Nasendoscopy in the Diagnosis of Velo-Pharyngeal Incompetence

The surgeon faced with the question of velopharyngeal incompetence is deprived of most resources of classical diagnosis. On inspecting, he may speculate (astronomer like) on the mysteries above the vault; while from lateral X-rays or cinefluorography he must be content, as it were, to lip-read from the shadows upon a wall. However, shadows are two dimensional; perhaps because of this, both primary and secondary treatment are usually designed to treat a symmetrical defect existing mainly in the sagittal plane. The very words “short palate” and “palate lengthening” suggest the sagittal concept. The production of a medial obstruction and the reduction of the circumference of the apparently too capacious pharynx, inherent in current pharyngoplasties (Schonborn,18 Rosen-thai,17 Roselli,16 Hynes7), are again symmetrical procedures. That “normal speech” is produced in some 80 per cent of cases confirms the fundamental right-ness of the sagittal concept (Peet,11 Reidy,13 Braithwaite1). It is in “the other 20 per cent” (Reidy14) that we may benefit most from a third dimension. Direct observation of the oral side of the palatopharyngeal valve has been effectively solved by Taub.19 Using his oral panendoscope, around which the lips can be closed, a combination of vowels and plosives may be built into a reasonable and practical facsimile of continuous speech, while the valve is observed and photographed. Observation of the nasal surface could permit unobstructed speech patterns and also offer an unobstructed view of the palatopharyngeal valve, which would be advantageous. A standard nasendoscope, of course, cannot be made to visualize the point of contact between palate and pharyngeal wall. However, the absence of the bulky bulb housing in the fiberoptic instruments has permitted them to be passed one centimeter further. The American Cystoscope Company's fiberoptic infant cystoscope has the added advantage of a smaller diameter.