indicate paralysis of the levator muscles, a muscular dehiscence at the median raphe as in submucous cleft, or more commonly restriction by scar tissue. (e) Position at Rest : The soft palate at rest reclines upon the dorsum of the tongue, leaving the nasopharyngeal isthmus widely patent and preventing oral FIG. 9 The position of soft palate at rest. A, Normal patient, female, aged 26. The soft palate reclines on the dorsum of the tongue at rest. B, Repaired cleft palate in male, aged 26. The soft palate just reaches the tongue and does not look "relaxed." respiration even when the mouth is slightly open. It does not hang in mid-air as anatomical sketches would have one believe: this position may indicate scar tissue within it or laterally, and may occasionally be seen where the palate is short and the oral cavity large (Fig. 9). z. Hard Palate.--A line joining the anterior to the posterior nasal spines can be measured as representing the length of the hard palate. This line when projected backwards will usually meet the posterior pharyngeal wall on a plane a little above that of the arch of the atlas. The latter distance can be measured and represents the depth of the nasopharyngeal isthmus. The area on the posterior pharyngeal wall above this line will be the site of expected contact for the soft palate. Descent of the hard palate occurs during growth of the face in the early years of childhood and hence there are three possible relationships that it may have to the posterior pharyngeal wall (Fig. IO) :w (I) High : Level with the basisphenoid : the infantile position.

11 DIAGNOSIS, PROGNOSIS~ AND TREATMENT OF ~ PALATO-PHARYNGEAL INCOMPETENCE ~' 275 (2) Medium : Level with the upper border of the arch of the atlas : the adult position. (3) Low : Level with the atlas or lower ; seen less frequently in the normal, but in cleft-palate patients is probably a bad prognostic sign. Since the growth of the face is downwards and forwards, obviously the farther the hard palate descends the farther it will lie from the posterior pharyngeal wall. In addition, the forward inclination of the posterior wall at the point of contact may be important. F~a. io Relation of the level of the hard palate to the arch of the atlas. has a repaired post-alveolar cleft palate. Each patient A, Male, aged 5. High position (infantile), the hard palate level being well above the arch of the atlas. B, Female, aged I5. Average position (adult) : the hard palate is level with the upper border of the arch of the atlas. C, Girl, aged I i. Low position : the hard palate is level with the lower border of the arch of the atlas. This is the most favourable type for Passavant's ridge to be able to do useful work. In infants it is an inclined plane, at an angle of 45 degrees to the horizontal, while in some adult cleft-palate patients it may be 90 degrees. A vertical posterior wall may be a decided disability for the patient whose soft palate can only just meet it (Fig. IO). 3" Nasopharynx.--Two diameters are important :-- (1) Anteroposterior.JThe distance from the posterior nasal spine to the posterior pharyngeal wall represents the depth of the isthmus. The length of soft palate should be judged in relation to this diameter in attempting to gauge the possibility of adequate closure. The mobility of the posterior wall should be noted. As mentioned elsewhere (Calnan, 1954) there are grave objections to considering Passavant's ridge essential to normal speech, but a well-developed formation may allow a short soft palate to produce apparently normal speech in isolation, even though nasal escape of air may become obvious with the rapidity of conversational speech (Fig. I I). (2) LateraL--The width of the nasopharyngeal isthmus has assumed greater importance since Hynes (195o) described an effective way of reducing it. In

12 276 BRITISH JOURNAL OF PLASTIC SURGERY adult cleft-palate patients this diameter may be enormous and will frequently be inferred from the hyper-rhinophonia which colours their speech. Lateral X-rays are of no help, but recently we have been investigating a method of coronal tomography with encouraging results. Such films are difficult to interpret. In this initial probationary period they have been checked against direct clinical measurements and a mould of the nasopharyngeal isthmus made at the At rest. " EE... " (i). Blowing. FIG. I I Passavant's ridge. A, Female, aged 22. Cleft palate repair in infancy. Speech good, but there is some nasal escape. X-rays show a long soft palate which elevates well on " EE... " and blowing, but is incompetent. The projection of Passavant's ridge (P) at the level of the uvula is shown. If only the adenoid pad was a little larger! B, The usual concept of Passavant's ridge and how it acts in speech, as seen in a male, aged 22. Cleft palate repair in infancy : speech in isolation appears to be normal, but current speech shows nasal escape, increasing with the duration and speed of the conversation. time of operation. If such a method can be standardised then it will be possible not only to obtain the width of the isthmus but also to visualise the degree of lateral closure occurring during speech. 4. Adenoids.--Radiographically it is possible to observe the site and configuration of this tissue : its importance in speech may be deduced from the way in which the soft palate when elevated impinges on its surface. The adenoid pad often represents nature's own pharyngoplasty--a free gift to patient and surgeon alike. To destroy this contribution may bring tragic consequences. The

13 DIAGNOSIS~ PROGNOSIS~ AND TREATMENT OF " PALATO-PHARYNGEAL INCOMPETENCE " 277 one absolute indication for adenoidectomy we believe to be recurrent attacks of otitis media. Even then the curette need not be used with gothic ferocity : it may be possible to remove those vegetations around the Eustachian orifice while preserving the functional pad posteriorly. Mr E. W. Peet of this Department has done such an operation on several occasions to the benefit of his patients. The X-ray tracing in Fig. 12, c, is a case in point : to have lost this buttress from FIG. I2 Adenoids. Size of the adenoid pad and its influence on paiato-pharyngeal competence. All these patients have a repaired cleft palate and normal speech. All are phonating " EE... " (i) in these films. A, Female, aged 1I. Small adenoid pad, could be removed without deterioration of speech. B, Male, aged I I. This larger pad would be missed. C, Male, aged io. Lateral adenoidectomy had been performed preserving the central vegetations. D, Enormous pad of adenoids and a short soft palate in a schoolmaster, aged 29. Truly nature's pharyngoplasty! To loose this mass of tissue from the posterior pharyngeal wall would be disastrous. the posterior pharyngeal wall would surely have led to deterioration of the good speech result which followed the palate repair carried out some six years previously. Contrary to teaching, the adenoid pad may remain until adult life, although it generally begins to atrophy just before puberty. 4 ~

14 278 BRITISH JOURNAL OF PLASTIC SURGERY 5" Tongue.--The position of the tongue during speech is of some importance, but little information can be obtained from lateral radiographs. Cineradiography would appear to be essential for an adequate study of this versatile organ. F~G. I3 Gain in length of the soft palate after Kilner V-Y operation. All patients are saying " EE... " (i). A, Female, aged I4. Cleft palate repair in infancy. Incompetent sphincter. Speech fair. B, Three weeks after secondary V-Y retroposition of the soft palate. Note gain in length of nearly I cm. C, Submucous cleft palate in female, aged 2 4. Note the short, thin, soft palate and rather tenuous Passavant ridge. D, Three months after V-Y retroposition of the palate. Note the gain in length of the soft palate (about i¼ cm.) : the wavy lines on the posterior pharyngeal wall represent tucking of the mucosa without production of an actual ridge. E, Male, aged 2 4. Palate repair in infancy. F, Secondary V-Y retroposition of the palate has produced considerable gain in length. Note the well-marked Passavant ridge which is at too low a level to be really useful. Film taken ten months after operation : had six months' speech therapy. 6. Eustachian Cushions.wThe position of the Eustachian cushions in relation to the level of the hard palate may sometimes be defined from lateral films. In planning a pharyngoplasty by muscle transplantation, the height at

15 DIAGNOSIS~ PROGNOSIS, AND TREATMENT OF " PALATO-PHARYNGEAL INCOMPETENCE " 279 which the prominence can be placed is to a large extent determined by the base of the flaps--i.e., the Eustachian cushions. TREATMENT From the foregoing information it should be possible to prescribe a rational line of treatment and expect to obtain a result which we believe can be predicted EFFECT OF HYNES PHARYNGOFLASTY Moulds ~ at level of nasophapjngeal sphlr~er to show amount of nariowing obtamed. Before POSt. After 'o~1 O Area 5.~ ~. cnl. A~rca - I sq cm T.S. aged 23. [ cm Y. \ A /~ cm. i i B FIG. 14 Hynes' pharyngoplasty, Female, aged 20. Post-alveolar cleft palate, The composite record outlines the course of treatment for this patient. It also demonstrates the rational use of radiography as an aid in diagnosis and treatment. Above--Photographs of the cleft before and after palate operation. Moulds of the nasopharyngeal isthmus before and after pharyngoplasty. Below-- A, Lateral X-ray of palate before any operation. The soft palate fails to reach the posterior pharyngeal wall by I cm. Speech : nasal escape and incorrect articulation. B, One year and four months after repair of the cleft and speech therapy : The soft palate fails to reach the posterior pharyngeal wall by o.4 cm. but the levator eminence is well defined and elevation is normal. Speech : nasal escape, correct articulation. C, Three weeks following a Hynes' pharyngoplasty. Speech : normal. with fair accuracy. Unfortunately each surgical operation introduces personal variables into any prophecy. The Kilner (1937) V-Y operation leaves the palate relatively unscarred and with a mobility comparable to that present before operation (Fig. 13). The amount of retroposition obtained in an adult has been found to be I cm. or a little less : in an infant o. 5 cm. of lengthening can be expected, while in children and C

16 280 BRITISH JOURNAL OF PLASTIC SURGERY adolescents the figure approaches that for adults. This is the only operation that I know to produce such a standardised result. With this information it should be possible to answer the question whether an operation on the palate alone wi]] permit a competent pa]ato-pharyngeal mechanism. It may be considered (either because the distance of the elevated soft palate e t,cm. A B C FIG. 15 Prognosis. Male, aged 24. Unilateral cleft lip and palate. Primary repair of palate cleft at age 24. No previous treatment. Note long mobile competent soft palate one year after speech therapy. A, Before operation. Speech : nasal escape, incorrect articulation. B, Two weeks after operation. Speech : no change. C, One year later. Speech : normal. The X-rays show the patient saying "EE... " (i) in each view. (Mr Eric Peet's case.) elements from the posterior pharyngeal wall is greater than I cm. or by reason of their lack of mobility) that a pharyngoplasty is indicated. Pharyngoplasty by muscle transplantation (Hynes, 195o, I953) in our hands produces a prominence on the posterior pharyngeal wall, to which the soft palate can elevate and meet, of the order of I cm. Radiographs will indicate the site at which this projection should be placed (Fig. I4). PROGNOSIS Hippocrates has said : " I hold that it is an excellent thing for the physician to practise forecasting. For if he discover and declare unaided by the side of his patients the present, the past, and the future, and fill in the gaps in the account

17 DIAGNOSIS, PROGNOSIS~ AND TREATMENT OF " PALATO-PHARYNGEAL INCOMPETENCE " given by the sick, he will be the more believed to understand the cases, so that men will confidently entrust themselves to him for treatment. Furthermore, he will carry out the treatment best if he knows beforehand from the present symptoms what will take place later." Such advice still stands to-day. Prognosis, a most neglected art, is a dutywto the patient and relatives: it should be a discipline for the surgeon, to set himself standards in observing, in note-taking, and in critical commentary; and finally it may influence treatment and diagnosis. We have found lateral radiographic films of value :-- I. As a check on the results of operation (Figs. 14 and I5). 2. To indicate the need for speech therapy and its probable outcome. 3- To confirm the result of speech therapy. 28I CONCLUSION An attempt has been made to show how radiographic investigations may help in the diagnosis, treatment, and prognosis of an incompetent palato-pharyngeal mechanism. They cannot, and should not, replace the routine physical examination and speech assessment. They may, and frequently do, convey information and knowledge which cannot be obtained in any other way. It has become customary in recent years to embody tables of measurements in papers dealing with radiography of the face. This practice is common (and probably rightly so) in cephalometry, and especially in publications from the New World. We, too, have tables of measurements, graphs, and scales, but so far have derived little practical benefit from them and hence they are not included here. Any pretence at dogmatism would be improper. To clothe this investigation with an appearance of scientific accuracy would be to infer a naive denial of the many variations that may occur in the normal. It is a common error to think that the more a surgeon sees, the greater his experience and the more he knows. What is required is not knowledge but wisdom in treating palato-pharyngeal incompetence. Osier (I948) defined sense or wisdom as " knowledge ready for use made effective and bearing the same relation to knowledge itself as bread does to wheat." Palato-pharyngeal radiography may provide knowledge : it will not and cannot provide wisdom. These investigations have been the product of teamwork. To acknowledge publicly the assistance received from my teachers and colleagues, it is my duty, my privilege, and my pleasure. SUMMARY Palato-pharyngeal incompetence is defined and its causes are mentioned briefly. The use of radiography in sorting out cases is emphasised together with a method of producing suitable films. The value of radiography in diagnosis, prognosis, and treatment is described in some detail and with illustrations. All patients with speech defects, particularly those of obscure origin, should have a complete palato-pharyngeal radiographic analysis in addition to the routine clinical examination.

18 - - (I95O). 282 BRITISH JOURNAL OF PLASTIC SURGERY REFERENCES BOREL-MAISSONY, S. (1947). Rev. Stomat., 48, II8. Bull. Soc. Odonto-stomat., 4, 1. CALNAN, J. S. (1952). Brit. J. plast. Surg., 5, (1954). Plast. reconstr. Surg., i3, 275. DORRANCE, G. M. (I933). " The Operative Story of Cleft Palate." London : Saunders & Co. HAGERTY, L., and HOFFMEISTER, F. S. (I954). Plast. reconstr. Surg., i3, 29o. HARRINGTON, R. (I944). J. Speech Dis., 9, 325 HIXON, E. (I949). M.S. Thesis. State University, Iowa. I-IYNES, W. (I95O). Brit. J. plast. Surg., 3, (I953). Ann. R. Coll. Surg. Engl., I3, I7. KALTENBORN, A. L. (I948). M.A. Thesis. Northwestern University, Chicago. KILNER, T. POMFRET (I937). St Thorn. Hosp. Rep., 2, I27. NORRIS, M. A. (1949). M.S. Thesis. State University, Iowa. OLDFIELD, M. (1947)- Brit. J. Surg., 35, 173. OSLER, W. (1948). " ~-~quanimitas and Other Addresses," 3rd ed. London : Lewis & Co. PODVlNEC, S., and MARK, B. (I95I). Ann. Oto-laryng., 68, 225. RICKETTS, R. M. (I954). Plast. reconstr. Surg., I4, 47- RYLE, J. A. (1948). University Press. " The Natural History of Disease," 2nd ed. London: Oxford StmTELNY, D. (1954). Personal communication. TREVINO, S. N., and PARMENTER, C. E. (1932). Quart. J. Speech, I8, 351. VAUGHAN, H. S. (194o). " Congenital Cleft Lip, Cleft Palate, and Associated Deformities." London : Henry Kimpton. VEAU, V., and BOREL-MAISSONY, S. (1943). Mdm. Acad. Chit., 69, I. VEAU, V., and RECAMIER, J. (1938). " Bec-de-li~vre." Paris : Masson & Cie. WOLFE, W. G. (1942). M.A. Thesis. State University, Iowa.