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

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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?

1 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? " This question is in the mind of the surgeon as he examines the result of his operation on the palatopharyngeal valve. For a quick answer, special blowing tests have been devised. It is generally thought that if the patient under review can accomplish the same feats of blowing as can an individual with a normal palate, then the mechanism is capable of functioning normally. If the patient demonstrates his ability to blow normally then, it is argued, the surgeon has completed his task; logically it is now the duty of the speech therapist to teach the patient how to get rid of his bad speech habits. Hence blowing tests have been used for many years in the diagnosis and prognosis for speech of patients with an incompetent palatopharyngeal mechanism, yet no results have been published to demonstrate their value. In England the carnival blower test was introduced by Wardill in I933 and is widely used. Several writers (Kilner, I937 ; Oldfield, i94i ; Hynes, 1953) have recommended its use and commented favourably. The test is carried out as follows : The patient is presented with the carnival blower and asked to blow it out to its full length (Fig. I). If he does not know how to blow it out the carnival blower is unrolled a little to give him encouragement. If this fails on several attempts the instrument is reinspected to exclude a defect in it, and the test is then reported as " negative." A positive test is recorded where the carnival blower can be fully extended. The carnival blower has many advantages: it is small, simple to operate, and attractive to children. It requires a strong, steady stream of air to extend it fullymthe person with a competent mechanism can accomplish it with just a little effort while the individual with gross incompetence usually cannot and so the test appears to be discriminating. Later the use of the Windsor measure was recommended by Hynes (I954). The principle is the same. The patient blows through a tube into a bottle of water and the air displaces a column of water up into another tube from the same bottle. The column can be measured and a chart made to show progress in the ability to displace more and more water. Recently a manometer has been described by Spriestersbach (I959). Its purpose is to measure the air pressure used during blowing (in ounces per square inch) and appears to be a more accurate measuring instrument than hitherto devised. Over the years, refinements to these various blowing tests have been made. It was found that some patients could produce the same results from blowing as could a person with a normal palate, because these individuals had a large enough 1 Now Lecturer in Experimental Plastic Surgery, Postgraduate Medical School, University of London. 34o

I The carnival blower test. A, The carnival blower held by the patient ready to be inserted between the lips. B, A negative test.

2 BLOWING TESTS AND SPEECH 341 vital capacity to allow for loss of pressure through nasal escape. Consequently it was necessary to hold a cold mirror under the patient's nose while he was blowing so that the presence of nasal escape could be registered. In some cases the attempts A B C FIG. I The carnival blower test. A, The carnival blower held by the patient ready to be inserted between the lips. B, A negative test. The cheeks are distended but all air comes down the nose and there is insufficient pressure to unroll the carnival blower. C, A positive test. No air comes down the nose to cloud the mirror and the carnival blower is fully extended. at blowing were compared, one with the nostrils occluded, the other with the nostrils open. In spite of these refinements, test results from blowing were often highly variable in the same patient. Moreover, some patients learned that they could be more successful with a quick blow than with a slow, steady one, and it was difficult to standardise the test procedure. 43

3 342 BRITISH JOURNAL OF PLASTIC SURGERY Much effort has been expended in devising more accurate and effective blowing tests, whereas very little research has been done on more fundamental questions. These would appear to be :-- I. Does performance in blowing help in the diagnosis or prognosis of persons with nasal speech? 2. Does the palatopharyngeal mechanism act in the same way for blowing as for speech? 3. Does development of skill in blowing have a transfer value to speech? The discerning reader will already have recognised the deceptive nature of the extrapolation implied in blowing tests, and the present investigation was planned to answer these questions. MATERIAL AND METHOD Although all three devices--the carnival blower, the Windsor measure, and the manometer--have been used in our department, the largest series of tests have been carried out with the carnival blower. We came to the conclusion that it gave us as much useful information as did either of the other tests. The carnival blower test was carried out in a consecutive series of 225 patients who attended because of persistent nasal speech. While the patient was blowing, a cold mirror was held beneath his nostrils to detect the presence of nasal escape. The results are shown in Table I. It will be seen that more than a third of the nasal speakers, i.e., those in whom the test was positive, were already as efficient in blowing as a person with a normal palate. All patients had still lateral X-ray films taken at the time of consultation, and the three standard films (at rest, saying "EE...," and while blowing the carnival blower) were analysed. The X-ray films confirmed that all the 225 patients had an incompetent palatopharyngeal valve on saying "EE..." but that eighty-five of them apparently had a competent mechanism. TABLE I The Blowing Test 225 nasal speakers " EE... " Blowing. Competent Incompetent. Per cent. Nil IO0 Per cent RESULTS Since we are here interested only in those eighty-five nasal speakers in whom the blowing test was positive, the clinical and X-ray findings are confined to this group.

4 BLOWING TESTS AND SPEECH 343 As a result of examination of the X-ray films it was found that, during blowing, certain compensating mechanisms of the palatopharyngeal valve were used and that such compensations either did not occur or were ineffectual during the phonation of" EE..." (Table II). Representative X-ray tracings are shown as line drawings in Figs. 2 to 7. THE CARNIVAL BLOWER TEST Incompetent on " E~... " Competent on blowing. REST EE... BLOWING REST E E BLOWING FIG. 2 FIG. 3 Fig. 2.--Greater than normal elevation of soft palate on blowing (28 per cent.). Fig. 3.--Posterior third of soft palate blown back (28 per cent.). REST EE. BLOWING REST EE... glowing FIG. 4 FIG. 5 Fig. 4.--Passavant's ridge (22.5 per cent.). Fig. 5.--Normal elevation on blowing, less on " EE... " (9"5 per cent.). REST EE BLOWING REST EE BLOWING FIG. 6 FIG. 7 Fig. 6.--Passavant's ridge and posterior third blown back (7 per cent.). Fig. 7.--Passavant's ridge and greater elevation of soft palate (5 per cent.). FIGS. 2 to 7 Direct X-ray tracing of patient representative of this group in whom the carnival blower test was positive (see text and Tables I and II). It was originally thought that a positive carnival blower test might indicate that the amount of incompetence during speech must be very small, and the eighty-five cases were therefore re-examined from this point of view. The gap on the X-ray between the elevated soft palate and the posterior pharyngeal wall during the "Er..." sound was measured to assess the degree of incompetence during speech. An arbitrary figure of 5 ram. was chosen as the dividing line between those having a large gap and those having a small gap. Table III shows

5 L 344 BRITISH JOURNAL OF PLASTIC SURGERY clearly that although fifty-five (65 per cent.) of the eighty-five patients who were efficient blowers had a small gap (less than 5 mm.) on "EE...," more than one-third (35 per cent.) of the total had a large gap. If to the X-ray evidence we add the result of the cold mirror test to assess the presence of nasal escape of air during blowing (Table III), the results again change. About half the patients in each group have nasal escape of air during blowing. TABLE II Compensatory Mechanisms seen on X-ray in Eighty-five Nasal Speakers with a Positive Carnival Blower Test Compensatory Mechanism seen on X-ray. Total Cases. Proportion of all Cases. Greater than normal elevation of soft palate on blowing. 24 Normal elevation on " EE... Posterior third of soft palate blown back to contact 24 posterior pharyngeal wall with or without greater elevation than on " EE... " Passavant's ridge alone making mechanism competent I9 Less than normal elevation of soft palate on " EE... " 8 Normal elevation on blowing Posterior third of soft palate blown back to contact I 6 Passavant's ridge Passavant's ridge plus greater elevation of soft palate 4 Total i 85 Per cent. 28 "O 28"o 22 '5 9" IO0"O TABLE III Eighty-five Nasal Speakers competent on blowing, incompetent on X-ray and clinical findings ~' EE... " Compensatory Mechanism seen on X-ray. Gap on " EE... " less than 5 mm. Totals. Nasal Escape on Mirror. Gap on " EE... " more than 5 ram. Totals. I Nasal Escape ] on Mirror. Greater elevation than normal of soft palate on blowing. Normal elevation on " EE... " Posterior third of soft palate blown back to contact posterior pharyngeal wall with or without greater elevation Passavant's ridge alone making mechanism competent Less than normal elevation on " F.E... " Normal elevation on blowing Posterior third of soft palate blown back to contact Passavant's ridge Passavant's ridge plus greater elevation of soft palate x7 9 I I O I I I 5 I 3 2 Total I7

BLOWING TESTS AND SPEECH 345 DISCUSSION It has been shown by these investigations that the carnival blower test cannot be relied upon to provide accurate information in diagnosis.

6 BLOWING TESTS AND SPEECH 345 DISCUSSION It has been shown by these investigations that the carnival blower test cannot be relied upon to provide accurate information in diagnosis. Although the number of "false positives " can be reduced by the addition of the mirror test, even this does not improve the efficiency of the carnival blower test for diagnosis, because nasal escape can be eliminated in blowing by compensatory mechanisms. It is possible to pocket air in the mouth by raising the back of the tongue to form a seal with the depressed soft palate and then to close the lips in such a way as to impound air within the mouth, and the cheeks can be distended by this air pressure. Such impounded air can be used in blowing, as an initial impetus by patients with an incompetent nasopharyngeal mechanism, but it is not of sufficient volume to sustain a positive carnival blower test for more than a few seconds. The proportion of persons with marked incompetence (more than 5 rnm. gap) remains too high for blowing to be regarded as a discriminating test. As a prognostic aid it is of even less value, for all the patients under investigation had persistent nasal speech and many had had long periods of speech therapy. The compensatory mechanisms by which such persons manage to perform with a positive result are interesting to observe, but we have no evidence that any of these mechanisms are used during the normal flow of speech. It is even doubtful if the development of such compensatory mechanisms is desirable. Is the Mechanism the Same?--McDonald and Baker (1951 ) describe the muscular action of blowing as a swift tonic contraction, and that of speech as a series of clonic contractions, a ballistic movement. Hence, although the mechanism involved may indeed be the same anatomically, the present investigation has shown that its use physiologically can be completely different: similarly one might compare the value of catching a ball as a preparation for playing the piano. Transfer of Skill in Blowing to Speech.--Until comparatively recently conventional speech therapy for the correction of nasal speech has included many exercises in blowing. Wardill (I928), Van Thal (1931), Oldfield (I94I, 1947, I949), Morley (I945, 1951, I954), and many others have advised them, although in later publications Morley (I957, 1958) gave them less prominence. Many speech therapists, however, have come to realise the futility of constant blowing practice and have turned their attention, with more gratifying results, to improving the patient's articulation. They found that, after all, the best exercise for speech is speech. Certain writers on cleft palate speech have, from time to time, questioned the value of blowing exercises (Kantner, 1947; McDonald and Baker, 1951 ; Van Riper and Irwin, 1959), but tradition dies hard. The results of our investigation into the means by which nasal speakers may achieve competence during blowing suggest that practice in blowing may well bring into play mechanisms which are useless in speech. Success in blowing may lead on the patient and therapist in a false hope that speech will vicariously improve. If speech therapy merely stimulates the production of compensatory mechanisms during blowing, there is no indication that these mechanisms can be carried over into speech, so that time and energy spent on this activity have been wasted. This argument is supported by an examination of serial X-rays in a

7 346 BRII'ISH JOURNAL OF PLASTIC SURGERY small group of patients : two, after a course of speech therapy, including much blowing, developed a useless Passavant's ridge ; the others, who had had no speech therapy, developed competence for speech nearly a year after cleft palate repair late in life. SUMMARY AND CONCLUSIONS I. A series of 225 persons with nasal escape during speech were examined radiologically and clinically, using the carnival blower and mirror tests. 2. Of these, eighty-five had a positive carnival blower test and the mechanisms by which this was achieved are reported. 3. The carnival blower test provides little information of diagnostic value for speech. REFERENCES HYNES, W. (I953). Ann. R. Coll. Surg. Engl., r3, (I954). Brit. J. plast. Surg., 7, 242. KANTNER, C. E. (I947). J. Speech Dis., r2, 28I. KILNER, T. P. (I937). St Thorn. Hosp. Rep., I27. McDoNALD, E. T., and BAKER, H. K. (I95I). J. Speech Dis., i6, 9. MO~EY, M. E. (I945). " Cleft Palate and Speech." Edinburgh : E. & S. Livingstone. -- (i951). " Cleft Palate and Speech," 2nd ed. Edinburgh : E. & S. Livingstone. -- (1954). " Cleft Palate and Speech;" 3rd ed. Edinburgh : E. & S. Livingstone. -- (I957). " The Development and DNorders of Speech in Childhood." Edinburgh : E. & S. Livingstone. -- (1958). " Cleft Palate and Speech," 4th ed. Edinburgh : E. & S. Livingstone. OLDFIELD, M. (1941). Brit. J. Surg., 29, (1947). Brit. J. Surg., 35, (1949). Brit. J. Surg., 38, 178. SPRIESTERSBACH, D. C. (1959). ft. Speech Res., 2, 4. VAN RIPER and IRWIN, J. V. (1959). " Voice and Articulation." London: Pitman Medical Books. VAN THAL, J. H. (1931). " Cleft Palate Speech." London : Allen & Irwin. WARDILL, W. E. M. (1928). Brit. J. Surg., 26, 127.

Stanford University School of Medicine, Department of Surgery, Stanford, California

THE RESTRICTIVE PHARYNGEAL FLAP By JAROY WEBER, Jr., M.D., ROBERT A. CHASE, M.D. and RICHARD P. JOBE, M.D. Stanford University School of Medicine, Department of Surgery, Stanford, California THE historical