[ Music ] [Narrator:] It is our primary objective in this motion picture to alert surgeons to the danger of postoperative velopharyngeal incompetence in T and A surgery. A lasting hypernasality following adenoidectomy is not an uncommon complication. It has been reported to occur in one of every 100 T and A operations, with a temporary hypernasality in 7.2 percent. Thus, it becomes obvious that velopharyngeal function should be taken into consideration preoperatively. [Pre-Adenotonsillectomy Cinefluorography] [ Music ] [Narrator:] Historically, the concept of motion picture x-rays was presented in 1897, two years following Von Roentgen's discovery of x-ray. It was reported that the use of x-ray would be important to document speech. As we view the normal phonation pattern, it is of interest to note that cinefluorography presents the dynamic aspects of function in contrast to the classical static x-ray. The lateral skull film does not provide the functional aspects of head and neck anatomy. Cinefluography allows us to view swallowing, respiration, and speech patterns. Normal head and neck anatomy, as it relates to speech, has been thoroughly documented. The anatomical relationships during the phonation of the vowel, ahh, demonstrate the following anatomy. Fourteen anatomical components are considered essential in the routine radiological and physical examination of a preoperative T and A patient. Number one, adenoidal area. This lymphoid tissue will vary greatly in mass as we will see. The area is critical during phonation in children with slight velopharyngeal incompetencies. Number two, the tonsils. Number three, velum. The size, shape, and placement of the velum is also critical. In normal phonation, the velum is in this position during the phonation of the vowel, ahh. The constrictor muscles of the pharyx, number four, move in conjunction with the velum and other pharyngeal musculature to accomplish phonation and deglutition. Note the position of the arch of the atlas, number five. During phonation of vowels and the majority of consonants, the velum will elevate to the level of or slightly superior to the arch of the atlas. Number six, the tongue. Number seven, the hard palate. At the posterior aspect of the hard palate is number eight, the posterior nasal spine. The absence of the spine is of considerable clinical significance. Nine indicates the position of the other cervical vertebrae. Number two, the tonsil, is located between 10, the palatoglossus muscle, and 11, the palatopharyngeus. The eustachian tube is number 12. Number 13, the tensor palatal muscle, and 14, levator palatal muscle, tense and elevate the velum during deglutition and phonation. Normal velopharyngeal function should serve as a basis for the pre-adenotonsillectomy evaluation. Deglutition has three phases, oral, bolus organization, movement of the bolus from the anterior position in the mouth into the pharynx. During this stage, the velum is elevated and contacts the superior constrictor muscle, or posterior pharyngeal wall, while the tongue compresses the bolus against the velum. The velum's purpose is to seal off the nasopharynx and to prevent any portion of the bolus from being regurgitated into the nasopharynx. The third, the esophageal phase, the bolus moves into and down the esophagus. Normal phonation, as demonstrated by this 18-year-old postoperative T and A patient. The velum contacts and seals the nasopharynx from nasal air escapage on all vowels and all consonants except the three nasal consonants, M, N, and NG. The phonation of ahh demonstrates one of the best positions to view the essential anatomical components, soft palate, superior constrictor, arch of the atlas, and the tongue. [Patient:] Ee, ahh, oooh, rang the bells and sang.] [Doctor:] Once more. [Patient:] Ee, ahh, oooh, rang the bells and sang. [Narrator:] When considering adenotonsillectomy, the surgeon should examine the oral and pharyngeal areas closely, noting bluish coloration in the mucosa of the median raphe, the presence of a bifid uvula, and the size and shape of the velum. He should palpate the palate to establish the presence of a posterior nasal spine. The history should note feeding problems during infancy, especially incidents of nasal regurgitation, slow or delayed speech development, and whether the preoperative speech quality is hypo or hypernasal. When one or more of these findings are confronted, one should be alert to the possibility of a congenital velopharyngeal incompetence, submucous cleft palate, or other anomalies. A radiological examination to include cinefluorographic studies during deglutition and phonation in preoperative evaluation of suspicious cases will serve to avoid a speech disaster and medical-legal challenge. Three types of patients will be compared: postoperative T and A incompetence, cleft palate incompetence, and submucous cleft palate incompetence. A T and A was performed at the age of three. The patient is now nine. Deglutition is considered adequate. However, during phonation, note the large velopharyngeal incompetence. No posterior nasal spine was evident. [...] Note the velopharyngeal incompetence during phonation. Positions of the soft palate, superior constrictor, arch of the atlas, and the tongue are indicated. This 11-year-old had a T and A at the age of seven. The deglutition pattern is normal. The velum is mobile. It elevates but does not flex during phonation, resulting in a velopharyngeal incompetence. The T and A was considered indicated due to frequent respiratory infections. The third case, a 14-year-old, had a T and A at age 11. Hypernasality resulted. Note the large velum, the position of the tongue, and superior constrictor. A posterior nasal spine was present. Only occasionally the velum contacts the superior constrictor on isolated vowels. The high concavity of the sphenoid vault is the result of the adenoidectomy. This 12-year-old cleft palate patient had a T and A performed at age nine. Continuous nasal speech was noted. Visually compare these patients, born with palatal defects, with the previous group who preoperatively presented no palatal or facial anomalies. The classical cleft palate deglutition pattern is illustrated during the pharyngeal stage. The posterior base of the tongue is depressed to allow the bolus flow into the esophagus because the residual velum is not adequate to seal the nasopharynx. This compensatory deglutition pattern is established early in life to prevent continuous nasal regurgitation. During phonation, the velopharyngeal incompetence is extreme. [...] The open vowel position demonstrates the insufficient anatomical relationships noted between the tongue, soft palate, arch of the atlas, and pharyngeal constrictors. This 11-year-old medial repair of a cleft palate had a T and A performed at 10 and demonstrates minimum velopharyngeal incompetence. The T and A was performed due to continuous upper respiratory infections. Note minimum incompetence during phonation. The loss of the adenoidal tissue increased the incompetency and hypernasality. Normal deglutition is demonstrated by this 11-year-old cleft palate patient. However, palatal incompetence is seen during phonation. [...] Note the high sphenoid vault in the nasopharynx and the relationships of velum to the pharyngeal constrictors, arch of the atlas, and tongue. Each of the last group of patients preoperatively indicated no hypernasal speech patterns. The initial patient, 12 years of age, had a T and A at age five. He has no posterior nasal spine, and soon after the T and A was performed, hypernasal speech resulted. Note the minimum velopharyngeal incompetence. [...] Another postoperative T and A with minimum velopharyngeal incompetence. Again, note the relationship of the velum to the pharyngeal constrictors, arch of the atlas, and tongue. This patient, nine years of age, had a T and A at seven, resulting in marked hypernasality. He presented classical submucous symptoms of compensatory deglution pattern, no posterior nasal spine, and a bifid uvula. Note the small size of the velum and the lack of contact between the velum and pharyngeal constrictors. This film has presented cinefluorography as one modality and examination criteria for pre-adenotonsillectomy evaluations. When velopharyngeal function is abnormal, adenotonsillectomy should be carefully considered. The surgeon must be on guard against a potential speech complication. [ Music ]