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Section V. Resonance and Phonation SAMUEL G. FLETCHER, Ph.D. (CHAIRMAN) Despite an Ever Widening Scope of Topics in Cleft Palate

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Section V. Resonance and Phonation SAMUEL G. FLETCHER, Ph.D. (CHAIRMAN) Despite an Ever Widening Scope of Topics in Cleft Palate Section V. Resonance and Phonation SAMUEL G. FLETCHER, Ph.D. (CHAIRMAN) Despite an ever widening scope of topics use of instrumentation and procedures to in cleft palate research, progress in reha- increase diagnostic and management pre- bilitation is still largely defined by the ex- cision, and (c) systematic evaluation of tent to which speech disorders exist, may «speech treatment restults. The importance be prevented, or are eradicated (Bauer, of multistructural dynamic impairment 1972; Randal, 1974; Kraus, VanDemark, - has also been mentioned frequently but and Tharp, 1975; Wilder and Baken, has received little direct attention. 1975). In the speech section of the previous Palatopharyngeal Disturbance Without state-of-the-art review (Spriestersbach et Overt Cleft al., 1973) major attention was given to Identification of palatopharyngeal dis- three broad aspects of speech research: 1) turbance in the absence of overt cleft disturbances in anatomical and physiologi- serves to highlight a variety of disorders cal aspects of speaking; 2) assessment of with potentially common speech symptom- special speech characteristics and disor- atology. Calnan (1976) recently re-pre- ders attributable to maxillofacial anomaly; sented his system for classifying such dis- and 3) therapeutic processes and proce- turbances. Minami and associates (1975) dures for speech habilitation. A number of proposed an expanded etiological classifi- issues identified in the earlier review re- cation system in which nearly fifty types of main unresolved. For example, informa- disability known to affect palatopharyn- tion is still unavailable concerning a variety geal structure and function are itemized. of essential components of velopharyngeal They also reviewed observations from 188 (V-P) movement in speakers with V-P in- patients and attempted to differentiate eti- sufficiency. These include a description of ological indices, certain speech characteris- the distribution of forces impinging upon tics, and appropriate surgical management the velopharyngeal valve during normal as a function of disability type. Such infor- and impaired speaking, physiologic pat- mation provides an excellent foundation terns of altered velar function as a conse- for definitive documentation of speech quence of adenoidectomy and other forms signs, disorders, and incidence of impair- of surgical intervention, and modifications ment among patients with the heteroge- in sound transmission occurring in re- neous disabilities. sponse to partial-to-complete obstruction Several papers have appeared recently of the nasal passageways and associated that provide information about aspects of disturbances in V-P valving. palatopharyngeal function that have been Three major concerns appear in the given little prior attention. Gibb and Stew- forefront of speech resonance and phona- art (1975) described a patient with "hysteri- tion research during the 1972-1976 period: cal" hypernasality following simple tonsil (a) incidence and characteristics of defi- dissection. Adenoridectomy was not per- ciencies in palatopharyngeal structure formed. They suggested that the possibil- without overt cleft, (b) development and ity of emotional reactions should be con- sidered when organic impairment cannot Dr. Fletcher is Professor of Biocommunication, be firmly established. Dentistry and Rehabilitation Medicine, Chairman, Messengill, Pickerel and Robinson Biocommunication Department, University of Ala- bama in Birmingham, P.O. Box 187, University Sta- (1973) observed that some patients with tion, Birmingham, Alabama 35294. submucosal cleft palate (SMCP) do not 313 314 Cleft Palate Journal, October 1977, Vol. 14 No. 4 have hypernasal speech. However, in their through study of such patients appears opinion, patients of this type are few in promising. number. The low incidence claim was re- cently challenged by Porterfield, Mohler, Vocal Tract Functions Related to Cleft and Sandel (1976) who reported that 18 of Palate ’ 97 patients they identified with SMCP had The introduction of new instrumenta- normal speech. tion brings opportunity to re-evaluate cur- An electronic instrument which uses the rent concepts about structural deficiencies principle of translumination to detect mus- and speech performance as well as to in- cular discontinuity in submucous cleft pal- crease the precision of observations being ate has been described by Pawlawski made. In a review of radiographic tech- (1975). The data reported demonstrated niques used to study velopharyngeal func- an ability to distinguish such persons from tion, Skolnick (1975) called particular at- those with normal palatal structure. tention to the three-dimensional, sphinc- Hypernasality is typically identified as a teric valving characteristics of the V -P por- consequence of developmental or disease tal. Drawing upon evidence from a series trauma to velopharyngeal structures. Re- of frontal-, lateral- and basal-view studies, cent advances in facial surgery to correct he and his associates made videoflurosco- retroposition of the maxilla have provided pic observations which provide unique in- an additional opportunity to learn more sight into specific dynamics of V-P action. about the relationships between palato- A system for classifying the spectrum of pharyngeal morphology and nasality. sphincteric patterns from the basal view Schwartz and Gruner (1976) identified orientation supports this thesis. A problem perceptable alterations in nasal resonance of basal view x-ray is the "sphinx" position as a function of surgically changing the used to visualize the soft tissue activities. position of the maxilla and attached soft Shelton and Trier (1976) pointed out that palate. Maxillary advancement was associ- this abnormal posture can influence both ated with a slight to moderate increase in the anatomical relationships of the palato- perceived nasality in 27 of 31 (87%) pa- pharyngeal structures at rest and the sub- tients studied with repaired palatal clefts. sequent motion patterns as the person A small, but identifiable, increase in per- speaks. They also note that the use of ra- ceived nasality was detected in two (22%) diopaque media to define soft tissue of 9 patients with no overt palatal clefts. boundaries has been shown to change There appeared to be little correspond- speech patterns in certain subjects. ence between the extent of maxillary ad- Visualization of sphincteric action of vance and the degree of change in nasality. palatopharyngeal valving similar to that of Using Schwartz and Gruner's data, a cor- basal-view videofluoroscopy may be ob- relation coefficient was calcualted to ex- tained by oral and nasal endoscopy or fi- amine the strength of this association. The beroscopy without the risk of radiation. resultant value (r = .18) was low and non- Willis and Stutz (1972) and Zwitman, Son- significant. A variety of explanations could derman, and Ward (1974) have presented be advanced to account for the intersubject systems for classifying the V-P valving pat- differences in speech degradation follow- terns from oral endoscopy. Piggot and ing maxillary advancement. For example, Makepiece (1975) and Matsuya, Miyazaki, differences in degree of velopharyngeal and Yamaoka (1974) have described V-P competency could have been unmasked by functions from nasal endoscopic and fiber- the- changes in structural morphology. optic viewpoints respectively. Conversely, variation in the strategies used The obvious disadvantage of oral endos- to adapt to the surgically restructured copy is that the instrument lies on or above morphology may have been an important the tongue during examination. This re- factor in the degree of speech degradation stricts the phonetic repertoire for speech found. The potential for gaining new in- observations essentially to low vowels and formation concerning speech adaptation labial consonants. Nevertheless, as shown Fletcher, STATE-OF-ART (RESONANCE) 315 by Zwitman, Gyepes and Ward (1976) the other than those of the velopharyngeal observations which can be made show area. good agreement with those from basal From pneumographic studies Tron- view fluoroscopy. ‘ cyznska (1972) reported that cleft palate While nasal endoscopy and fiberoscopy speakers as a group have a greater fre- yield data on V-P function without the quency of breaths during speech than phonetic restrictions of oral endoscopy, their normal counterparts, and the rate possible changes in physiology from the difference tends to become more exagger- discomfort incident to insertion of the in- ated with speech habilitation. Similar ob- strument through the nasal cavities has not servations with respect to control of the been investigated. airstream were summarized by Warren A serious problem of all endoscopic and (1975) in his recent review of aerodynamic fiberoptic systems for visualizing sphinc- changes related to palatopharyngeal in- teric actions of palatopharyngeal valving is competency. quantification. Present lens systems used Changes in laryngeal function have also in endoscopy have progressive distortion been observed in speakers with palato- from the center of the image (Schwartz, pharyngeal anomalies. McWilliams, La- 1975), and none of the instrumental ap- vorato, and Bluestone (1973) reexamined proaches now available enable specifica- 27 patients approximately five years after tion of the cephalocaudal level at which V - abnormalities of the vocal cords had been P function is being monitored. Use of identified. They found that 70 per cent of multi-element
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