Citation
Velopharyngeal mechanism:

Material Information

Title:
Velopharyngeal mechanism: : the factor of sex
Creator:
McKerns, Dorothy McDuffe, 1923- ( Dissertant )
Bzoch, Kenneth ( Thesis advisor )
Moore, G. Paul ( Reviewer )
Abbot, Thomas ( Reviewer )
Horel, James ( Reviewer )
Bunnell, Bradford N. ( Reviewer )
Jones, E. ( Degree grantor )
Place of Publication:
Gainesville, Fla.
Publisher:
University of Florida
Publication Date:
Copyright Date:
1968
Language:
English
Physical Description:
v, 70 leaves. : illus. ; 28 cm.

Subjects

Subjects / Keywords:
Cineradiography ( jstor )
Cleft palate ( jstor )
Geometric lines ( jstor )
Nasopharynx ( jstor )
Palatal consonants ( jstor )
Palate ( jstor )
Pharynx ( jstor )
Soft palate ( jstor )
Velar consonants ( jstor )
Vowels ( jstor )
Cinematograpy, Medical ( lcsh )
Dissertations, Academic -- Speech -- UF ( lcsh )
Speech ( lcsh )
Speech thesis Ph. D ( lcsh )
Genre:
bibliography ( marcgt )
non-fiction ( marcgt )

Notes

Thesis:
Thesis--University of Florida.
Bibliography:
Bibliography: leaves 65-69.
Original Version:
Manuscript copy.
General Note:
Vita.

Record Information

Source Institution:
University of Florida
Holding Location:
University of Florida
Rights Management:
Copyright [name of dissertation author]. Permission granted to the University of Florida to digitize, archive and distribute this item for non-profit research and educational purposes. Any reuse of this item in excess of fair use or other copyright exemptions requires permission of the copyright holder.
Resource Identifier:
022059302 ( AlephBibNum )
13489120 ( OCLC )
ACY4876 ( NOTIS )

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VELOPHARYNGEAL MECHANISM:
THE FACTOR OF SEX












By
DOROTHY McDUFFE McKERNS













A DISSERTATION PRESENTED TO THE CMADUATE COUNCIL OF
THE UTNIFTRITY OF FLO~mA
w PMMTI MFULILLAENT OF THE REQUIREMlENTS FOR THE
DECREE OF DOCTOR OF PHILOISOPHY


UNIVERSITY OF FLORIDA
1968









ACKNI~OWLE:DGEXENTST


Appreciation. and gratitude are: extended to the

chairman of my committee, Dr. Kenneth Bzoch, Professor

and riead of the Department of Communicative Disorders,

College of Health Related Professions, who provided the

opportunity for me to become involved wiith the techniques

and understandings prerequisite to the definition of the

stud~y undertaken. Dr, Bzoch generously allowed his library

of films to be used in this study. The progress of the

investigation wazs imm~easurably assisted by his patient

constructive criticism and many perceptive suggestions.

I wish to than~k the other members of m~y co-nmiittee,

DrI. G. Paul Nioore, Dr. Thomas Abb~ott, Dr. Jam!es H-orel., and.

Dr. Bradford N,. junnell for giving generously of their time

and assistance in bringing the study to its conclusion.

It is no exaggeration to say that this investiZ-

a~tion could not have been carried out without the constant

encouragement and tireless assistance of -y two friends,

Dr. Richardi LeaSue andi ir. Jlilliamr H.jillia-s, They have

ny deepest gratitude.

Appreciation is extended to Dr. Lowell C. Hammer

for help with th- pilot studies and to Dr. John Thornby for

assistance wiith a major statistical problem.













TABLE OF" CONTENTS

Chapter Page

I Introduction. .. .. .. ... .. 1

Review of the Literature. ... . .. 2

II Statement of the Problem. .. .. .. 22

Hypothesis. ....... ... .. 23
Purpose of the Study. 29

III Methods and Procedures. .. .. ... 31

Initial Selection of Subjects . ... 31
Procedures for Obtaining Films. 1
Selection of Subjects for This Study. 2
Procedure for Collecting Data .. .. 35
Reliability .. ...... 41
Method of Analysis. ... 43

IV Results .. ... .. ... .. .. 46

V Discussion, Conclusions, Summary.. .. 55

Discussion. .. .. .. .. .. .. 55
Conclusions . .. .. .. ... .. 61
Summary ... .. .. .. .. .. 62

Blibliography. . .... .. .. .. ... 65

Biographical Sketch . .. .. .. .. ... 70


111











LIST OF IA3LESS

Table Page

1 K~ruskall-ljallis One-way Analysis
of Variance of Sounds /pi/, /tl/, /ki/. . 34

2 Relationship of Inferior Point of Contact
to Palatal Plane. .. ... .. .. .. 46

3 Saw Data for Females . .... .. .. 47

4 9aw Data for Males .. .. ... .. .. 48

5 Comparison of Mean Yeight of Elevation
between Males and Females .. .. .. .. 49

6 Comparison of iMeans of Amount of Contact . 50

7 Comparison of Means for Males and
Females for LAEC. ........ ... 50

8 Comparison of Mleans for Kales and
Females for Ratio EC:EF . ... . ... 51

9 Comparison of Means of Velar Length
in Bales and Females. .. .. .. .. 51

10 Significance of Difference in
IKeasurements of PNS-X and PNIS-Y .. .. 52

11 Crganization of Subjects by Measurements
of Angle ABC. ... . ... .. .. 57











LIST OF FIGREL_4S


Figure Page

1 An Orientation and Configuration of
the Velum in Closure for Speech. .. .. 12

2 Illustration of Height of Elevation,
Closure, and Lepth of Nasopharynx. .. 16

3 "Squared-off" F~emale and "Arcute"
Male Velar Configurations. . .. ... 25

4 Actual Line Tracing of a Cinefluoro-
graphic Frame of a Female Subject. , 26

5 Actual Line Tracing of a cinefluoro-
graphic Frame of a Xale Subject . . 27

6 Illustration of Ileiasrements Palatal.
Plane, ~epth of N~asoph~arynx AlonT
Palatal Pla~ne a~nd to IDidp~oint Closure. . 37

7 Illustration of LAB . .. .. .. .. 38

8 Illustration of Anount of Contact
and method of Leterminin? ?
9 Frequency Distribution Curve for LAiEC. . 54

10 Frequency Distribution Curve for
Velar Length ... .. .. ... .. 54












CHIAPTR I


INTHODUC TION


The subject of the study reported here is the

velopharyngeal mechanismn for speech in normal young adults

as visualized on lateral cinefluorographic films.

It can be stated as a general principle that for

English, separation of the nasopharynx and oropharynx by

the interpositioning of the velum (soft palate) is usual

for the production of all of the sound elements other than

/m/, /n/, and / /. There are variations in the amount of
nasal resonance on you~els which are related to dialectal

differences in normal speech. However, physiological

aberrations which make it impossible either to achieve or

to maintain appropriate contact of the velun with the

phnaryngeal wrall may result in serious problems of hypernasal

distortion. The velopharyngeal mechanism is thus central to

investigations of both normal and abnormal speech.

Phoneticians, speech pathologists, orthodontists,

and surgeons have used various X-ra~y techniqlues to study the

speech mechanisn according to their special interes-s in the

structures, processes, and problems involved, d~ith regard

to the velopharyngeal nechanism, efforts have been made both







to define what occurs in normal closure for speech and to

Identify and describe velopharyngeal insufficiencies.

The comparatively new technique of cinefluorography

is the method used in the present study. Cinefluorography

is the photographing with a motion picture camera of an

electronically intensified X-ray image projected on a

fluoroscopic screen. The resulting mid-sagittal views of

the speech structures in motion recorded on films can be

projected at life size to be analyzed in detail, In the

study reported in this thesis, the velopharyngeal mechanism

of males, as visualized on such films, was compared with

that of females. The results demonstrated that the con-

figuration assumed by the velum in its functional positions

for speech observed in male subjects differed from that seen

in the females. The nature of this difference has been des-

cribed in detail in the following pages.

Review of the Literature

This review of the literature has been organized to

reveal the concerns of those reporting information about the

velopharyngeal mechanism within three broad areas. Some

papers have had as their major purpose the description of

technical principles and! development of methods which allow

for the application of X-ray to the special problems involved

in revealing the dynamics of the speech process. Other

papers have explained the clinical application of cinefluor-

ography to speech problems resulting from velopharyngeal

insufficiencies. Papers which have reported the systematic







study of diverse questions pertaining to velopharyngeal

function for speech form the final area of review. In some

of these studies, the goal has been to define what occurs

during normal speech production with regard to certain

aspects. In others, the purpose has been to compare the

normal and abnormal functioning of the velopharyngeal mech-

anism~ in terms of specific questions.

Methodology

The "still" X-ray techniques were the first to be

used in speech. Cephalometrics and laminagraphy have been

described many times. An historical development of cephal-

ometry has been traced by A.G. Brodie (1949). T.M. Graber

(1952) lists, defines, and illustrates the anthropometric

and cephalometric measure points that have been developed

in order to standardize information from lateral X-rays and

make comparisons possible. Wiildm~an (1961) has proposed

that a standardization of measurements such as that pro-

vided by cephalometrics be achieved for lateral laminagraphy

and cinefluorography. He has selected, described, and

illustrated those measurements he feels are most effective

froa the studies of researchers who developed the?. Sloan

et al. (1964) have also described the application of ceph?-

alometries to cinefluorography. Subtelny, Pruzansky~, and

Subtelny (1957) and H'oll (1965) are sources for a descrip-

tion of lamnina3raphy.

Cephalometric techniques w~er-e popular writh

researchers before the advent of cineflucrography and still








have advantages in better resolution of the image. Cine-

fluorography has the advantage of adding the dimension of

motion to the X-ray pictures.

Carrell (1952) described a technique for reducing

radiation effects by synchronizing the roentgen generator and

the picture and commended the application of cineradiogra~phy

to the diagnosis of velopharyngeal closure inadequacies and

for post-correctional evaluation. It was the development of

image intensification that made cinefluorography a practic-

able technique. With this, the image formed on the fluoro-

scopic screen by the passage of roentgen' rays through the

subject is intensified 1,000 or more times in brightness by

means of an electron optical intensifier. Berry and

Hofmann (1956; 1959) have written an excellent description

of the principle of image intensification and other details

of the cinefluorographic technique. Details of the

principles of image intensification and procedures of cine-

fluorography are also provided by M:organ (1961).

A problem which has had to be considered is that of

effective filming rate. This question has been raised in

papers by Moll (1960), Bjork (1961), Bjork and ISylen (1963),

and Shelton et l. (1967). Sparrowr, Brogdon, and Bzoch

(1964) have show~n that for specific types of studies of

velopharyngeal function a filming rate of 30 frames per

second is adequate. They say that this filming rate gives

better image resolution than a rate of 60 frames per second.

:'oll (1960) noted the failure of most investigators







to quantify information from the films they used to make

descriptive reports. He undertook a study to determine

procedural techniques for obtaining clear cinefluorographic

pictures of the articulatory structures during speech with-

out excessive exposure to radiation. As a second step, he

studied the reliability of extracting information from the

films in terms of objective measurements directly from the

projection of the films or from tracings of the projectlans.

Els paper Is therefore useful for description of equipment

and procedures to be used in quantitative studies. Subse-

quent papers are also useful in this respect (Powers, 1960;

jjork, 1961; ilarren and aofmann, 1961; Sparrow, Brogdon,

and ;jzoch, 1964).

Clinical Application of Cinefluorography
to Speech problems

A partial 11st of papers in which the application

of cinefluorography to clinical diagnosis and treatment is

described and advocated includes those of Cooper (1956),

Calnan (1955-56), F'letcher (1958), Fletcher et al. (1960),

Aram and subtelny (1959), Kirkpatrick and 01mstead (1959),

Smith et l.1 (1960), Ashley et al. (1961), Green (1961),

;iazabert and hofmann (1962), and Kirkpatrick (1964). The

identification of velopharyngeal inadequacy by contrast

with the normal velopharyngeal mechanism, the making of

propnoses, the prescribing of treatment, the placement of

speech bulbs and assessment of their efficacy, have been

topics of the foregoing papers.








Application of X-ray Technicues to Definition
of normal and Abnormal Velcoharynneal Mechanisms

The historic attempts of early phoneticians to

apply standard radiography to the definition of articula-

tory positions have been reviewed in an interesting paper

by IMacmillan and Kelemen (1952). subtelny, Pruzanskxy and

Subtelny (1957) also reviewed the work of the pioneer

phoneticians. Their emphasis was more on tongue-arch post-

tions than on other aspects of articulation.

Specific attention to variations in velar position

began with Allen in 1884. Variations are possible in a

vertical direction in terms of the height to which the velum

rises for closure, and in terms of the vertical span of the

velar tissue making contact with the pharyngeal wall, In a

horizontal direction, variations are possible in the extent

of the gap between the posterior surface of the velum and

the posterior surface of the pharynx.

Variations in velar position have been studied in

terms of the sounds produced. Bloomer (1953) had reported

small and not always consistent variations during the pro-

duction of both vowels and consonants on the basis of

tracings from photographs taken through facial defects.

-arren, Hofmann, and Miller (1961) reported that they found

a significant difference in the elevation of the velum for

different sounds in their cinefluorographic study. Moll

(1960) studied velar changes in two female subjects. He

found a greater extent of velopharyngeal contact for sustained

vowels than for vowels In consonant contexts. For vowels in







consonant contexts there was more contact w~hen the

consonant was a non-nasal than when it was the sound /n/.

Contact for /a/ was less than for /1/, Bzoch (1968) has

shown that in th~e production of the three sounds /i/, /a/,

and /u/, the velumo rises higher for /i/ and /u/ than for

/a/, iiagerty et al. (1958) showed that elevation of the

velum is higher for /s/ than for /z/ when seen in lateral

laminagraphs. Moll (1962) showed that velar elevation was

related to tongue height.

The question whether absolute closing of the velo-

pharyngeal gap is necessary for the production of sounds

perceived acoustically as normal is one that still receives

attention. Earlier research poertaining to this ollestion has

been reviewed by iMc~onald and Baker (1951). It had been

shown that closure as it is visualized by X-ray Is not

always acheievedfor the production of scustained vowtels (I011,

1960). Bijoirk and :;ylen (1963) reported that in many persons

with normal speech, the production of the consonants /k/,

/v/, /s/, /t/, /b/, and /d/ w~as achieved and acoustically

perceived as correct, without complete velophnaryng~eal clo-

sure, as seen wiith- cinefluorography. Their subjects spoke

Swedish, however, BJork (1961) had earlier reported finding

openings only for nasal consonants and neighnboring vowels in

his analysis of the production of four sentences by Swedish

speakers. Ezoch (1967) has subsequently correlated the

points on cinefluorogr~aphic films at which velophary~ngeal

closure appeared absolute with the sounds produced in an







English sentence. In all of his 74 normal subjects there

was an invariant pattern of 3 closures and 4 openings

corresponding to the production of the non-nasal and nasal

sounds respectively. There were, however, occurrences of

assimilatee nasality" on some vowels which preceded or

followFed. nasals: in some subjects.

The condition of cleft palate has been of partic-

ular interest. Using X-ray, the problem in cleft palate

speech has been studied with regard to the importance of

tongue position (Hixon, 1949), and to the size of mouth

opening (Xelly, 1934). However, when Buck- (1953) studied

these factors and the factor of velopharyngeal closure, he

concluded that the extent of velopharynlgeal closure deter-

mined the major difference between his normal and cleft-

palate subjects, Because some persons with cleft palates

nonetheless have worse speech than others also with cleft

palates, the question of other contribution factors has been

studied comparing cleft-palate subjects with each other by

means of cinefluorographny (Powers, 1960). Sloan et al.

(1964) compared the deglutition anda phonation patterns of

normal And cleft-palate subjects in a demonstration study

explicating the use of cineflucrography. These investigators

maintained that, for the production of vowiels, if nasophar-

yngeal closure! is not sustained, hypernasal production w~ill

occur.

The question of velopharyingeal inadequacy in the

absence of cleft palate has also been studied for its effect








on speech. Blackfield et al. (196i2) have reviewed the lit-

erature in which velopharyngeal dysfunction without cleft

palate has been defined and described. In their study they

made measurements from tracings of cineflucrographic films

of 24- patients wiith velopharyngeal dysfunction and compared

them with those of 30 individuals with norm-al speech.

Anatomic abnormalities were found to be either excessive

depth of the nasopharynx, short hard and soft palates, short

soft palate but normal hard palate, or inadequacy of palatal

motion when compared with the normals. They concluded that,

with the exception of 2 patients, there was a direct rela-

tionship between the degree of inadequacy of velopharryngeal

closure and the severity of the speech defect. M'azaheri,

Millard and Erickson (1964), on the other hand, clain that

in their study of noncleft subjects with velepharyng~eal

inadequacy they found no relationship between the degree of

velopharyngeal inadequacy and the severity of the speech

defect. Tihe size of the gap between the vehlu and pharyinx

durinE phonation was correlated with judgements of voice

quality and intelligibility.

Shelton (1964) defined six categories of closure

patterns; i.e. patterns of closing the gap between velum and

pharynx and of maintainir? or being unable to maintain

appropriate closure. A nor-al pattern was established by

speakers with no speech problems similar to that reported by

Bjork (1961) and found by Ezoch (1967). Deviations fro-n this

pattern were plotted. for subjects who had palatal inadequa-







01es or who had surgically repaired cleft palates.

Bzoch (1967) showed that the correspondence he found

of velopharyngeal closure and sound produced for his normal

subjects was not achieved by deaf oral speakers, persons

with cleft-palate speech, or with problems of velopharyngeal

insufficiency in which~ there w~as an Inability to achieve or

sustain appropriate timing rates.

One finding based on X-ray studies of velopharyngeal

function about which there seems to be no argument is that

adenoid tissue can provide a surface for the velum to close

against and can be a means of narrowing the distance to be

spanned, so that often where velopharyngeal inadequacy would

otherwise be present, the problem is avoided (Calnan, 1953;

Buck, 1954; subtelny and 9s)ker, 1956t~).

It has been a goal in clinical practice to kcnowa

such things as the expected site of velar contact along the

pharynGeal wrall, the height to which the velum elevates

relative to palatal plane, the amount of tissue making con-

tact, and whether there is a relationship of velar length to

pharyn~eal depth in order to cope more effectively with

rcehailitation in velopharyngeal insufficiency. However,

these variables have not been considered in terns of a total

pattern but rather, in terms of some other variable or

special rationale.

In its functional or closed position, the velum, as

seen in lateral X-ray pictures, assumes a certain configur-

ation resultinS frome the height to which it elevates (rola-

tive to palatal plane), the place on the pharyngeal wall








where it touches, the extent of contract, the area on its

surface which makes the seal, and the position of the uvula

relative to the posterior pharyngeal wall.

The high point on the velar surface seen when in

the closed position for speech has been called "levator

eminence" and defined as the point of insertion of the

elevator muscles (Green, 1961; W~estlakre and Rutherford, 196E,

p. 61). Podvinec (1952) had stated that the point at which

the insertion of levators and of palatopharyngeus cross

causes the "dimpling" seen on the oral surface of the velum.

This point, according to Podvinec, also becomes the center or

focal point of the velar tissue which effects the closure

and is as well in the area of greatest excursion from rest

to closure. FiS. 1 illustrates an orientation of the veluma

in closure similar to that which has been described and/or

illustrated by rPodvinec (1952), Riclketts (1954), nagcerty et

gl, (1958), and Green (1961). As it has been described in

the above papers, the uvula, is a~ngled well forward.

On the basis of observations nade possible by the

use of Xi-ray, the area of the velum~ which malres closure had'

been defined as the middle third (Calnan, 1955-56). Eaxever,

when Graber, Bzoch and Aoba (1959) divided the outline of

the velun into quadrants rather than thirds they found that

the third quadrant made closure in 100 percent of their sub-

jects and in 27 percent the fourth quadrant w~as also in-

volved. The highest point on the upper surface did not co-

incide with the area of contact but was farther forward at














































Figure 1. An orientation and configuration of
the velum in closure for speech.







the midpoint of the middle third. The midpoint of the

palate sihowed the greatest extent of upward and backwardp

movement.

Mazaheri, Millard and Erickson (1964) used 10

normal subjects as controls in a study of velopharyngeal

inadequacy. They also said that they found a significant

difference between the high point on the superior velar sur-

face and the height of the superior point of velar contact

with the pharynx. Further than this, they stated that the

height of velopha~ryngeal closure took, place belowu the palatal

plane in 80 percent of their normal subjects.

In the G~raber, Bzoch and Ao0ba (1959) study 22 of

the 44 subjects wrere females, and in the KIazaheri, Millard

and Erick:son study, 8 of the 10 normal subjects w~ere females

but no significance was attached to this in interpretinS the

findings in either study.

Ricketts (1954) pointed out that the size and shape

of the pharynx are influenced by the bones which surround

it--the occipital, the sphenoid, and the ethnoid. He showed

in particular the effect of variations in the inclination of

the b-silar part of the occipoital bone. ;:hen this was in-

clin~ed nore horizontally the nasophnarynx bsecamne wid~er, and

as it was nore vertically Inclined thle "cranial bzse" became

acute and the nasophrarynx correspond~in31y n~arrower.

R~ick~etts claimed the velum~ accommnodated itself to the space

provided in the pharynx by a~ssuing either obtuse or acute

angles wiith reference to the posterior nasal spine w~hen in

the rest position. Rickett's study pointed out the ponsib-







ility that structural variations might account for varia-

tions in the dimensions of velopharyngeal closure. The

velum might accommodate itself to the space available in the

pharynx in its functional position, Just as Ricketts said it

did in the rest position,

dlarren and iEofmann (1961) tried to determine

possible relationships between velar length and pharyngeal

depth; pharyngeal depth and velar height during closure; and

velar length and velar height during closure. Cinefluoro-

graphy was used for their study. They concluded there was

no relationship between soft palate length and pharyngeal

depth. An inverse relationship was found between length of

palate and height of closure--the longer the palate, the

lower the elevation. Warren and Hiofma~nn suggested that the

reason for this inverse relationship is the anterior sloping

of the pharyngeal wall as it becomes the nasopharynx, which

causes depth to decrease with height. They theorized that

a short velum would have to rise higher to contact the

pharyngeal wall than a longer one which could span the

wider distance at a lower level. It wazs their opinion that

velar length was a more significant deterniner of closure

height than pharyngeal depth.

%azaheri et al. (1964) found a correlation between

length of velua and depth of the pharynx, in contrast to the

findings of Wasrren and Hiofmann, They found no significant

relationship between depth of nasopharynx and eight of

elevation above palatal plane or between length of velum and

height of closure (in contrast again to larren and Hiofrgnn);








nor between length of velum and height of elevation,

M~azaheri et al. say that the theory of warrenn and E:ofmann

that the short velum elevates higher than the long to achieve

closure does not necessarily hold true.

Fig, 2 illustrates how depth of the nasopharynx,

height of elevation, and height of closure are defined.

B~jork and Nylen (Bjork, 1961; Bjorkr and Nylen,

1963) are the only investigators found to have considered in

any way the possibility of a sex difference in any of the

variables involved in velopharyngeal closure. They found no

difference that was significant between males and females on

measures of amount of excursion, amount of contact, height of

elevation, or velar length in the rest position.

Ha~gerty et _al. (1958) reported that there were some

differences in the amount of excursion from rest to closure

between their Kegro and white subjects and som~e difference in

amount of contact of velum writh pharyinx in the tw;o groups.

Age as a variable in thne velophnarynseal m3echasnies

has been considered, Aram and Subtelny (1959) found that

th~e amount of velar tissue ma'ing the seal with the pharyn-

geal wall decreased with age. The average for this neasure-

ment in their subjects ageE 4 to 5 w~as 3.6 nm. and in their

oldest subjects, aged 18 to 20, it w~as approxlhately one

half as much,

A~ran and Subtelny (1959) found changes in the site

of closure writh age as well. They described the site for

their younger age groups as being the "superior and/or the

superior-posterior aspects of the nasopharynx." Site of


























AB=depth of
nasopharynx


Figure 2. Illustration of height of elevation, height
of closure, and depth of the nasopharynx.






17

closure for the older groups was described as "posterior

pharyngeal wall." The transition tooke place in their 9 to

11 age group.

Calnan (1955-56) stated that the area just above

palatal plane would be the probable site of closure. He

then defined three possible relationships of the palatal

plane to the backc wall. The highest site, level with

basisphenoid, was described as the "Infantile." The adult

position, Calnan said, was normally level with the upper

border of the arch of the atlas or lower.

Both Aram and Subtelny (1959) and calnan (1955-56)

stated that the higher position for velopharyngeal closure

in young children was due to the fact that the hard palate

was closer to the upper limit of the nasopharynx. As growth

of the face occurs downwa~rds and forwards, the palate

descends and the distance increases from the posterior phar-

yngeal wall, according to these authors. Calnan (1955-56)

expressed the opinion that closure is higher in children

because the forward inclination of the posterior wall at the

point of contact is at an angle of h50 to the horizontal,

while It may be vertical in some adults.

BJork and Nylen (1963) found the site of closure in

children; to be lower than in their adult subjects. They

state the reason for t`?is is because of the Greater forward

inclination of the posterior wall in children as opposed to

the almost vertical plane of the adult. Thus, the sane

hypothesis has been used to explain opposite findings.

Some attention has been given to determining





18

whether the action of Passavant's pad is significant in the

normal velopharyngeal mechanism. Calnan (1953: 1955-56) has

completely discounted it, Graber et al. (1959) claim it wias

present in 3 percent of their subjects. Others say they

have found no anterior movement of the posterior pharyngeal

wall in normals (Cooper, 1956; Wiarren and Hiofmann, 1961; and

Bjork; and Nylen, 1963). Hagerty et al. (1958) said they did

not think Passavantrs pad was significant in normal speech

production.

Another concern about the mechanism of muscle action

by which closure Is achieved has been with the role of the

muscles in the lateral wall of the pharynx, Harrington

(1944) determined the presence of a palatal origin (different

from the hamular origin) of the pterygopharyngeus muscle in

8 of 10 cadaver dissections. He felt that these pterygo-

pharyngeus fibers with a palatal origin probably contributed

to mesial movement of the pharyngeal walls, Becau~se the

pterygo7pharynqeus also has connections writh palatophasrynseus,

Harrington suggested that approximation of the palato-

pharyngeus muscles could. also contribute to mesial movement

of the lateral pharyngeal walls,. L.E'. Strong (1949) reported

that he and Lochi, indsependently of each other, had pro-

posed as ea-rly as 19!c3 that the: palatine bundle of the

superior constrictor wias a "niajor force component in naso-

pharyn Cal occlusion," This proposal w!as made by these

authors, StronG said, as a mechanismn to account for the

ability of palatopharyngeus to move medially. In their








mechanism, palatopharyngeus is forced medially by the con-

tractions of the palatine bundle of the superior constric-

tor.

An action of salpingopharyngeus muscles causing

medial movement of the lateral walls was reported by

Harrington (1944). This action was viewed in one subject

who had had a radical resection of the left axillary sinus.

Bloomer (1953) stated his opinion that the salpinsopharyn-

geal folds were more likely brought into approximation by

the sphincteric contraction of the superior constrictor and

the palatopharyngeus muscles than by their own action.

Westlake and Rutherford (1966, p.55) point out that the sal-

pingopharyngeal folds which can be seen on oral inspection

in people who have either thin palatopharyngeus muscles or

whose palatopharyngeal muscles do not move medially in

closure, probably act to na~rrowa the oral and nasal pharynx,

There seems to have been sone shift of opinion amon~

those using X-ray away from the idea of any kind of

sphincteric or narrowing of the pharyng-eal dimensions in

the normal velopharyrngea~l mechanism. Calnan (1955-56) has

stated flatly that closure is not "sphinater-like" and that

the superior constrictor does not play an important part in

speech, Bjork (1961) and, Bjork and Nylen (1963) reported

the results of tomodraphy used in their study to estin~ate.

the role of lateral movements of the pharyngeal w~all in the

nasop~harynx. They asserted that there were no im-portant

changes in lateral dimensions in normals, In cases of





20

velopharyngeal incompetence, such contractions are compen-

satory, in their opinion.

The review of the literature so far has shown that

the area for investigation into the velopharyngeal mechanism

for speech is extremely broad in scope. There are still

many unanswered questions within those problems which have

been the focus of attention. Interest in some other direc-

tions is just beginning to develop.

J. Subtelny (1964) has pointed out that progress in

the physiological aspects of phonetics has not kept pace

with progress in acoustic phonetics. She has suggested the

need for making more correlations between shifts in velar

positions and the rest of the vocal tract and changes in

sound spectra.

Behind the effort which has been put into velar

research, there seems to have been an implicit belief that

the velum functions as an articulator with adjustments being

made as appropriate by the muscles of the velum. MIoll and

Shriner (1967) have raised the question of whether the velui

really functions as an articulator at all. They feel that

the velum may act nerely as an "on-off" valve. The valve

would be "on" for non-nasals and "off" for nasa~ls and have

a ready position in between "rest" and "on," The more

subtle adjustments would be due to changes in and restraints

resulting from tongue position and time available.

In response to this question, Lubter (1968) has

undertaken electromyographic and cinefluoroeraphic studies






21

and has reported that his findings do not support the

suggestion of Moll and Shriner. Hie finds evidence to the

contrary, that the velum does in fact change in response to

activation of its own muscles,

M~ore evidence is needed regarding this question.

The difference between an "on-off" valve and a "precision"

articulator would be immense. When the velum is considered

as an articulator, the question of the significance of velar

variations for acoustic output is a relevant one and the

question of the muscle actions involved in making the

variations remains as important as ever.

The definition of the velopharyngeal mechanism? into

discretely different confiGurationsn as seen cinefluorograph-

ically could be a useful first step toward the further study

of such proolels.














CBAPTE~RII


jTATEMEiNT OF THE PROBLEM~


The factor of sex as a variable in the velophar-

yngeal mechanism has been considered in only one previous

study. Bjork and Nylen (1963) obtained some measurements

for males and females separately for the purpose of com-

paring adults to children, and normals to cleft-palate

subjects. They reported finding no significant differences

between the sexes on the measurements they made. Nonethe-

less, it may be possible that certain differences do exist.

The possibility remains that failure to consider

sex as a variable may have influenced the results in some

studies. Data obtained. in studies where the subjects are

all males may not be comparable to data from studies in

which the subjects are all females or which include members

of both sexes.

Because information obtained about the normal

process has such immediate practical application in the

identification and treatment of abnormalities, there has

been a tendency on the part of investigators to focus on






23

comparison between normal and abnormal. In these compar-

1sons, normal subjects and subjects with velopharyngeal

inadequacies have been matched for sex as well as age in

some studies, but all subjects have then been treated only

as either normal controls or as experimental subjects with-

cut sex comparisons.

In other studies where the objective has been to

define what occurs in normal velopharyngeal closure, sub-

jects have been classified as normal on the basis of having

no velopharyngeal inadequacies or speech deviations and

then treated equally, Kean measurements for normal indiv-

iduals have then been determined without regard to possible

sex differences. Graber, Bzoch and Aoba (1959) included

equal numbers of males and females in their study but did

not makle comparisons,

A review of the literature reveals no study which

has specifically considered velar configuration er se or

the possible significance of variations from basic confiS-

urations. It has been recognized that velar configuration

as it is revealed in lateral X-rays is the result of the

balance of muscle forces exerted upon the velum in achiev-

ing closure (9ickette, 1954), but it seems that velophsryn-

geal closure has been assumed to vary only in accordance

with individual differences (Ilazaheri et al., 1964;

destlak~e and %utherford, 1966. P. 5j).


I-yvothesis

It is hypothesized that, as it is visualized on







cinefluorographic films, the velopharyngeal mechanism is

different for males as compared to females. This difference

is manifested in a different orientation of elevator eminence

to uvula so that the configuration of the velum for females

has the appearance more of a right angle within the pharynx

and that for males an acute angrle as shown in Fig. 3. Fig.

4 is an actual line tracing of a female subject and Fis. 5

Is of a male subject.

This hypothesis was derived from subjective impres-

sions of the closure patterns of males and females viewed at

the normal filming rate of 30 frames per second on cinefluor-

ographic film. Certain differences in motion and configura-

tion of the velum could be discerned. In the films of males

the velun as it elevates is seen to lift at the levator

"bulge" elevatorr eminence). This bulge then rises In a

throbbing mannier and seemns to thrust toward closure at the

basi-occipital level. This is essentially the upper limit

of the nasopharynx along the posterior wall. The presentin3

surface of the velumo is curved as it contacts the pharyngeal

wall. The uvula is pointed anteriorly so that considerable

space Is formed between it and the pharyngeal wall.

In the female pattern, as the velum elevates for

closure it usually moves posteriorly in a relatively

st~raight-backe notion along the palatal plane wiith a comnpr-

atively flat presenting surface. The "thrusting" of the

elevator bulge is in an upward direction while the direction

of palatal movement as a whole is bacl:ward. The uvula

















FENALE NALE





















Figuvre 3. "Square2-off" female and "acute" male
velar configurations. Arrowsi showr directions of move-
ment. drokEln lines show velum a~t rest,





Figure 4. Actual line tracing of a cinefluoro~raphic
frame of a female subject.

























































Figure 5. Actual line tracing of a cinetwuorographic
framce of a nale subject.





28

points downward and often even posteriorly so that there is

a notch between it and the pharyingeal wall rather than the

definite space of the male pattern.

Green (1961) had called the configuration of the

veluma in closure "comma-likxe" with the elevator eminence

forming the apex. Ricketts (1954) had described the velum

in closure as being a "hooking" action. Their descriptions

fit wiell what is being described here as the male configur-

ation. The action of the velum in the female could be

called "squared-off" as contrasted with the other hookingn"

action. The male configuration is here described as "acute."

Pilot studies have shown that it is possible to

tell male from female subjects on the basis of judgement of

the pattern of notion in movement and the configurations of

the velum in closure during connected speech. It has been

found to be relatively simple, with experience, to classify

85 percent of the subjects with 100 percent accuracy. Those

subjects w~ho wsere not readily classified have required a

most judicious balancing of clues from the perceived motion

toward closure and the configuration in closure in7 order to

be declassified. The subtleties are such that furth-er analysis

will be required to objectify the significant; clues.

In a pilot study, twro independent viewers had no

clues other than representative drawings of the two velar

configurations and the instructions: "In your opinion, does

the velum of the subject on the filn look~ more like (3C

or (2i ) when in closuree" Thle 12 films viewed wnere
randomly selected from 71: films. One viewer knew the purpose






29

of the study and one did not. Decisions were made accord-

ing to a seven-point scale, Their results showed selection

in the right direction wuith a P=.0256.

The score obtained by this investigator when the

choice was either "male" or "female" for 27 subjects, was

correct as determined by a Fisher's Exsct Probability Test

at a level P=.ooco5, At the time of these studies, no

criteria for making a decision had been specifically

discerned, but it was felt that the ultimate deciding factor

was the "angle the velum made w~ith itself" in closure.

Purpose of the Study~

This study was undertaken to determine whether it

would be possible to demonstrate in an objective manner

that the apparent differences between the velopharyngeal

mechanisms of males and females which had been subjectively

perceived do exist. The following questions were formu~lated:

1, Can it be shown by an angular measurement that

the basic orientation of the velum to the pharynx is diff-

erent in the sexes?

2.-Can it be established by measurement of the

height of elevation above palatal plane, the amount of con-

tact, the distance of the uvula from the pharynsell wall,

and determination of the site on the pharyneeal wall at

which the inferior point of contact falls relative to pal-

ata~l plane that discretely different configurational

patterns are manifested?

3, Can differences in configuration be accounted






30

for on the basis of the ratio between velar length and

pharyngeal de pth?

Rationales for the establishing of certain

measurements not previously described in the literature and

for other questions arising during the analysis of the data

are described in the following chapter.













CHA.PTER III


NETHODS AND PROC~3UESS


A library of films made by the process of cine-

fluorography has been built in the D~epartment of Communica-

tive Disorders, University of Florida Health Related

Professions. The procedure for the selection of subjects,

photographing, and analyzing has been described previously

(Sparrow, Brogdon and Ezoch, 1966; Bzoch, 1968) but is

summ~arized here for convenience.

Initial election fS2 et

The subjects were sales and females between 18 and

30 years old. They were monolingual (General American

dialect), had Angle Class I occlusion, no articulation or

voice deviations, and hearing= acuity of between f10 dB

through the speech frequencies for both ears.

Procedures for Obtainini Films

A Ficker fluoroscopic unit with an 8-inch image

intoensfier and a modified 16 un. Cstman Cine II camera

were used. Kodak Linagrzap Shellburst filmn was used and

processed in a Smith-Picker automatic processor, Careful

body positioning and the use of a lucite cephalortat pro-

vided stability during filming and uniformity in head, neck,

and body positioning in the upright position. A monitorinp






12

directional Electro Voice microphone Hotel 644 was placed

6 inches from th~e subject's mouth and recording was on a

Mlagnacord Model MI90-A tape recorder.

Each subject performed a speech sample within a

limit of 90 seconds. Radiation dosage was less than 3

roentgens. Filming rate was 30 frames per second.

Selection of Subjects for This Study

From the library of films available, 40 subjects

(20 males and 20 females) were chosen for this study. The

subjects had been filmed randomly with regard to sex just as

they camce in for their appointments. The films to be used

here w~ere therefore taken in order front subject; number one

on. The only criterion for rejecting a film as a subject of

study wias lack of sufficient clarity for tracing.

Speech jsamle

The total speech sample filmed consisted of nine

consonant-vowrel (CV) "syllable" sets, a list of 13 words,

and a sentence. The sentence was repeated three times at

increasing effort. Nornal pitch and conversational effort

level were used for the syllable sets and word series. A4

speech sample lasting lI mins, could be observed for each

subject, A characteristic pattern of mnovement toward clos-

ure and velar configuration in closure could be recognized

for each subject.

For analysis, one frame" for each subject was chosen

from any one of the syllable sets containing the vocalic

element /1/.






33

A syllable set consists of seven CV combinations.

These CV combinations were either /pi/, /pa/, /pu/; /ti/,

/ta/, /tu/; or /ki/, /ka/, /kcu/, The organization into

speech utterances was according to the following system in

which /pt/, /pa/, /pu/ is used as illustration:

Inspiration: (A) pi pi pi pi pi pl pi
(B) pa pa pa pa pa pa pa
(C) pu pu pu pu pu pu pu

Inspiration (D) pa pa pa pa pa pa pa
(E) pu pu pu pu pu pu pu
(F) pi pi pi pi pi pi pl

Inspiration (G) pu pu pu pu pu pu pu
(d) pi pl pi pi pi pi pl
(I) pa. pa pa pa ps pFa pa

It can be seen that, using series A. F, or H, there

were 21 occurrences of the production of syllables contain-

ing the vowiel /1/. Any frame within series Al, F?, or a w~as

used if it provided sufficient clarity for tracing. It had

been established earlier (Bzoch, 1968) that once closure

was achieved for the production of these syllables, opening

did not occur again until the end of series C, ?, or I. It

is not known precisely what ninor variations may have

occurred from frame to frame w~ith the velurm in closure all

the while, but it is believed they wiould not be of a nature

to affect the! measurements relevant to the: major pur'poset of

this study. Because it can be plainly seen On the fillmS in

notion thrat w~hen velopsharyrngeal closure occurs for the pro-

duction of these syllable sets it is according to a charac-

teristic pattern, it was concluded that the selection made

was representative of the velopharyngeal mechanips for each

of the 40 subjects.







Twenty subjects said /pl/ on the films used, 13

said /ti/, and 7 said /kl/. In order to determine the

effect of the different consonants on the measurements, a

Kruskal-Wallis One-way Analysis of Variance Test was ap-

plied for each measurement for the females and for the males

separately. Anything greater than .05 was not considered

statistically significant for the purpose of this study. It

can be seen from Table I that, with the exception of the

measurement of height of elevation for females, nothing was

found to be significantly different.

TABLE I

KRUiSKAL-WAgLLIS ONE-WIAY ANATLYSIS OF VARIANCE
OF SOUNDoS /pi/, /ti/, AND /ki/


Corrected H
measurement Females Males

neight elevation 7.294 .03
Angle ABC 2.56 .4o
Eight contact 4.59 2.39
Amount contact 3.95 1.75
Leng-th .80 .82

*Significantly different from zero at the 5 percent level.

A Mann-Wihitney U Test comparing height of eleva-

tion in females between /pi/ and /ti/, /ti/ and /ki/, and

/Pi/ and /ki/ revealed no significant difference between

/pi/ and /ti/ but a difference between /ti/ and /ki/ and

between /pi/ and /ki/ both at a level P=.015. It is be-

lieved, therefore, that the influence of the /ki/ would

cause the mean height of elevation in females to be higher

than it would have been without the /ki/ sound. Films of








only twoe males producing /k~i/ were used in the study.

Procedure for Collectino Data

Trac__gg

During filming, each subject had inserted a radio-

opaque narker into his mouth backe to the wvall of the pharynx

so that it would subsequently be possible by measuring the

distance between the holes on the marker to gauge the pro-

jection size. After determining that projection was at life

size, structures from the chosen frames were traced by hand

onto ordinary 16 lb. white bond typing paper as shown in the

reproductions of actual tracings in Figs. 4 and 5.

A piece of Dietzgen draft film (clear acetate paper

with a matte surface) was laid over each tracing so that the

lines needed for measuring could be drawnm on it, leaving the

actual tracing unmlarked. Lines wrere: drawn and mreasurements

taken according to the following descriptions using dividers,

a millineter ruler, and a protractor.

Eleasure.7entsc Dfin~ed

Palatal lane

This line was drawn according to the usual proced-

ure in the literature; i.e. fromn the tip of the anterior

nasal spine (AN;S) through the post~erior nasal spine (v;,S) and'

projected. to the back wall of the phairynx to point X, as~

seen in Fi5. 6.

CDeth of the nesonhgranx~

The depth of the nasopharynx has usually been

defined as the distance along; the palatal plane from PNS to






36

the back pharyngeal wall. The distance PNS to X represents

the depth of the nasopharynx along palatal plane in Fig, 6.

Depth of the nasooharynx at midpoint of closure

A line w;as drawn from PNS to the midpoint of the

area of the velum naking contact with the pharyngeal wall to

represent the depth of the nasopharynx at the midpoint of

closure. PNS to Y is the line illustrating this measure in

Fig. 6.

Alsle AgC

Angle ABC was constructed to s~how the basic orien-

tation of the volum to the pharyngeal wall. The point on

the posterior nasal spine intersected by the palatal plane

line became A. The superior point of contact between velum

and pharynx became B and the inferior point (midpoint) of

the uvula became C. Angle AFC was thus formed by lines from

the PNdS to the superior point; of contact, and from the

superior point of contact to the inferior point of the uvula.

This angrle is shown in Fig. 7,

Velar length

The length of the velum, was mealsured according to

the procedure described bjy Graber, Bzoch, and Aoba (1959).

In this procedure, velar length in the functional position

for speech, is determined by measuring along the superior

curvilinesr border from the posterior nasal spine to the

nidpoint of the uvula,

Amount of contact: with shsryn-real wa~ll

The measurement in mm. of the distance spanned by






















AN -P









ANS to X = palatal plane

PNS to X. = depth of nasopharynx
along palatal plane

PNS to Y = depth of nasopharynx
to midpoint of closure



Figure 6, Illustration of the neasurements palatal plane,
depth of the nasopharynx along palatel plane, and depth of
the nasopharynx to midpoint of closure.



































Fig~ure 7. Illustration of LJABC which is formed oy lines
drawn froms the poster-ior nasal spine to the superior
poit of contact and from the superior point of contact
tothe midpoint of the uvula.






39

the velar tissue contacting the pharyngeal wall measured

along the pharyngeal wall from the superior point of con-

tact to the inferior point of contact is the definition of

"amount of contact." This is shown in Fig. 8.

Height of elevation

Height of elevation has been measured in the manner

usually described. In this, a line perpendicular to the

palatal plane extending to the highest point on the superior

surface of the velum? in the closed position is measured in

Imm, This has been shlown in Fig, 2.

HeigJUL of closure

The height of closure is the perpendi~cular distance

from the palatal plane to the superior point of contact,

measured in mm., as illustrated in Fig, 2.

Rastio 3C:,F'

An arbitrary line was draw:n froll the midpoint: of

the measurement of the depth of the nasopharynx along pal-

atal plane (poinlt i in FIg, 8) perpendicular to the palatal

plane. Tlhis line intersects another line drawn parallel to

the palatal plane at 'he level of the inferior point of the

uvula at point I3. The distances SC (th-e distance fro-? pointf

Z to the midpoint of the uvula) and 2? (th~e distance from

point X to the back iall of the pharyn~x) w;ere CeaSUr~ed in

mn. The ratio of the distance EC:;F ? wa calculat~ed and

called "ratio 1`C:3?."

Inferior 3oint of contact

The inferior point of contact of velum wlith pharyn-x























amount of
contact


Figure 8, Illustration of amount of contact and method
of determinin? ratio EC:ZF.







has been defined In terms of being above, on, or below

palatal plane.

Reliability

The reliability of tracing: technique was deter-

mined by a tracing-retracing procedure separated by consid-

erable periods of time. In no instance was there any

change in the features such that the outcome of the results

would have been affected. When the original data were

compared wuith retracings of the same frames for 12 subjects,

the following levels of correlation wcere obtained using a

Pearson _r test: amount of contact=.927, height of eleva-

tion=.95, angle ABC=.989, velar length=.993, depth of the

nasopharynx along palatal plane=.970, and depth of the

nasopharynx to midpoint of closure=.938.

nhen all tracings had been made, validity was con-

firmedi by another independent experienced tracer according

to the following procedure.

1, The criteria, as they had come to be understood,

on which to Dake a decision as to the sex of the subject on

th~e fil-: .were learned by the second tracer. The first step

in the procedure for confirming the accuracy of the tracinge

was for the second tracer to decide the sex of the subject

wibh no clues other thran the application of the defined

criteria to the viewing of the films. Thirty-eight of the

40 subjects wrere correctly classified in this wa7y, Subjects

hos. 30 and ?8 w;ere at first incorrectly classified.

This does not represent error in Judgement, however, as






412

these twvo subjects do not fit the pattern for their sex.

(See Table XI .)

2. The outline of the velum as seen directly on

the projection was then pointed out, according to the

following routine: "This is a (male) (female). I see the

velum as follows (outlined). Hjere is posterior nasal

spine. The back wall of the pharynx if here. Eere is

superior point of contact, Closure would be (above) (on)

(below) palatal plane. Here is inferior point of contact.

The curve of the velum below; inferior point of contact is

here. The tip of the uvula is here."

j. The original tracing, not seen by the second

tracer before, was produced and Judg~ement made that it ob-

viously wcas not a gross misrepresentation of what had just

been pointed out.

4. The original tracing was laid on th~e projec-

tion and lined up with it. A nani1a folder was then held, in

front of the tracing to obscure it and to provide a new sur-

face for the projection. The film was run backwards to a

point where the velum was seen in rest position. The film

was run forwsardi again so that the entire movement into

closure could be watched, and thre actual. outline in closure

identified again apart from any confusion c'ue to other

overlying structures, particularly all surfaces and pro-

cesses of the mandiole.

5. TPhen all points on. the tracings w~ere re-estab-

lished by agreement. The shadow of a pencil point was made







to lie on the point to be established, the manila folder

was pulled away, and if the identifying point was located

correctly, the shadow was observed to fall directly on its

corresponding point on the tracing,

6, Minor changes were made on the original trac-

ings in accordance with the preceding procedure so that the

measurements made were from tracings which represented the

best judgement of two tracers.

Method of Analysis

The configuration of the velum during velopharyn-

geal closure for speech as it is visualized on lateral

cinefluorographic films results from the arrangement of

extrinsic nuscle insertions and front the dimensions of the

velum, the surrounding structures, and the nasopharyngeal

cavity. The factors of height of elevation, height of

closure (site of superior point of contact), amount of clo-

sure, and the site of the inferior point of contact rela-

tive to the palatal plane are used to describe this

configuration. There is further, a factor of orientation

of the velum to the pharyngeal wall. Two attempts have been

made to describe this orientation. Angle ABC, illustrated

in Fig. 7, has been devised as an attempt to define the

basic orientation of velun to pharynx. The ratio LC:EE nae

been calculated in an attempt to show the orientation of the

uvula to the posterior pharyngeal w:all.

TLhe followiing specific m~ethnods of analyzing the

data obtained front makine the defined measurements uere used:








1. The inferior point of contact has been classi-

fied for each subject as above, on, or below palatal plane.

2. The Hiann-W;hitney U Tiest was used to determine

the significance level of differences in scores of males

and females for measurement of a) LAE-C, b) velar length,

c) height of elevation, d) amount of contact, and e) ratio

EC:EF.

3. An attempt was made to determine the possible

significance of the depth of the nasopharynx and length of

the velum to the orientation assumed by the velum as des-

cribed by L;ABC. Tihe rationale for the specific question

asked was as follows. There is a distance of a given

measurement to be spanned (the depth of the nasopharynx) by

a structure of a given length (the length of the velun in

closed position). In effecting closure, the velum in some

subjects assumes an orientation which can be defined approx-

imately in terls of an acute a~ngle and in another group of

subjects, in terms of a right angle. The specific question

became: Loes the ratio of the length of the velum to the

depth of tnle nasopharynx determine the angle which is

assumed by the velum in effecting closure, or is this angle

determined according to the ser. of the subject on so-e other

basis? To deter-ine the answer, an analysis of co-vnriance

wras ma~de by constructing an e-atninated linear nodel to define

the effect of sex on LA;;C and the effect of depth-to-length

ratio on L[ABC. In this analysis, depth of the naeopharynx

was defined as the distance from the posterior nasal spine






45

to the midpoint of closure as this was the actual distance

spanned.

4. In 16 subjects, the distance from the post-

erior nasal spine to the midpoint of closure was the same as

the distance fromo the posterior nasal spine to the pharyngeal

wall measured along palatal plane. In 4 cases, the distance

from the posterior nasal spine to the midpoint of closure

was more than the distance along palatal plane, and in 20

subjects, the depth of the nasopharynx at the midpoint of

closure was less than the depth along palatal plane. A

llcoxon Xatched-Palrs Signed-Ranks Test was used to deter-

mine whether changing the site of the midpoint of closure

from palatal plane made any significant difference. The

specific question was: If it is assumed that there is an

optimal distance which can most effectively be spanned by

t~he velum, and closure is effected above, on, or below pal-

atal plane accordingly, was the distance significantly

changed as revealed by the difference between the depth of

the nasopharynx along palatal plane and the depth from PNS

to midpoint of closure?

5. Frequency distributions were plotted for velar

length and measurement of ZABC by sex.












CHAPTER IVr


RESULTS


Raw data for all female subjects are provided in

Table III and for male subjects in Table IV. The results

of the analyses made using these data are as follows.

1. Relationship of inferior point of contact to
calatal plane

Wihen tabulations are made of the relationship of

the inferior point of contact to palatal plane, as in Table

II, it can be seen that, whereas 17 of 20 males have the

inferior point of contact on or above palatal plane, an

equal number of females have this point below palatal

plane.

TABLE II

RELATIONSHIP OF INc'FRIOR POINT OF CONTACT TO
PALATAL PLANE


Above On Belowr

hales (20) 12 5 3

Females (20) 3 0 17




2. Height of elevation

As shown in Table V, the mean height of elevation














L& o Rel. Inf. Pt.
C) contact to ( 2
2 aa Palatal P~lane rl


17 A 15 90 2 27.76 7
19 43 14 92 2 9.7


26 40 11 90 25 25 .76 X 7 6

27 38 8 86 25 24 .63 X( 5 3
36 39 11 98 25 25 .67 x 5 5
38 44 5 75 25 24 .50 x 8 8
42 39 8 80 28 28 ,70 X 7 5
43 35 8 92 27 27 .75 x 4 3
45 38 ? 102 25 27 .71 X 1 0
46 40 11 98 27 27 .86 x 5 4
50 41 8 85 27 27 .63 X 2
51 44 12 90 25 25 .70 x 3 1
54 45 11 90 28 28 .72 x 5 5
56 46 5 75 32 29 .~55
61 36 9 90 24 24 67 X 6 5
62 38 6 76 27 23 .69 X 10 8
69 45 9 90 30 30 .66 X 7 6
88 42 ? 86 29 28 .75 x 8 6
93 40 9 90 26 25 .7.5 x 6 6


TA4E2 III
RAW DATA FOR FEMALES













r Rel. Inf. Pt.
a 0 aContact to > A
SPalatal Plane


18 61 6: 50 40 3 .0 6 1
20 w47 8 7 2 5


22 57 6 5 40 3 3 .247 x 16 13

24 57 7 70 35 31 .50 x 16 12
25 48 7 66 27 28 .53
2851 6 77 31 30 .57 X 11 8
30 48 9 80 27 27 .43 X 7 4
31 48 5 63 29 25 .35 x lo lo
39 lc0 7 80 23 23 .45 x 3 3
40 38 5 64 25 22 .4 1
47 39 6 51 23 22 .18 X 8 7
49 48 8 70 29 27 .36 X 9 9
55 44 5 68 27 27 .34 X 9 8
57 45 3 59 30 29 .50 x 9 6
58 46 6 73 30 30 .50 x 7 3
59 48 6 65 31 26 .31 X 11 11
60 50 4 65 33 31 .57 x 14 14
81 51 7 65 28 26 .36 X 9 8
95 51 6 65 35 31 .57 x 15 14


TABLE IVi
RArj DATA FOR MALE~S






49

for males is correspondingly higher than that for females.

The mean of this measurement for males (10.05 mm.) is

almost double the mean for females (5.9 mmn.). It has

already been noted that the sound produced may have

influenced this measurement for females in an upward direc-

tion. FIve female subjects (Naos. 56, 61, 62, 69, and 84)

produced the sound /ki/. TIhe mean height of elevation for

these subjects was 8 mm. as contrasted wijth the over-all

mean for females of 5.9 mn. The mean height of elevation

for females may thus be higher than otherwise because of

this difference. Only 2 males had said /ki/ and the effect

was not significant for the males' hei3'ht of elevation.

TABLE~ V

COMPAR'~ISONl OF MEAN; ;IGn-T CF ELEVATION BET EENl u
KALES AND FEMALUS


lMales (20) Females (20) U

Range 3-16 mn, 1-10 mm3.
711'
iMean 10.05 mm. j.9 3m.

S.D. 9,66 2.2

*Significantly different from zero beyond the .0003 level..

3 Amount ofcontact

The means for the anou~nt of contact of velar tissue

with pharyngeal tissue as shown in Table VrI .ho:w that this

measure in females is almost twice what it is in males.













Males (20) Females (20) U

Range in nm. 3 to 9 5 to 15
54-.5*
Mean 5.7 9.5

S.D. 1,41 2.74

*Significantly different from zero beyond the .00005 level.



The differences between nales and females for the

measuremnent of LA;C are shown in Table VII. It can be seen

that the difference between the means for the sexes is

18.40

TABLE VII

COIPAr~ISC;: CFr';AN:S FO ALE;fS A?;D FEM;iALES
FOs L[AEC


iiales (20) Fenales (20) U

Range in degrees 50-84 75-102
12.5*
iNean 69.7 88.1

s.D. 9.28 7.33

"Significantly different from zero beyond the <.00003 level.

5. aetto .ne:i2

There wass less variation in this ratio for females

as seen in the comparison of the range for this measurement

for males and femalese shown in Table VIII. The proportion

of the distance sP taken up by the distance EC in males


TABLE VI

COMPArlIJON OF iHEANiS OF AHOCUNT OF CONTACT






51

ranged from 18 percent to 57 percent and averaged 43 per-

cent. For the females, the distance EC was from 50 to 75

percent of the total distance to the pharyngeal wall (EF),

with an average of almost 69 percent. This measurement

shows, therefore, that the tip of the uvula is angled sig-

nificantly farther away from the posterior pharyngeal wall

in males.

TABLE VIII

COMPARISONS: OF MEANS FOR PEALZS AND3 FEMALES
FOR RAT'iIC EC:E~F



Mazles (20) Fema~les (20) U

Change .18 to .57 .50 to .75
30"
Mean .433 .689

S.D. .114 .076

qSignificantly different from zero beyond <.00003 (nil).

6. Velar length

The length of the velum varies more amon3 males

than anon3 fenales, as shown in Table: IX.

TABL'3 IX

COMPAHI~',SO.\ OF ;;EA;;S OF V-LAr" L;=IiGT3: IN
MALES ANDC FTEALESU~


Hange (21.) 38 to 61 36 to 46

acan 47.8 41.0


50.5*


S.D,


7.22


*Significantly different from zero beyond the <.0"003 level.







It can be seen from the frequency distribution graph in

Fig. 10 that, while all females are found within the inter-

vals between 35 and 46 mm., only 8 males are within these

intervals.

7. Significance of difference in measurements
of death of the nasocharynx alonrr palatal plane
and fron "aS to midpoint of closure

A Wilcox~on N~atched-P~airs Signed-Ranks Test showed

thaet the difference in the two measurements of depth of the

nasopharynx was significant for males at the 1 percent

level but not significant for females. This is shown in

Table X in which PNS-X represents the depth of the naso-

pharynx along palatal plane and PNS-Y is the depth to the

midpoint of closure.

TABLE X

SIGI:IFICAN;CIE OF jI~iFFEREN1CE
IY iR;ASUR S:: ET'iS OF PL.S-X AUiJ ?NS-Y


Iuesn Diff. Ad-Justed
in mm. N iloon5 T

nales -1.65 20 16 8i

Females -.3 20 8 9.5

?'The adjusted .;ilcoxon ii is lees th-n 20 in each case due to
the mieasuremrentfi s were no differences was observed. :dumber
of cases in eact group was 20.
* i"-inificantly different front zero at the .01 level.,

8. -;n~~lysis of _p~ z d-c-veriec ftecntiuino h



The equatione calculated howed that the t for sex

was 6.13 and was significant at the 4,001L level for its

contribution to the LAB~C. The t for the velar length:






53

pharyngeal depth was 0.84 and not significant for LABC,

The equations for the estimated angles and the coefficient

wrere:

Y =67.93 +27.19 (9Rtio .6140) (M~ales)

Y = 87.38 + 23.19 (Ratio .6140) (Females)

The angle assumed by the velum in closure is not

determined by the ratio of the length .of the velumn to the

distance to be spanned (depth of the nasopharynx) but is

determined on som~e other basis which appears: to be related

to sexr.











q Males

B Females ---

















3 1 a Females --

!I P Males~ -,












Figure 10, Frequency distribution ourve for elarC length












CHAPTER Vr

DISCUSSION,, CONCLUTSIONS, SUMM!ARZY


Discussion

The organizing of subjects in terms of their

measurements for LABC offers a systematic scheme for con-

sidering all measurements in relation to a total pattern.

When this is done, some interestingi questions can be raised

for speculation.

It has been claimed here thant LABC describes the

basic orientation of the velum to the pharynx. Ratio SC:TE

has been calculated to Sather supporting evidence for the

idea that the uvula is angled a~n-triorly a'a-y from the

pharyngeal wall in males but not in females. This could be

a result of either or both a pulling forward of the avula

in the male or a pulling: backw:ard in the female. The

orienetaton of the superior point of contact is diagonal to

the inferior tip of the uvula when the measurements of

LABC are acute. AE the neasurements of LABC approximate a,

right an-Le, the ori~entation of the superior point of con-

tact to the tip of the uvula beco-es vertical owiLng to an

apparent pulling; back of the tip of the uvula to t're phor-

yngeal wall. This difference in orientation can be seen in

Figs. 3, 4-, and 5.

.:hen the chan~e in orientation is toward the





56

vertical, there seems to be a concomitantly greater amount

of contact of velum with pharynx, a site of closure such

that the inferior point of closure is below palatal plane,

and a height of elevation relative to palatal plane which

is also concomitantly lower. These differences are not

explainable by chance.

Table XI, in which subjects are organized accord-

ing to measurements of LPABC showYs that total patterns for

each sex among the several variables describing the velo-

pharyngeal mechanism do emerge.

In the male pattern, amount of contact is less, and

height of elevation is greater than in the female. The

Inferior point of contact is most often above palatal plane.

In the female pattern, the reverse of these situations is

found .

It can be seen from Table XI that the measurement

of 740 defines the upper limit for a "clear-cut" male

category in which no femlales are found. The lower linit

for defining a corresponding "clear-cut" female category is:

850

Fifteen of the mFale subjects fell into the clear-

cut male ca~tegor-y and 16 of the femal~es into the female

category. F'ive marles and four fonales madie up an overlap-

ping category in conformity with the freouency distribution

for LkAM alone shown in Fig. 9, The limiits for j(AEC in

the "ovlerlapo" category were 750_ggo

But statistically spceakinr, there are two basic

























































27
85-99 50
ES

17
19
26
90-9" '13



69

95-99 3"
16

100-104 45
I'ear.S
*FEmale


)j
41
42

li6
43
?5
35
41
5i
36


39
40

3?


Amount Helstionship of
LABC Subj. of Inferior Pt. Contract Helsht :.eight Velar
ho. Contact to Palatal Plane 'Jev. Closure Length

Above On Below


heans 5.8 11 1
28 6 X 11 P 51
21 4 X 5 8
75-7 *38 5 x 8 G
*56 59 7 6
*62 t X 10 s 38

h*2 8 X 7 5 39
80-FII 20 7 X 7 6 l
30 9 :: 7 4 ii?
39 7 X 3 3 L0
rneans b,] 7.5 .


TABLE; XI


ORGANIZATION OF SUBJECTS BY MEASUREMENiTS OF AN-Lr: ABC


18
50-54 22
"7

55-59 57

60-5* 31
40

25
S55
65-69 59
60
95
81

69
70-7h 58
26


16




10
10



14


15


x 7
S5
x 3
X 8

x 7
h 6
X 7
x i
h 3

S7




X 1
5. 3






58
patterns into which all subjects have fallen. All subjects

with measurements for LABC of 790 or less are found to fit

the male pattern as it has been defined here, and all writh

measurements of 800 or more fit the female pattern. Then 3

of each sex are found in the category of the opposite sex.

A clear-cut sex differentiation would seem to be compromised

accordingly.

Extrapolating from these findings, it could be

expected that 85 percent of all individuals who would fit the

male pattern of velopharyngeal mechanism would, in fact, be

males, and similarly, 85 percent of all persons who would

fit the female pattern would in truth be females.

This raises the question of what factors could be

operating within or on the velopharyngeal mechanism to re-

sult in such a high correlation on a sex basis and yet still

allow for some "crossing over."

Configuration could be anatomically ordained on the

basis of either structural (skeletal) variations and their

consequent influence on the orientations of muscles, or

differences in mechanisms of muscle actions. On the other

hand, the configurations could represent the effect of

muscle adjustments which must be made by whatever muscle

action necessary to achieve certain balances between reson-

ating cavity proportions for the purpose of achieving

certain acoustic effects.

There has been essentially only one question asked

in the literature with regard to structural differences,







and that has been with reference to velar length and

pharyngeal depth relationships. The finding reported here

that the difference between the depths of the nasopharynx

measured along palatal plane and at actual site of closure

is significant only for males is evidence against the idea

that shorter palates have to rise higher to achieve

closure. It is the males who have the higher height of

elevation and who also have the greater mean velar length.

This, together with the finding that the ratio of the

leng-th of the velum to the depth of the naseopharynx does

not influence the orientation of the velhn in closure (as

described by LAB9C) sug-gests that the question asked about

structural differences has not been the relevant one.

This would not preclude the possibility of there

being other significant structural relationships within

which differences could be found.

For example, the diagonal orientation between

superior point of contact and tip of the uvula in ma~les,e

which is manifested in the acuteness of LABC, could be due

to a particular orientation of levator palatini to palato-

glossus muscles existing because of particular head size

and oral and pharyngeal disensiions

The corresponding vertical orientation of the

superior point of contact and tip of the uvula in fenales

could be due to a vertical orientation of elevator and palat-

opharynJaus such that palsto510ssus was not in the line of

major influence. Tihis could be the resultant of a differ-







ence in sku~ll size, orientation of skcull to cervical

column, or oral and pharyrngeal size differences, Such

hypotheses would allow for some cross-over between the

sexes because of size differences.

Size considerations aside, it could be possible

that the two different velar orientations are the end pro-

ducts of two different mechanisms of muscle actions, It

may be that in those persons having the male pattern, the

palatopharyngeus muscles are caused to move medially,

allowing levators and palatoglossus to act antagonistic-

ally to cause the "hookinS" action described by Ricketts

(19~54). In those individuals having the fenale pattern,

movement of palatopharyngeus muscles could be posterior-

ward so that they become the direct antagonriscts of the

elevator muscles, thus causing the tip of the uvula to be

directed downward and causing closure to occur at the level

of palatal plane with a conconitant decrease in height of

elevation above palatal plane.

The whole purpose for velopharyngeal closure in

speech has been defined as the regulation of nasal reson-

ance. The different velar orientations and configurations

could have some special significance to the acoustic output

during speech. TIhe differences in the measu~rements of the

variables contriouting to the configurations could represent

adjustments which have to be made in one sex or the other to

compensate for the basic difference in fu~ndamrental frequency

compoundced by differences in the oral and pha~ryngeal





61

cavities. It may be that such compensations must be made

in order to achieve comparable phonetic results.

Conclusions

1. The velopnaryngeal mechanism as it is visualized with

lateral cinefluorography has been found to differ for males

and females in every measure studied. Control for sex as

a variable should be a part of studies of the velopharyngeal

mechanl-ism.

2. The basic orientation of velum to pharynx is different

for the sexes and configuration of the velum in outline is

conconitantly different according to specific patterns. The

basic orientation of the velum to pharynx in males can be

described in terms of an acute angle, and that of females

more approximately a right angle. Velar length is greater

in males, the height of elevation is greater, the amount of

contact is less, and the inferior point of contact is most

usually above palatal plane. The reverse of these findin_7s

is the usual condition in the female pattern.

These differences are not due to chance and are

not explainable on the basis of a velar length to pharyngeal

depth ratio.

3. The establishing of the basic pattern of configuration

for experimental subjects un'er controlled conditions could

be a useful technique to use in the further study of

variations within the velopharyngeal mechanism for thn

definition of anatomic or physio-acoustic relationships,









It has been hypothesized that the velopharyngeal

mechanism as visualized on cinefluorographic films is

different in young adult males as compared with young adult

females. Evidence has been presented that the basic orien-

tation of the velum to the pharynx is different in the

sexes. In males, the uvula is seen to angle forward away

from the posterior pharyngeal wall. The orientation of the

superior point of contact with the mnidpo0int of the uvula is

such that when a line is drw~n~ from the midpoint of the

posterior nasal spine to the superior point of contact and

another line is drawn from the superior point of contact to

the midpoint of the uvula, an angle of acute dimensions is

formed. In females, the angle described by comparably

placed lines approximates a right angle. The descriptive

angle has been designated L.ABC. The upper limit that w~lll

define a male measurement of this angle has been found to be

790. In females, the measurement will be 800 or larger.

The orientation of the velun to the pharynx has

been further defined by a ratio which describes the distance

of the tip of the uvula fromi the back pharyngteal wiall. This

ratio has been called EC:EF.

There are different patterns of configuration out-

lined by the veluml in closure which are concomitants of the

basic orientations. Once the basic orientations have been

established, the configurations are the further result of

the amount of contact, height of elevation, and the place on

the pharyngeal wall relative to palatal plane which is the







site of the inferior point of contact.

The following specific findings have been

reported here.

1. Seventeen of 20 males had the inferior point of contact

on (5) or above (12) the palatal plane. Seventeen of 20

females had this point below palatal plane.

2. Height of elevation was greater for males. The mean

height of elevation for males was 10.05 nm. while for

females it was 5.9 mm.

7. The mean amount of contact for females was 9.5 ne. and

5.7 nm. for males.

4. The mean measurementi of LABC in males was 69.7 and for

females it was 88.1. W~ith 790 defined as the upper limit

for a male category as defined by LAaC, and 800 the lower

limit for a female category, 17 out of 20 of each sex were

in their appropriate categories and 3 of each sex w~er-e in

the category for the opposite sex.

5. The average ratio of Ec to ZF in males was 43 percent

and was 69 percent in females demonstrating that the uvula

is angled forward away from the posterior wall of the

pharynx in males.

6. VlarT length was significantly greater in nales, rang-

ing from~ 38 to 61 ma. wcith ae -ean of 47.8 ?im. The! ranre for

females ;;as 3; to 46j with a miean of 41 -m,

7. Tihe depth of the nasopharynx was ~eas~uredi fro- P::S along

palatal plane and from Pi;S to th~e midpoint of closure. Tihe

difference in the two measurements was significant only for

males,





64

It wias concluded that the velopharyngeal mechanism

was significantly different for the sexes on every measure

tested. This difference could not be due to chance,

The basic orientation of the velum to the pharyn-

geal wall as defined by measuremcents of LABC and Ratio

EC:EF is different for the sexes. This difference in

orientation as defined by LrABC does not depend on a ratio of

velar length to pharyngeal depth. As angle measuremenlt

increased, amount of contact increased, and height of eley-

ation decreased.

Some speculation as to reasons for the differences

was included. Plans for future research include the inves-

tigation of possible acoustic correlates of variations from;

the basic configurations which might be induced as well as

the possibility of a difference in muscle necha7nismis.












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mechanism of the nasophary~nx. Ana t.C Mc 10,
1949, 510.

Subtelny, Joanne 3. Physio-acoustic considerations in the
radiotiraphic study of rpeech. Clf Palate J., 1,
1964, 402-1110.

Subtolny, J.D., andi Baker, H!. Koepp3. The significance of
adenoid tissue in velopharyngeal function. Plsst.
Reconstr. Sure., 17, 1956, 235--250.





69

Subtelny, J.D., Fruzansky, S., and Subtelny, J. The ap-
plication of roentgenography in the study of speech.
In Kaiser, L. (Ed.) Manual of Phonetics, Amsterdam:
Ndorth-Hiolland, 1957. 1 5-179.

;arren, D.W. and Hiofmann, F.A. A cineradiographic study of
velopharyngeal closure. Plastr. Rcnt.Sr
28, 1961, 656-659.

darren, D.;d., Hofmann, F.A., and M/iller, R.MI. A study of
velopharyngeal closure using cineradiography with
image intensification. Abstract. J.D. Res., 40,
1961, 733-734.

IWestlake, Hi. and D. Rutherford. Cleft Palate. Englew~ood
Cliffs, N.J.: Prentice-Sall, Inc., 1966.

Wildnan, A.J. Tongue, soft palate, and pharyngeal wall
movement. Amo. J. Orthodontics, 47, 1961. 439-461.













BIOGRAPHIICAL SKETCEY~

Dorothy Vivian McDuffe McKerns w~as born in

Brandon, Mianitoba, Canada, on Maiy 3, 1923, Hier primary

and secondary education were received in Canada, She and

Kenneth McKerns were married in 1947 and have two

daughters, Maureen and Leslie, and a little granddauGhter,

Laura. The Mc~erns family has lived in Edmonton, Montreal,

and Toronto in Canada, and St. Andrews, Scotland before

coming to the United States in 1956 to make their home in

iNew Jersey. while e living in N~ew Jersey, Dorothy attended

Paterson State College in azyne, N.J. and Fraduated cum

laude in June, 1960 with a Bachelor of Arts in ilementsry

Education. She entered the University of Florida in

September, 19t0, when she and her family moved to Gaines-

ville, and received, a M~aster of Ed~ucation degree in Second-

ary education (Snglish) in December, 1.962. Worke toward a

doctorate in Speech Pathology was begun in September, 1963.

American citizenship was granted in October, 1963. Special

interests aside from those involved in the field of~speech

include th-ose shared writh her husband in his w~ork inl endo-

crinolo-gy, and. in their home, gardecn, and family.









This dissertation was prepared under the direction

of the chairman of the candidate's supervisory committee

and has been approved by all members of that committee. It

was submitted to the Dean of the Coll~ege of Arts and

Sciences and to the Graduate Council, and wvas approved as

partial fu~lfillment of the requirement for the degree of

Doctor of Philosophy,


June, 1968


nee






Dean, Graduate School



Supervisory Committee:




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VELOPHARYNGEAL MECHANISM: THE FACTOR OF SEX By DOROTHY McDUFFE McKERNS A DISSERTATION PRESENTED TO THE GRADUATE COUNCIL OF TEIE UNIVERSITi' OF FLORIDA IN PABTLVL FULFILLMENT OF THE REQUIREMENTS FOR THE DEGREE OF DOCTOR OF PHILOSOPHY UNIVERSITY OF FLORIDA 1968

PAGE 3

ACKNO'/jLSDGJJKiiNTS Appreciation and gratitude art? extended to the chairman of my committee. Dr. Kenneth Bzoch, Professor and Head of the Department of Communicative Disorders, Collese of Health Related Professions, who provided the opportunity for me to become involved v/ith the techniques and understandin;iS prerequisite to the definition of the study undertaken. Dr. Bzoch generously allowed his library of films to be used in this study. The progress of the investigation vras immeasurably assisted by his patient constructive criticism and many perceptive suggestions. I wish to thank the other mem.bers of my committee, Dr. G. Paul iioore, Dr. Thomas Abbott, Dr. James Horel, and Dr. Bradford N. Bunnell for giving generously of their tim.e and assistance in bi'inging the study to its conclusion. It is no exaggeration to say that this investigation could not have been carried out vrithout the constant encouragement and tireless assistance of my two friends. Dr. Hichard League and ilr. .'/illiam N. Williams. They have ny deepest gratitude. Appreciation is extended to Dr. Lowell C. Hammer for help with the pilot studies and to Dr. o^'ohn Thornby for assistance with a m.ajor statistical problem. 11

PAGE 4

TABLE OF CONTENTS Cnapter Page I Introduction 1 Review of the Literature 2 II Statement of the Problem 22 Hypothesis 23 Purpose of the Study 29 III Methods and Procedures 31 Initial Selection of Subjects 31 Procedures for Obtaining Films 31 Selection of Subjects for This Study. . 32 Procedure for Collecting Data 35 Reliability ^1 Method of Analysis -113 IV Results 46 V Discussion, Conclusions, Summary S5 Discussion 55 Conclusions 6l Siimmary 62 Bibliography 65 Biographical Sketch 70 ill

PAGE 5

LIST OP TAz>LES :able p Comparison of Means for Kales and ir'emales for Ratio SC:E? . . i^age 1 Kruskall-^'allis One-way Analysis of Variance of Sounds /pi/, /ti/, /ki/, . . 3^^ 2 Relationship of Inferior Point of Contact to Palatal Plane 14,^, 3 Raw Data for Females i+7 ^ Raw Data for Kales 48 5 Comparison of Kean Height of Elevation rietween Hales and Females k^ 6 Comparison of Keans of Amount of Contact . . 50 7 Comparison of i-ieans for Males and remales for /ABC 50 51 9 Comparison of Means of Velar Length in Males and Females 5I 10 Significance of Difference in Measurements of PN3-X and PMS-Y 52 11 Organization of Subjects by Measurements of Angle ABC 57 iv

PAGE 6

LIST OF PIGUEES Figure 1 10 An Orientation and Configuration of the Velum in Closure for Speech, . . Illustration of Height of r:ievatlon, Closure, and Lepth of Nasopharynx. . "Squared-off " Female and "Acute' Male Velar Configurations. . . Actual Line Tracing of a Cinefluorographic Frame of a Female Subject. , Actual Line Tracing of a Cinefluorographic Frame of a Male Subject . . Illustration of lleasurements Palatal Plane, Depth of :>Jasopharynx Alon£: Palatal Plane and to iiid point Closure Illustration of /ABC Illustration of Amount of Contact and .'iethod of Deternining liatio ECiEF Frequency Distribution Curve for /ABC Frequency Distribution Curve for Velar Length Page 12 16 25 26 27 37 38 5^ 54

PAGE 7

CHAPIER I INTRODUCTION The subject of the study reported here is the velopharyngeal mechanisra for speech in normal young adults as visualized on lateral cinef luorographic films. It can be stated as a general principle that for English, separation of the nasopharynx and oropharynx by the interpositioning of the velum (soft palate) is usual for the production of all of the sound elements other than /m/, /n/, and /ri/. There are variations in the amount of nasal resonance on vo^rels which are related to dialectal differences in normal speech. Hov;ever, physiological aberrations which make it impossible either to achieve or to maintain appropriate contact of the velum with the pharyngeal wall may result in serious problems of hypernasal distortion. The velopharyngeal miechanism is thus central to investigations of both normal and abnormal speech. Phoneticians , speech pathologists, orthodontists, and surgeons have used various X-ray techniques to study the speech mechanism according to their special interests in the structures, processes, and problems involved. .''ith regard to the velopharyngeal mechanism, efforts have been made both

PAGE 8

2 to define v;hat occurs in norraal closure for speech and to identify and describe velopharyngeal insufficiencies. The comparatively nev; technique of cinefluorography is the method used in the present study. Cinefluorography is the photographing with a motion picture camera of an electronically intensified X-ray image projected on a fluoroscopic screen. The resulting mid-sagittal views of the speech structures in motion recorded on films can be projected at life size to be analyzed in detail. In the study reported in this thesis, the velopharyngeal mechanism of males, as visualized on such films, was compared with that of females. The results demonstrated that the configuration assumed by the velum in its functional positions for speech observed in male subjects differed from that seen in the females. The nature of this difference has been described in detail in the following pages. Review of the Literature This revie'w of the literature has been organized to reveal the concerns of those reporting information about the velopharyngeal mechanism within three broad areas. Some papers have had as their major purpose the description of technical principles and development of methods which allow for the application of X~ray to the special problems involved in revealing the dynamics of the speech process. Other papers have explained the clinical application of cinefluorography to speech pi-oblems resulting from velopharyngeal insufficiencies. Papers which have reported the systematic

PAGE 9

3 study of diverse questions pertaining to velopharyngeal function for speech form the final area of reviev;. In some of these studies, the goal has been to define v;hat occurs diiring normal speech production vfith regard to certain aspects. In others, the purpose has been to compare the normal and abnormal functioning of the velopharyngeal mechanism in terms of specific questions. Methodolo gy The "still" X-ray techniques were the first to be used in speech. Cephalome tries and laminagraphy have been described many times. An historical development of cephalometry has been traced by A.G. Brodie (l9'+9). T.M. Graber (1952) lists, defines, and illustrates the anthropometric and cephalometric measure points that have been developed in order to standardize information from lateral X-rays and make comparisons possible. wildman (I96I) has proposed that a standardization of measurements such as that provided by cephalometrics be achieved for lateral lamdnagraphy and cinefluorography . He has selected, described., and illustrated . those measurements he feels are most effective from the studies of researchers vfho developed them. Sloan et al. (196^) have also described the application of cephalometrics to cinefluorography. Subtelny, Pru.zansky, and Subtelny (195?) and iloll (I965) are sources for a description of laminagraphy. Cephalometric techniques were popular with researchers before the advent of cinefluorography and still

PAGE 10

have advantages in better resolution of the image. Cinefluorography has the advantage of adding the dimension of motion to the X-ray pictures. Carrell (1952) described a technique for reducing radiation effects by synchronizing the roentgen generator and the picture and commended the application of cineradiography to the diagnosis of velopharyngeal closure inadequacies and for post-correctional evaluation. It vras the development of image intensification that made cinefluorography a practicable technique. With this, the image formed on the fluoroscopic screen by the passage of roentgen' rays through the subject is intensified 1,000 or more tines in brightness by means of an electron optical intensifier. Berry and hofmann (195^; 1959) have v/ritten an excellent description of the principle of image intensification and other details of the cinef luorographic technique. Details of the principles of image intensification and procedures of cinefluorography are also provided by morgan (I96I). A problem v."hich has had to be considered is that of effective filming rate. This question has been raised in papers by lioll (I960), Bjork (I96I), Bjork and Nylen (19^3) , and Shelton et al. (I963) . Sparrow, Brogdon, and Bzoch (1964) have shown that for specific types of studies of velopharyngeal function a filming rate of 30 frames per second is adequate. They say that this filming rate gives better image resolution than a rate of 60 frames per second. I'lOll (i960) noted the failure of most investigators

PAGE 11

5 to quantify information fro^i the filias they used to make descriptive reports. He undertook a study to determine procedural techniques for obtaining clear cinefluorographic pictures of the articulatory structures during speech without excessive exposure to radiation. As a second step, he studied the reliability of extracting information from the films in terms of objective measurements directly from the projection of the films or from tracings of the projections, His paper is therefore useful for description of equipment and procedures to be used in quantitative studies. Subsequent papers are also useful in this respect (Powers, I96O; Bjork, I96I; .barren and Hofmann, I96I; Sparrow, Brogdon, and Bzoch, 196^) . Clinical Application of Cinefluorography to Speech Problems A partial list of papers in which the application of cinefluorography to clinical diagnosis and treatment is described and advocated includes those of Cooper (1956), Calnan (1955-56), Fletcher (1953), Fletcher et al. (I96O), Aram and subtelny (1959), Kirkpatrick and Olmstead (1959), Smith et al. (I96O), Ashley et al. (I96I) , Green (I96I), Hazaheri and nofmann (I962), and Kirkpatrick (196^). The identification of velopharyngeal inadequacy by contrast wirh the normal velopharyngeal mechanism, the making of prognoses, the prescribing of treatment, the placement of speech bulbs and assessment of their efficacy, have been topics of the foregoing papers.

PAGE 12

Application of X-ray Techniques to Definition of i^^io^Inal and Abnormal Velopharyn.Q:eal Mechanisms The historic attempts of early phoneticians to apply standard radiography to the definition of artlculatory positions have been reviewed in an interesting paper by I^acmillan and Kelemen (1952). Subtelny, Pruzansky and Subtelny (195?) also reviewed the work of the pioneer phoneticians. Their emphasis was more on tongue-arch positions than on other aspects of articulation. Specific attention to variations in velar position began with Allen in 188^. Variations are possible in a vertical direction in terms of the height to which the velum rises for closure, and in terms of the vertical span of the velar tissue making contact with the pharyngeal wall. In a horizontal direction, variations are possible in the extent of the gap between the posterior surface of the velum and the posterior surface of the pharynx. Variations In velar position have been studied in terms of the sounds produced. Bloomer (1953) had reported small and not always consistent variations during the production of both vowels and consonants on the basis of tracings from photographs taken through facial defects. .'.'arren, Hofmann, and Miller (I96I) reported that they found a significant difference in the elevation of the velum for different sounds in their clnefluorographic study. Moll (i960) studied velar changes In two female subjects. He found a greater extent of velopharyngeal contact for sustained vowels than for vowels in consonant contexts. For vowels in

PAGE 13

7 consonant contexts there was more contact when the consonant was a non-nasal than vrhen It was the sound /n/. Contact for /a/ was less than for /i/. Bzoch (I968) has shovm that in the production of the three sounds /i/, /a/, and /u/, the velum rises higher for /i/ and /u/ than for /a/. Hagerty et al. (195S) shov.'ed that elevation of the veliim is higher for /s/ than for /a/ when seen in lateral laminagraphs . Moll (19-2) showed that velar elevation was related to tongue height. The question vjhether absolute closing of the velopharyngeal gap is necessary for the production of sounds perceived acoustically as normal is one that still receives attention, r^arlier research pertaining to this o_uestion has been reviewed by i-lcDonald and Baker (1951). It had been shown that closvire as it is visualized by X-ray is not alvfays achievedfor the production of sustained vowels (Holl, 1960). Bjorl: and .^ylen (19^3) reported that in many persons V7ith norT.al speech, the production of the consonants /a/, /v/, /s/, /t/, /b/, and /d/ was achieved and acoustically perceived as correct, without co:nplete velopharyngeal closure, as seen with cinefluorography . Their subjects spoke Swedish, r.owever, Sjork (I96I) had earlier reported finding openings only for nasal consonants and neighboring vowels in his analysis of the production of four sentences by Swedish speakers. Bzoch (I967) has subsequently correlated the points on cinefluorographic filras at which velopharyngeal closure aooeared absolute with the sou.nds produced in an

PAGE 14

English sentence. In all of his 7k normal subjects there was an invariant pattern of 3 closures and kopenings corresponding to the production of the non-nasal and nasal sounds respectively. There v/ere, however, occurrences of "assimilated nasality" on some vowels which preceded or followed nasals in some siibjects. The condition of cleft palate has been of particular interest. Using X-ray, the problem in cleft palate speech has been studied with regard to the importance of tongue position (Hixon, 19^9), and to the size of mouth opening (Kelly, 193^^). However, when Buck (1953) studied these factors and the factor of velopharyngeal closure, he concluded that the extent of velopharyngeal closure determined the major difference between his normal and cleftpalate subjects. Because some persons w^ith cleft palates nonetheless have vrorse speech than others also vrith cleft palates, the question of other contributing factors has been studied comparing cleft-palate subjects with each other by means of cinef luorography (Powers, I96O). Sloan e_t al. (190^) compared the deglutition and phonation patterns of noicmal and cleft-palate subjects in a demonstration study explicating the use of c inef luorography . These investigators maintained that, for the production of vowels, if nasopharyngeal closure is not sustained, hypernasal production will occur. The question of velopharyngeal inadequacy in the absence of cleft oalate has also been studied for its effect

PAGE 15

9 on speech. Blackfield e_t al. (1962) have revlev:ed the literature in V7hich velopharyngeal dysfunction v7ithout cleft palate has been defined and described. In their study they made measurements from tracings of cinefluorographic films of 24 patients vrith velopharyngeal dysfunction and compared them vrith those of 30 individuals with normal speech. Anatomic abnormalities v.^ere found to be either excessive depth of the nasop.:arynx, short hard and soft palates, short soft palate but normal hard palate, or inadequacy of palatal motion when compared v^ith the normals. They concluded that, with the exception of 2 patients, there v;as a direct relationship betvreen the degree of inadequacy of velopharyngeal closure and the severity of the speech defect. Hazaheri, Millard and Erickson (1964), on the other hand, claim that in their study of noncleft subjects v.'ith velopharyngeal inadequacy they found no relationship between the degree of velopharyngeal inadequacy and the severity of the speech defect. The size of the gap betv;een the velum and pharynx during phonation was correlated V7ith judgements of voice quality and intelligibility. Shelton (1954) defined six categories of closure patterns; i.e. patterns of closing the gap betv7sen velum and pharynx and of maintaining or being unable to maintain appropriate closure. A normal pattern vras established by speal-:ers with no speech problems similar to that reported by Bjor> (1961) and found by Ezoch (I967). Deviations from this pattern v;ere plotted for subjects v.-ho had palatal inadequa-

PAGE 16

10 cles or v;ho had si^.rgically repaired cleft palates. Bzoch (1967) shou-ed that the correspondence he found of velophaiyngeal closure and sound produced for his normal subjects was not achieved by deaf oral speakers, persons with cleft-palate speech, or 'with problems of velopharyngeal insufficiency in which there vras an inability to achieve or sustain appropriate tining rates. One finding based on X-ray studies of velopharyngeal function about v^hich there seems to be no argument is that adenoid tissue can provide a surface for the velam to close against and can be a means of narroviing the distance to be spanned, so that often v/here velopharyngeal inadequacy -would othervjise be present, the problem is avoided (Calnan, 1953; Buck, 195^1'; Subtelny and Saucer, 195^). It has been a goal in clinical practice to knov; such things as the expected site of velar contact along the pharyngeal wall, the height to v/hich the velujn elevates relative to palatal plane, the amount of tissue making contact, and whether there is a relationship of velar length to pharyngeal depth in order to cope more effectively V7ith rehabilitation in velopharyngeal insufficiency. Ho'.rever, these variables have not been considered in terns of a total pattern but rather, in terms of some other variable or special rationale. In its functional or closed position, the velum, as seen in lateral X~ray pictures, assumes a certain configuration resulting from the height to which it elevates (relative to palatal plane), the place on the pharyngeal wall

PAGE 17

11 where It touches, the extent of contact, the area on Its surface which ma'ces the seal, and the position of the uvula relative to the posterior pharyngeal wall. The high point on the velar surface seen when in the closed position for speech has been called "levator eninence" and defined as the point of insertion of the levator muscles (Green, 19-1; V/estlalce and Rutherford, I966, p. 61). Podvinec (1952) had stated that the point at which the insertion of levators and of palatopharyngeus cross causes the "dirapling" seen on the oral surface of the velum. This point, according to Podvinec, also becomes the center or focal point of the velar tissue which effects the closure and is as well in the area of greatest excursion from rest to closure. Fig. 1 illustrates an orientation of the velum in closure similar to that "which has been described and/or illustrated by Podvinec (I952), Ric'retts (195^). Hagerty et al. (1958), and Green (1961). As it has been described in the above papers, the uvula, is angled well forward. On the basis of observations made possible by the use of X-ray, the area of the velun which ma":es closure had been defined as the middle third (Calnan, 1955-56) . r:owever, 'when Graber, Bzoch and Aoba (1959) divided the outline of the velum into quadrants rather than thirds they found that the third quadrant made closure in 100 percent of their subjects and in 27 percent the fourth quadrant -was also involved. The highest point on the upper surface did not coincide with the area of contact but -was farther forv;ard at

PAGE 18

12 IjS ^I^Jasopharynx Velum Pharyngeal ^•/all Uvula Oropharynx Tongue Figure 1. An orientation and configuration of the velum in closure for soeech.

PAGE 19

13 the midpoint of the middle third. The midpoint of the palate shov;ed the greatest extent of upward and baok;vard movement. Kazaheri, Killard and Erickson (19^^) used 10 normal subjects as controls in a study of velopharyngeal inadequacy. They also said that they found a significant difference betv.-een the high point on the superior velar surface and the height of the superior point of velar contact with the pharynx. Further than this, they stated that the height of velopharyngeal closure took place below the palatal plane in 80 percent of their normal subj'ects. In the Graber, Bzoch and Aoba (1959) study 22 of the ^^ subjects were females, and in the i-Iazaheri, Liillard and Erickson study, 8 of the 10 normal subjects were females but no significance v:as attached to this in interpreting the findings in either study. Hicketts (195^) pointed out that the size and shape of the pharynx are influenced by the bones which surround it-"the occipital, the sphenoid, and the ethmoid. He showed in particular the effect of variations in the inclination of the basilar part of the occipital bone. V/hen this was inclined more horizontally the nasopharynx became wider, and as it was more vertically inclined the "cranial base" became acute and the nasopharynx correspondingly narrower, iiicketts clairied the velum accommodated itself to the space provided in the pharynx by assuming either obtuse or acute angles -with reference to the posterior nasal spine when in the rest position. Rickett's study pointed out the possib-

PAGE 20

1^ility that structural variations might account for variations in the dimensions of velopharyngeal closure. The velum might accommodate itself to the space available in the pharynx in its functional position, just as Hicketts said it did in the rest position. V/arren and Hofraann (I96I) tried to determine possible relationships between velar length and pharyngeal depth; pharyngeal depth and velar height during closure; and velar length and velar height during closure. Cinefluorography vras used for their study. They concluded there v.-as no relationship betvzeen soft palate length and pharyngeal depth. An inverse relationship vras found between length of palate and height of closure — -the longer the palate, the lovrer the elevation. v/arren and Hofmann suggested that the reason for this inverse relationship is the anterior sloping of the pharyngeal wall as it becomes the nasopharynx, which causes depth to decrease v;ith height. They theorized that a short velu?u would have to rise higher to contact the pharyngeal wall than a longer one which could span the wider distance at a lower level. It v;as their opinion that velar length was a more significant determiner of closure height than pharyngeal depth. nazaheri et aj^. (196^,'-) found a correlation between length of velum and depth of the pharynx, in contrast to the findings of V/arren and Hofmann. They found no significant relationship between depth of nasopharynx and height of elevation above palatal plane or between length of velum and height of closure (in contrast again to V/arren and Hofmann);

PAGE 21

15 nor between length of velum and height of elevation. Kazaheri et al. say that the theory of warren and >:ofmann that the short velum elevates higher than the long to achieve closure does not necessarily hold true. Fig. 2 illustrates hov; depth of the nasopharynx, height of elevation, and height of closure are defined. Bjork and iiylen (3jor]-:, I96I; Bjork and Nylen, 1953) are the only investigators found to have considered in any v.'ay the possibility of a sex difference in any of the variables involved in velopharyngeal closure. They found no difference that V7as significant between males and females on measures of amoijint of excursion, amount of contact, height of elevation, or velar length in the rest position. irlagerty e_t al. (1953) reported that there v;ere some differences in the amount of excursion from rest to closure betv.'een their Kegro and v/hite subjects and some difference in amount of contact of velum with pharynx in the two groups. Age as a variable in the velopharyngeal mechanism has been considered. Aram and Subtelny (1959) found that the amount of velar tissue ma'cing the seal with the pharyngeal wall decreased with age. The average for this measurem.ent in their subjects a^ed ^ to 5 "'as B.6 mm. and in their oldest subjects, aged 18 to 20, it was approximately one half as much. Aram and Subtelny (1959) found chan.^es in the site of closure with age as v;ell. They described the site for their younger age groups as being the "superior and/or the superior-posterior aspects of the nasopharynx." Site of

PAGE 22

16 ight of levation _Heisht of closure Figure 2. Illustration of height of elevation, of closure, and depth of the nasopharynx. heiG:h1

PAGE 23

17 closure for the older groups was described as "posterior pharyngeal vmll," The transition too'-: place in their 9 to 11 age group. Calnan (1955-56) stated that the area just above palatal plane would be the probable site of closure. He then defined three possible relationships of the palatal plane to the back wall. The highest site, level with basisphenoid, was described as the "infantile." The adult position, Calnan said, was normally level with the upper border of the arch of the atlas or lov^er. Both Aram and Subtelny (1959) and Calnan (1955-56) stated that the higher position for velopharyngeal closure in young children vras due to the fact that the hard palate v;as closer to the upper limit of the nasopharynx. As grow'th of the face occurs dov;nv<'ards and forvrards, the palate descends and the distance increases from the posterior pharyngeal v;all, according to these authors. Calnan (1955-56) expressed the opinion that closure is higher in children because the forward inclination of the posterior v:all at the point of contact is at an angle of ^5° to the horizontal, v;hile it may be vertical in some adults. Bjork and Nylen (I963) found the site of closure in children to be lower than in their adult subjects. They state the reason for this is because of the greater forward inclination of the posterior wall in children as opposed to the almost vertical plane of the adult. Thus, the same hypothesis has been used to explain opposite findings. Some attention has been given to determining

PAGE 24

18 whether the action of Passavant's pad is significant In the normal velopharyngeal mechanism. Calnan (1953; 1955-56) has completely discounted it. Graber et al. (1959) claim it v/as present in 3 percent of their subjects. Others say they have found no anterior movement of the posterior pharyngeal wall in normals (Cooper, 195^; Warren and Hofmann, 19-1; and Bjork and Nylen, I963) . Kagerty et al. (1953) said they did not think Passavant's pad was significant in normal speech production. Another concern about the mechanism of muscle action by which closure is achieved has been vfi'th the role of the muscles in the lateral wall of the pharynx. Harrington (19^^^^) determined the presence of a palatal origin (different from the hamular origin) of the pterygopharyngeus muscle in 8 of 10 cadaver dissections. Ee felt that these pterygopharyngeus fibers vjith a palatal origin probably contributed to mesial movement of the pharyngeal v:alls. Because the pterygopharyngeus also has connections with palatopharyngeus , Harrington suggested that approximation of the palatopharyngeus m.uscles cou.ld also contribute to m.esial movement of the lateral pharyngeal walls. L.H. Strong (19^-9) reported that ho and Lochi, Independently of each other, had proposed as early as 19^13 that the palatine bundle of the superior constrictor was a "major force component in nasopharyngeal occlusion." This proposal v:as made by these authors, Strong said, as a mechanism to account for the ability of palatopharyngeus to m.ove medially. In their

PAGE 25

19 mechanism, palatopharyngeus is forced medially by the contractions of the palatine bundle of the superior constrictor. An action of salpingopharyngeus muscles causing medial movement of the lateral v;alls was reported by Harrington (19^^). This action ;-7as viewed in one subject who had had a radical resection of the left maxillary sinus. Bloomer (1953) stated his opinion that the salpingopharyngeal folds were more likely brought into approximation by the sphinctcric contraction of the superior constrictor and the palatopharyngeus muscles than by their own action. Westlake and Rutherford (I966, p. 55) point out that the salpingopharyngeal folds which can be seen on oral inspection in people who have either thin palatopharyngeus muscles or whose palatopharyngeal muscles do not move medially in closure, probably act to narrow the oral and nasal pharynx. There seems to have been some shift of opinion among those using X-ray away from the idea of any kind of sphincteric or narrowing of the pharyngeal dimensions in the normal velopharyngeal mechanism. Calnan (1955-5^) has stated flatly that closure is not "sphincter-like" and that the superior constrictor does not play an imiportant part in speech. Bjork (I96I) and Bjork and Nylen (19 ^'3) reported the results of tomography used in their study to estimate the role of lateral movements of the pharyngeal wall in the nasopharynx. They asserted that there were no important chana-es in lateral dimensions in normals. In cases of

PAGE 26

20 velopharyngeal incompetence, such contractions are compensatory, in their opinion. The revievr of the literature so far has shovm that the area for investigation into the velopharyngeal mechanism for speech is extremely broad in scope. There are still many unansv;ered qxiestlons v;ithin those problems which have been the focus of attention. Interest in some other directions is just beginning to develop. J. Subtelny (196^) has pointed out that progress in the physiological aspects of phonetics has not kept pace with progress in acoustic phonetics. She has suggested the need for making more correlations between shifts in velar positions and the rest of the vocal tract and changes in sound spectra. Behind the effort v;hich has been put into velar research, there seems to have been an implicit belief that the velum functions as an articulator with adjustments being made as appropriate by the muscles of the velum. Moll and Shriner (I967) have raised the question of whether the velum really functions as an articulator at all. They feel that the velum may act merely as an "on-off" valve. The valve would be "on" for non-nasals and "off" for nasals and have a ready position in betv;een "rest" and "on." The more subtle adjustments vrould be due to changes in and restraints resulting from tongue position and time available. In response to this question, Lub^cer (19o8) has undertaken electromyographic and cinefluorographic studies

PAGE 27

21 and has reported that his findings do not support the suggestion of Holl and Shriner. He finds evidence to the contrary, that the velum does in fact change in response to activation of its ov;n muscles. More evidence is needed regarding this question. The difference betv;cen an "on-off" valve and a "precision" articulator would be immense. When the velum is considered as an articulator, the question of the significance of velar variations for acoustic output is a relevant one and the question of the muscle actions involved in making the variations remains as important as ever. The definition of the velopharyngeal mechanism into discretely different conf igiarations as seen cinefluorographically could be a useful first step toward the further study of such problems.

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CHAPTER II STAT21^'iENT OF TH2 PROBLEM The factor of sex as a variable in the velopharyngeal mechanism has been considered in only one previous study. Bjork and Nylen (I963) obtained some measurements for males and females separately for the purpose of comparing adults to children, and normals to cleft-palate subjects. They reported finding no significant differences between the sexes on the measurements they made. Nonetheless, it may be possible that certain differences do exist. The possibility remains that failure to consider sex as a variable may have influenced the results in some studies. Data obtained in studies where the subjects are all males may not be comparable to data from studies in which the subjects are all females or which include members of both sexes. Because information obtained about the normal process has such immediate practical application in the identification and treatment of abnormalities, there has been a tendency on the part of investigators to focus on 22

PAGE 29

23 comparison betv;een normal and abnormal. In these comparisons, normal subjects and subjects with velopharyngeal inadequacies have been matched for sex as well as age in some studies, but all subjects have then been treated only as either normal controls or as experimental subjects without sex comparisons. In other studies where the objective has been to define what occurs in normal velopharyngeal closure, subjects have been classified as normal on the basis of having no velopharyngeal inadequacies or speech deviations and then treated equally. Kean measurements' for normal individuals have then been determined without regard to possible sex differences. Graber, Bzoch and Aoba (1959) included equal numbers of males and females in their study but did not mal:e comparisons. A reviev; of the literature reveals no study v;hich has specifically considered velar configuration per se_ or the possible significance of variations from basic configurations. It has been recognized that velar configuration as it is revealed in lateral X-rays is the result of the balance of muscle forces exerted upon the velum in achieving closure (Hicketts, 195^), but it seems that velopharyngeal closure has been assum.ed to vary only in accordance vrith individual differences (^azaheri et al. , 19-^+: ,v"estla":e and Rutherford, 19 "^6, p. 55). Hypothesis It is hypothesized that, as it is visualized on

PAGE 30

24 cinef luorosraphic films, the velopharynseal mechanism is different for males as compared to females. This difference is manifested in a different orientation of levator eminence to uviila so that the configuration of the velum for females has the appearance more of a right angle within the pharynx and that for males an acute angle as shovm in Fig. 3. Figk is an actual line tracing of a female subject and Fig, 5 is of a male subject. This hypothesis was derived from subjective impressions of the closure patterns of males and females viewed at the normal filming rate of 30 frames per second on cinefluorographic film. Certain differences in motion and configuration of the velum could be discerned. In the films of males the velum as it elevates is seen to lift at the levator "bulge" (levator eminence). This bulge then rises in a throbbing manner and seems to thrust toward closure at the basi-occipital level. This is essentially the upper limit of the nasopharynx along the posterior v/all. The presenting surface of the velum is curved as it contacts the pharyngeal v.'all. The uvula is pointed anteriorly so that considerable space is formed betvreen it and the pharyngeal wall. In the female pattern, as the velum elevates for closure it usually moves posteriorly in a relatively straight-back motion along the palatal plane with a com.paratively flat presenting surface. The "thrusting" of the levator bulge is in an upv.'ard direction while the direction of palatal movement as a whole is backward. The uvula

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25 F^i'-IALE KALE Figure 3. "Squared-of f " female and "actite" male velar configurations. Arrov7s shovf directions of movement. iBroken lines shovr veluT. at rest.

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26 Figure ^. Actual line tracing frame of a feniale subject. of a cine fluorographic

PAGE 33

27 Figure 5. Actual line tracinr^ of a cinef luorographlc frame of a nale subject.

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28 points dovrn'Aard and often even posteriorly so that there is a notch between it and the pharyngeal wall rather than the definite space of the male pattern. Green (I96I) had called the configuration of the velum in closure "comma-like" v.'ith the levator eminence forming the apex. Ricketts (195^'-) had described the velum in closure as being a "hooking" action. Their descriptions fit well v;hat is being described here as the male configuration. The action of the velum in the female could be called "squared-of f " as contrasted v;ith the other "hooking" action. The male configuration is here described as "acute." Pilot studies have shovm that it is possible to tell male from female subjects on the basis of judgement of the pattern of motion in movement and the configurations of the velum in closure during connected speech. It has been found to be relatively simple, with experience, to classify 35 percent of the subjects with 100 percent accuracy. Those subjects who were not readily classified have required a most judicious balancing of clues from the perceived motion toward closure and the configuration in closure in order to be classified. The subtleties are such that further analysis will be required to objectify the significant cl\xes. In a pilot study, two indepenrjent viewers had no clues other than representative drawings of the two velar configurations and the instructions: "In your opinion, does the velum of the subject on the film look more like ( rrO* ) or i'^J\ ) when in closure?" The 12 films viewed were randomly selected from 7^ film.s. One viewer knew the purpose

PAGE 35

29 of the study and one did not. Decisions were made according to a seven-point sca.le. Their results showed selection in the right direction vjith a F=.0256. The score obtained by this investigator v;hen the choice was either "male" or "feraale" for 2? subjects, v;as correct as deternined by a Fisher's Exact Probability Test at a level P=:. 00005. At the time of these studies, no criteria for making a decision had been specifically discerned, but it was felt that the iiltimate deciding factor v.-as the "angle the velum made v."ith itself" in closure. Purpose of the Stud y ' This study was undertaken to determine whether it v,rould be possible to demonstrate in an objective manner that the apparent differences between the velopharyngeal mechanisms of males and females which had been subjectively perceived do exist. The following questions were formulated: 1. Can it be shown by an angular measurement that the basic orientation of the velum to the pharynx is different in the sexes? 2. Can it be established by measurement of the height of elevation above palatal plane, the amount of contact, the distance of the uvula from the pharyngeal wall, and determination of the site on the pharyngeal vrall at which the inferior point of contact falls relative to palatal plane that discretely different conf igu.rational patterns are manifested? 3. Can differences in configuration be accounted

PAGE 36

30 for on the basis of the ratio betv^een velar length and pharyngeal depth? Rationales for the establishing of certain measurements not previously described in the literature and for other questions arising during the analysis of the data are described in the follov;ing chapter.

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CHAPTER III METHODS AND PROCEDURES A library of films made by the process of cinefluorography has been built in the Department of Communicative Disorders, University of Florida Health Related Professions. The procedure for the selection of subjects, photographing, and analyzing has been described previously (Sparrow, Brogdon and Bzoch, 19^^; Bzoch, I96B) but is summarized here for convenience. Initial S election of Subjects The subjects i';ere males and females between 18 and 30 years old. They v;ere monolingual (General American dialect), had Angle Class I occlusion, no articulation or voice deviations, and hearing acuity of betv;een llO d5 through the speech frequencies for both ears. Procedures fo r Ob tain in x Films A Picker f liioroscopic unit with an 8-inch image intensifier and a modified I6 mm. Eastman Cine II camera v/ere used. Kodak Linagraph Shellburst film vras used and processed in a Smith-Picker automatic processor. Careful body positioning and the use of a lucite cephalostat provided stability during filming and uniformity in head, neck, and body positioning in the upright position. A monitoring 31

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32 directional Electro Voice microphone Model 64^ v^as placed 6 inches fro.Ti the subject's mouth and recording was on a i'iagnacord Model i'i90-A tape recorder. Each subject performed a speech sample within a limit of 90 seconds. Radiation dosage was less than 3 roentgens. Filming rate was 30 frames per second. Sel ec tion of Subjects for This Stu dy From the library of films available, ^0 subjects (20 males and 20 females) were chosen for this study. The subjects had been filmed randomly with regard to sex just as they came in for their appointments. The films to be used here were therefore taken in order from subject number one on. The only criterion for rejecting a film as a subject of study was lack of sufficient clarity for tracing. Speech Sample The total speech sample filmed consisted of nine consonant-vowel (CV) "syllable" sets, a list of 13 words, and a sentence. The sentence was repeated three times at increasing effort. Normal pitch and conversational effort level vrere used for the syllable sets and word series. A speech sample lasting l| mins. could be observed for each subject. A characteristic pattern of movement toward closure and velar configuration in closure could be recognized for each subject. For analysis, one frame for each subject was chosen from any one of the syllable sets containing the vocalic element /i/.

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33 A syllable set consists of seven CV combinations. These CV conibinations i;ere either /pi/, /pa/, /pu/; /ti/, /ta/, /tu/; or /ki/, /ka/, /!-ai/. The organization into speech utterances was according to the following system in which /pi/, /pa/, /pu/ is used as illustration: Inspiration: (A) pi pi pi pi pi pi pi (3) pa pa pa pa pa pa pa (C) pu pu pu pu pu pu pu Inspiration (D) pa pa pa pa pa pa pa (E) pu pu pu pu pu pu pu (F) pi pi pi pi pi pi pi Inspiration (G) pu pu pu pu pu pu pu (ri) pi pi pi pi pi pi pi (I) pa pa pa pa 'p9 'pa pa It can be seen that, using series A, F, or H, there were 21 occurrences of the production of syllables containing the vovjel /!/. Any frajne within series A, F, or H was used if it provided sufficient clarity for tracing. It had been established earlier (Bzoch, I968) that once closure 'was achieved for the production of these syllables, opening did not occur again until the end of series C, F, or I. It is not known precisely what minor variations may have occurred from frame to frame v?ith the velum in closure all the while, but it is believed they would not be of a nature to affect the measurements relevant to the major purpose of this study. Because it can be plainly seen on the films in motion that when velopharyngeal closure occurs for the production of these syll3,ble sets it is according to a characteristic pattern, it was concluded that the selection made was representative of the velopharyngeal mechanism for each of the ^0 subjects.

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3^ Tv:enty subjects said /pi/ on the films used, I3 said /ti/, and ? said /ki/. In order to determine the effect of the different consonants on the measurements, a Kruskal-Wallis One-way Analysis of Variance Test was applied for each measurement for the females and for the males separately. Anything greater than .05 was not considered statistically significant for the purpose of this study. It can be seen from Table I that, with the exception of the measurement of height of elevation for females, nothing was found to be significantly different. TABLE I KRUSKAL-WALLIS ONE-WAY ANALYSIS OP VAHIAI^^CE 0? SOUNDS /pi/, /ti/, AlvD /ki/ i':easurement Height elevation Angle ABC Height contact Amount contact Length ^Significantly different from zero at the 5 percent level. A MannWhitney U Test comparing height of elevation in females between /pi/ and /ti/, /ti/ and /ki/, and /pi/ and /ki/ revealed no significant difference between /pi/ and /ti/ but a difference between /ti/ and /ki/ and betv;een /pi/ and /ki/ both at a level P=.015. It is believed, therefore, that the influence of the /ki/ would cause the mean height of elevation in females to be higher than it would have been without the /ki/ sound. Films of Corrected H

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35 only tvv'o males producing /ki/ V7ere used in the study. Procedure for Collecting Data Tracin.^ During filming, each subject had inserted a radioopaque marker into his mouth back to the wall of the pharynx so that it v.-ould subsequently be possible by measuring the distance betvreen the holes on the marker to gauge the projection size. After determining that projection was at life size, structures from the chosen fram^es were traced by hand onto ordinary 16 lb. vj-hite bond typing paper as sho\-m in the reproductions of actual tracings in Figs'. i|and 5. A piece of Dietzgen draft film (clear acetate paper Viith a matte surface) was laid over each tracing so that the lines needed for measuring could be drav:n on it, leaving the actual tracing unmarked. Lines v/ere drawn and measu.rements taken according to the following descriptions using dividers, a millimeter ruler, and a protractor. Measurements Defined Pal atal_ ola ne This line was dravai according to the usual procedure in the literature; i.e. from, the tip of the anterior nasal spine (AL-S) through the posterior nasal spins (PNS) and projected to the back wall of the pharynx to point X, as seen in Fig. 6. Depth of the nasopharynx The depth of the nasopharynx has usually been defined as the distance along the oalatal nlane from PNS to

PAGE 42

36 the back pharyngeal wall. The distance PNS to X represents the depth of the nasopharynx along palatal plane in Fig. 6. Depth of the n asophary nx a t midp oint of clos ure A line vms dravm from PNS to the midpoint of the area of the velum making contact v;ith the pharyngeal wall to represent the depth of the nasopharynx at the midpoint of closure. PNS to Y is the line illustrating this measure in Fig. 6. Angle ABC Angle ABC was constructed to show the basic orientation of the velum to the pharyngeal wall. The point on the posterior nasal spine intersected by the palatal plane line became A. The superior point of contact betvreen velum and pharynx became B and the inferior point (midpoint) of the uvula became C. Angle ABC was thus formed by lines from the PNS to the superior point of contact and from the superior point of contact to the inferior point of the uvula. This angle is shov;n in Fig. 7. Velar len-yth The length of the velum V7as measured according to the procedure described by Graber, Ezoch, and Aoba (1959). In this procedure, velar length in the functional position for speech, is determined by measuring along the superior curvilinesr border from the posterior nasal spine to the midpoint of the uvula. Amount of contac t wi th pharyngeal .wall The measurement in mm. of the distance spanned by

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37 ANS to X = palatal plane PNS to X = depth of nasopharynx along palatal plane PNS to Y = depth of nasopharynx to midpoint of closure Figure 6. Illustration of the neasureraents palatal plane, depth of the nasopharynx along palatal plane, and depth of the nasopharynx to niidpoint of closure.

PAGE 44

38 Figure 7. Illustration of /ABC vjiiich is formed by lines dra'.\'n from the posterior nasal spine to the superior point of contact and fron the superior point of contact to the midpoint of the uvula.

PAGE 45

39 the velar tissue contacting the pharyngeal v;all measured along the pharyngeal wall frora the superior point of contact to the inferior point of contact is the definition of "amount of contact." This is shovrn in Fig. 8. Height o f elevation Height of elevation has been measured in the manner usually described. In this, a line perpendicular to the palatal plane extending to the highest point on the superior surface of the velujn in the closed position is measured in m)ii. This has been sho^.m in Fig. 2. Hei^ght of closure The height of closure is the perpendicular distance from the palatal plane to the superior point of contact, measured in mm., as illustrated in Fig. 2. Ratio 3C;2F An arbitrary line vias drav.'n from the midpoint of the measurement of the depth of the nasopharynx along palatal plane (point D in Fig. 8) perpendicular to the palat3.1 plane. This line intersects another line dravrn parallel to the palatal plane at the level of the inferior point of the uvula at point L. The distances ?JC (the distance from point Z to the midpoint of the uvu.la) and SF (the distance from point U to the back v:all of the pharynx) v;ere measured in mm. The ratio of the distance ECriiiF v.-as calculated and called "ratio iC:Z.F." Inferior ooint of co ntact The inferior point of contact of velum v;ith pharynx

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40 Amount of contact Figure 8. Illustration of amount oj of determinin,^ ratio BC :::;?. contact and method

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li-2 these tv;o subjects do not fit the pattern for their sex. (See Table XI . ) 2. The outline of the velum as seen directly on the projection vj"as then pointed out, according to the follovrins routine: "This is a (male) (female), I see the velum as follovrs (outlined). Here is posterior nasal spine. The back wall of the pharynx is here. Here is superior point of contact. Closure would be (above) (on) (below) palatal plane. Here is inferior point of contact. The curve of the velum below inferior point of contact is here. The tip of the uvula is here." 3. The original tracing, not seen by the second tracer before, v;as produced and judgement made that it obviously was not a gross misrepresentation of vrhat had just been pointed out. k. The original tracing was laid on the projection and lined up vvith it. A manila folder 'was then held in front of the tracing to obscure it and to provide a nevi surface for the projection. The film v/as run backv;ards to a point v."here the velum was seen in rest position. The film was run forward again so that the entire movement into closure could be vreitched, and the actual outline in closure identified again apart from any confusion due to other overlying structures, particularly all surfaces and processes of the mandible. 5. Then all points on the tracings were re-established by agreem.ent. The shadov; of a pencil point v:a.s .made

PAGE 48

has been defined in terms of being above, on, or belowpalatal plane. Re liabi lity The reliability of tracing technique was determined by a tracing-retracing procedure separated by considerable periods of time. In no instance vras there any change in the features such that the outcome of the results would have been affected. When the original data were compared with re tracings of the same frames for 12 subjects, the following levels of correlation v;ere obtained using a Pearson r test: amount of contact-. 927, height of elevation^. 95, angle A3C=.989. velar length=.993. depth of the nasopharynx along palatal plane=.970, and depth of the nasopharynx to midpoint of closure=. 93S. v^'hen all tracings had been made, validity V7as confirmed by another indepenctent experienced tracer accor-ding to the following procedure. 1. The criteria, as they had cone to be understood, on v;hich to make a decision as to the sex of the subject on the film v,-ere learned by the second tracer. The first step in the procedure for confirming the accuracy of the tracings was for the second tracer to decide the sex of the subject with no clues other than the application of the defined criteria to the viewing of the films. Thirty-eight of the ^0 subjects v;ero correctly classified in this wo.y. Subjects I\.os. 30 and 3^ were at first incorrectly classified. This does not represent error in judgement, hovrever, as

PAGE 49

^3 to lie on the point to be established, the manila folder was pulled avray, and if the identifying point was located correctly, the shadow was observed to fall directly on its corresponding point on the tracing. 6. Minor changes were rnade on the original tracings in accordance V7ith the preceding procedure so that the measurements made viere from tracings v;hich represented the best judgement of two tracers. Kethod of Analysis The configuration of the velum during velopharyngeal closure for speech as it is visualized on lateral cinef luorographic films results from the arrangem.ent of extrinsic muscle insertions and from the dimensions of the velum, the surrounding structures, and the nasopharyngeal cavity. The factors of height of elevation, height of closure (site of superior point of contact), amount of closure, and the site of the inferior point of contact relative to the palatal plane are used to describe this configuration. There is further, a factor of orientation of the velum to the pharyngeal wall. Two attempts have been made to describe this orientation. Angle A5G, illustrated in Fig, 7. has been devised as an attempt to define the basic orientation of velum to pharynx. The ratio ZCiTL? has been calculated in an attempt to show the orientation of the uvula to the posterior pharyngeal wall. The follov7ing specific m.ethods of analyzing the data obtained from making the defined measurements vrere used:

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1. The inferior point of contact has been classified for each subject as above, on, or belo'w' palatal plane. 2. The Mann-Vihitney U Test was used to determine the significance level of differences in scores of males and females for measure^ient of a) /ABC, b) velar length, c) height of elevation, d) amount of contact, and e) ratio EC:EF. 3. An attempt vias made to determine the possible significance of the depth of the nasopharynx and length of the velum to the orientation assumed by the velum as described by /A3C . The rationale for the specific question asked was as follows. There is a distance of a given measurement to be spanned (the depth of the nasopharynx) by a structure of a given length (the length of the velum in closed position). In effecting closure, the velum in some subjects assumes an orientation which can be defined approximately in terms of an acute angle and in another group of subjects, in terms of a right angle. The specific question became: ooes the ratio of the length of the velum to the depth of the nasopharynx determine the angle 'which is assumed by the velum in effecting closure, or is this angle determined according to the sey: of the subject on some other basis? To determine the ansvrer, an analysis of co-variance ^ was made by constjructing an estimated linear model to define the effect of sex on /An-C and the effect of depth-to-length ratio on /ABC. In this analysis, depth of the nasopharynx was defined^ as the distance from the posterior nasal spine

PAGE 51

^5 to the midpoint of closure as this was the actual distance spanned. ^. In 16 subjects, the distance from the posterior nasal spine to the midpoint of closure was the same as the distance from the posterior nasal spine to the pharyngeal wall measured along palatal plane. In k cases, the distance from the posterior nasal spine to the midpoint of closure was more than the distance along palatal plane, and in 20 subjects, the depth of the nasopharynx at the midpoint of closure was less than the depth along palatal plane. A V/ilcoxon Hatched-Pairs Signed-Ranks Test was used to determine V7hether changing the site of the midpoint of closure from palatal plane made any significant difference. The specific question v;as : If it is assumed that there is an optimal distance which can most effectively be spanned by the velum, and closure is effected above, on, or below palatal plane accordingly, was the distance significantly changed as revealed by the difference between the depth of the nasopharynx along palatal plane and the depth from PNS to midpoint of closure? 5. Frequency distributions were plotted for velar length and measurement of /A3C by sex.

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CHAPTER IV RESULTS xRaw data for all female subjects are provided in Table III and for male subjects in Table IV. The results of the analyses made using these data are as follows. 1. Relationship of inferior point of contact to palatal plane when tabulations are made of the relationship of the inferior point of contact to palatal plane, as in Table II, it can be seen that, whereas 1? of 20 males have the inferior point of contact on or above palatal plane, an equal number of females have this point below palatal plane . TABLE II RELATIONSHIP OF INFERIOR POINT OF CONTACT TO PALATAL PLAlvE Above On Below Kales (20) 12 5 3 Females (20) 3 1? 2. neip;ht of elevation As shown in Table V, the mean height of elevation k6

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47

PAGE 54

he TABLE IV RAW DATA FOR KiALSS

PAGE 55

k9 for males is correspondingly higher than that for females. The mean of this measurement for males (10.05 mm.) is almost double the mean for females (5.9 ni'^i.). It has already been noted that the sound produced may have influenced this measurement for females in an upward direction. Five female subjects (Nos. 56, 6I, 62, 69, and 8^) produced the sound /ki/. The mean height of elevation for these subjects v:as 8 mm. as contrasted v;ith the over-all mean for females of 5-9 21C1. The mean height of elevation for females may thus be higher than othervrise because of this difference. Only 2 males had said /ki/ and the effect was not significant for the males' height of elevation, TA3L;3 V C0KPA3ISCN 0? iGAN H^ilGHT OF }^L3VATI0N B3TVJE2N I'IALh;S AilD FxLMALL;S ' Kkles (20) Fe^les (20~) U 71Range 3-I6 mm. 1-10 mm. Mean 10.05 mm. 5.9 21m. S.D. 3.66 2.2 ^•Significantly different from zero beyond the ,0003 level. 3 . Amount of contg.ct The means for the amount of contact of velar tissue v;ith pharyngeal tissue as shovjn in Table VI shov: that this measure in females is almost tvvice Vvhat it is in males.

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50 TABLE VI COKPAHISON CF MEANS 0? AHOUKT OF CONTACT Males (20) Females (20) Range In mn.

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51 ranged from 18 percent to 57 percent and averaged ^3 percent. For the females, the distance EC v;as from 50 to 75 percent of the total distance to the pharyngeal wall (EP) , with an average of almost 69 percent. This measurement shows, therefore, that the tip of the uvula is angled significantly farther away from the posterior pharyngeal vrall in males , TABLE VIII COi-IPARISO:^ 0? KEANS FOR MLES AND FEMALES FOH RATIO SC:EF Range Vie an S.D. Males (20)

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52 It can be seen from the frequency distribution graph in Fig. 10 that, vjhile all females are found within the intervals betv/een 35 and k6 mm., only 8 aales are within these intervals . 7 . _Sia;r. ificance of diffe r ence in measurement s of depth of the nasopharynx alon^: palatal plane and from Pa'S to midpoint of closur e A kJilcoxon I'latched -Pairs Signed-Ran'^s Test shovied that the difference in the two measurements of depth of the nasopharynx v;as significant for males at the 1 percent level but not significant for females. This is shown in Table X in which PMS-X represents the depth of the nasopharynx along palatal plane and PN3-Y is the depth to the midpoint of closure. TABL3 X SIGNIFICANCE OF DIFFEHSNC'i] IN MEASUR3Z2KTS OF PKS-X AHJ PKS-Y lean Diff. Adjusted in mm. N '.'/ilcoxon N""" T «-SiKales -1.65 20 16 Females -.3 20 8 9.5 ^''The adjusted ':.'ilcoxon M is less than 20 in each case due to the measurements where no difference was observed. . Niimber of cases in each group was 20. ^'"Significantly different from zero at the .01 level. 8 • A nalysis of co-variance of the contributi on of the ra tio of vel ar leng th to oharyn'^yeal depth and of the factor o f se x to the determination of /ABC The equations calculated showed that the t for sex was 6.13 anc was significant at the <.001 level for its contribution to the /A3C. The t for the velar length:

PAGE 59

53 pharyngeal depth was 0.8^ and not significant for /ABC. The equations for the estiaiated angles and the coefficient we re : Y = 67.93 + 23.19 (Hatio .61^-0) (Hales) Y = 87.33 + 23.19 (Ratio .61^0) (Females) The angle assumed by the velum in closure is not determined by the ratio of the length .of the velura to the distance to be spanned (depth of the nasopharynx) but is deterrained on some other basis vjhich appears to be related to sex.

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5^ Males Females So-SA^ SS~Sf (>oC4 ^s-ii •/o-7^ 75-7f So-f4SSSf 9o-ff
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CHAPTER V DISCUSSION, CONCLUSIONS, SUMMARY D iscussion The organizing of subjects in terms of their measurements for ^ABG offers a systematic scherae for considering all measurements in relation to a total pattern. When this is done, some interesting questions can be raised for speculation. It has been claimed here that /j^BC describes the basic orientation of the velujn to the pharynx. Ratio SC:SF has been calculated to gather supporting evidence for the idea that the uvula is angled anteriorly avjay from the pharyngeal xvall in m^ales but not in females. This could be a result of either or both a pulling forward of the uvula in the male or a pulling backvrard in the female. The orientation of the superior point of contact is diagonal to the inferior tip of the uvula -.'."hen the measurements of ^ABC are aciite. As the measurements of /A3C approxim.ate a right a.ngle, the orientation of the siiperior point of contact to the tip of the uvula becomes vertical ovring to an apparent pulling back of the tip of the uvula to the pharyngeal v;all. This difference in orientation can be seen in ?iss. 3, ^, and. 5. iv'hen the change in orientation is tovrard the . 55

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5^ vertical, there see.ms to be a concomitantly greater aruoimt of contact of velum v/ith pharynx, a site of closure such that the inferior point of closure is belovj palatal plane, and a height of elevation relative to palatal plane v.'hich is also concomitantly lovjer. These differences are not explainable by chance. Table XI, in which subjects are organized according to measurements of /A3C shov/s that total patterns for each sex among the several variables describing the velopharyngeal mechanism do emerge. In the male pattern, amount of contact is less, and height of elevation is greater than in the female. The inferior point of contact is most often above palatal plane. In the female pattern, the reverse of these situations is found . It can be seen from Table XI that the measurement of 7';-° defines the upper limit for a "clear-cut" male category in v;hich no females are found. The lower limit for defining a corresponding "clear-cut" female category is Fifteen of the male subjects fell into the clearcut male category and l6 of the females into the female category. ?ive males and four females made up an overlapping category in conformity vjith the frequency distribution for /A3C alone shovm in Fig. 9. ^he limits for /ABC in the "overlap" category were yS^-S^*^. But statistically speaking, there are two basic

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57. /ABC TABLE XI ORGANIZATION OF SUBJECTS BY KiEASUSSMENTS OF ANGLS ABC Amount

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58 patterns into vrhich all subjects have fallen. All subjects with measurements for /ABC of 79° or less are found to fit the male pattern as it has been defined here, and all v;ith measurements of 80° or more fit the female pattern. Then 3 of each sex are found in the category of the opposite sex. A clear-cut sex differentiation would seem to be compromised accordingly, Extrapolating from these findings, it could be expected that 35 percent of all individuals who would fit the male pattern of velopharyngeal mechanism would, in fact, be males, and similarly, 85 percent of all persons who would fit the female pattern would in truth be females. This raises the question of what factors could be operating within or on the velopharyngeal mechanism to result in such a high correlation on a sex basis and yet still allow for some "crossing over." Config\iration could be anatomically ordained on the basis of either structural (skeletal) variations and their consequent influence on the orientations of muscles, or differences in mechanisms of muscle actions. On the other hand, the configurations could represent the effect of muscle adjustments which must be made by whatever muscle action necessary to achieve certain balances between resonating cavity proportions for the purpose of achieving certain acoustic effects. There has been essentially only one question asked in the literature with regard to structural differences,

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59 and that has been with reference to velar length and pharyngeal depth relationships. The finding reported here that the difference betvieen the depths of the nasopharynx measured along palatal plane and at actual site of closure is significant only for .males is evidence against the idea that shorter palates hiave to rise higher to achieve closure. It is the males ivho have the higher height of elevation and vrho also have the greater mean velar length. This, together with the finding that the ratio of the length of the velum to the depth of the nasopharynx does not influence the orientation of the veraii in closure (as described by /ABC) suggests that the question asked about structural differences has not been the relevant one. This would not preclude the possibility of there being other significant structural relationships within which differences could be found. For example, the diagonal orientation bet'ween superior point of contact and tip of the uvula in males, which is manifested in the acuteness of /ABC, could be due to a particular orientation of levator palatini to palatoglossus muscles existing because of particular head size and oral and pharyngeal dimensions. The corresponding vertical orientation of the superior point of contact and tip of the iivula in females could be due to a vertical orientation of levator and palatopharyngeus such that palatoglossus v;as not in the line of major influence. This could be the resultant of a differ-

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60 ence in skull size, orientation of s]cull to cervical column, or oral and pharyngeal size differences. Such hypotheses v^ould allovj for sotub cross-over between the sexes because of size differences. Size considerations aside, it could be possible that the tv/o different velar orientations are the end products of tv.'o different mechanisras of muscle actions. It nay be that in those persons having the male pattern, the palatopharyngeus muscles are caused to move medially, allovjing levators and palatoglossus to act antagonistically to cause the "hooking" action described by Ricketts (195^). In those individuals having the female pattern, movement of palatopharyngeus muscles could be posteriorward so that they become the direct antagonists of the levator muscles, thus causin^c the tip of the uvula to be directed dovmward and causing closure to occur at the level of palatal plane vath a concomitant decrease in height of elevation above palatal plane. The whole purpose for velopharyngeal closure in speech has been defined as the regulation of nasal resonance. The different velar orientations and configurations could have some special significance to the acoustic output during speech. The differences in the measurem.ents of the variables contributing;to the configurations could represent adjustments which have to be made in one sex or the other to compensate for the basic difference in fimdamental frequency compounded by differences in the oral and pharyngeal

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61 cavities. It nay "be that such cooipensations must be made in order to achieve comparable phonetic results. Conclusions 1. The velopriaryngeal mechanism as it is visualized with lateral cinef luoro^raphy has been found to differ for males and females in every measure studied. Control for sex as a variable should be a part of studies of the velopharyngeal mechanism, 2. The basic orientation of velum to pharynx is different for the sexes and configuration of the velum in outline is concomitantly different according to specific patterns. The basic orientation of the velum to pharynx in males can be described in terms of an acute angle, and that of females more approximately a right angle. Velar length is greater in males, the height of elevation is greater, the am.ount of contact is less . and the Inferior point of contact is most usually above palatal plane. The reverse of these findings is the usual condition in the fem.ale pattern. These differences are not due to chance and are not explainable on the basis of a velar length to pharyngeal depth ratio. 3. The establishing of the basic pattern of configuration for experim.ental subjects under controlled conditions could be a useful technique to use in the further study of variations v;ithin the velopharyngeal mechanism for the definition of anatomic or physio-acoustic relationships.

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62 It has been hypothesized that the velopharynceal mechanism as visualized on cinefluorographlc films is different in young adult males as compared with young adult females. Evidence has been presented that the basic orientation of the velum to the pharynx is different in the sexes. In males, the uvula is seen to angle forward a'A'ay from the posterior pharyngeal wall. The orientation of the superior point of contact with the midpoint of the uvula is such that when a line is drai-m from the midpoint of the posterior nasal spine to the superior point of contsct and another line is dravm from the superior point of contact to the midpoint of the uvula, an angle of acute dimensions is formed. In females, the an^le described by comparably placed lines approximates a right angle. The descriptive angle has been designated /ABC. The upper limit that will define a male m^easurement of this angle has been found to be 79 . In females, the measurem.ent will be 80° or larger. The orientation of the velum to the pharynx has been further defined by a. ratio which describes the distance of the tip of the uvula from, the back pharyngeal ;vall. This ratio has been called EC:EF. There are different patterns of configuration outlined by the velum in closure which are concomitants of the basic orientations. Once the basic orientations have been established, the configurations are the further result of the amount of contact, height of elevation, and the place on the pharyngeal wall relative to palatal plane which is the

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63 site of the inferior point of contact. The following specific findings have been reported here. 1. Seventeen of 20 males had the inferior point of contact on (5) or above (12) the palatal plane. Seventeen of 20 females had this point belov; palatal plane. 2. Height of elevation was greater for males. The mean height of elevation for males v;as 10.05 mm. while for females it was 5.9 mm. 3. The mean amount of contact for females was 9-5 ^'^9-'^'^ 5.7 mm. for males. ^. The mean measurement of /{ABC in males was 69.7 and for females it was 88.1. With 79"^ defined as the upper limit for a male category as defined by /A3C, and 80 the lower limit for a female category, 17 out of 20 of each sex x^ere in their appropriate categories and 3 of each sex were in the category for the opposite sex. 5. The average ratio of EC to EF in males was ^3 percent and was 69 percent in females demonstrating that the uvula is angled forvjard av.-ay from the posterior wall of the pharynx in males . 6. Velar length -was significantly greater in males, ranging from 38 to 61 mm. with a mean of ^7.8 mm. The range for females was 36 to ^6 vrith a mean of ^1 mm. 7. The depth of the nasopharynx was measured from PMS along palatal plane and from PNS to the midpoint of closure. The difference in the two measurements was significant only for males.

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6^ It v;as concluded that the velopharyngeal mechanism v;as significantly different for the sexes on every measure tested. This difference could not be due to chance. The basic orientation of the velum to the pharyngeal vjall as defined by measurements of /A3C and Ratio EC:EF is different for the sexes. This difference in orientation as defined by /ABC does not depend on a ratio of velar length to pharyngeal depth. As angle measurement increased, amount of contact increased, and height of elevation decreased. Some speculation as to reasons for the differences was included. Plans for future research include the investigation of possible acoustic correlates of variations from the basic configurations which might be induced as well as the possibility of a difference in muscle mechanisms.

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BIBLIOGRAPHY Allen, H. On a new method for recording the motion of the soft palate. T r. Coll. Ph ysicians. VII, Philadelphia. 183^. Aram, A. and Subtelny, J.D. Velopharyngeal function and cleft palate prostheses. J. Pros . Dent . . 9, 1959, lij-9-153. Ashley, F.L., Sloan, R.F., Hahn, E. , Hanaf ee , Vl. , and Mlethke, J. Cinef luorographic study of palatal incompetency cases during deglutition and phonation. Pla st. Reco n str ., Surg;. . 28, 1961, 3^7-36^. Berry, BLM. and Kofnann, F.A. Cinef luorography V7ith image intensification for observing temporomandibular joint movements. J. Am. De ntal Assoc. , 53, 195^, 512-527. . Cineradio-^raphlc observations of temporomandibular joint function. J. Pro s. Den. . 9. 1959, 21-33. Bjork, L. Velopharyngeal function in connected speech. Studies using tomography and cineradiography synchronized with speech spec trography . Acta Hadiol . Supplement 202, I96I. Bjork, L. and Nylen, B. The function of the soft palate during connected speech. Acta Chir_. Scand . , 126, 1963, ky4-l^!^>4. Blaclifield, h.l'i.. Miller, S.R., Owsley, J.O... Jr., and Lav.'son, L.I. Cinefluorographic evaluation of patients vrith velopharyngeal dysfunction in the absence of overt cleft palate. Plast. Rec onstr. Surg.. 30, 1962, ^^1-^151. Bloomer, H. Observations on palatOTDharyngeal movements in speech and deglutition. JSHD. 18, 1953, 230-246. Brodie, A.C-. Cephalometric roentgenology: history, techniques and uses. J . Cral'^Sur.? . T 7, 19^!-9, I85-I98. Buck, i'l. '.•.'. Facial skeletal measurements anci tongue carriage in subjects with repaired cleft palates. JSHD, 18, 1953. 121-132. 65

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66 Buck, i'i. Post-operative velopharync;eal noveinents in cleft palate cases. JSriO, 19, 195^1, 288-29^1-. Bzoch, K.li. 196?. Personal com-iiunication of results of investigations supported in part by National Institute of Child Health and Human Development Grant HD00163-07. . Variations in velopharyngeal valving: The factor of vov;el changes. Clef t Palate J . . in press. Calnan, J.S. Movements of the soft palate. Br. J. Plast. ^rs.. 5. 1953, 286-296. . Diagnosis, prognosis, and treatment of "palatopharyngeal incompetence," \vith special reference to radiographic investigations. Br. J. Plast. Sur g. . 8, 1955-56, 265-282.' Carrell, J. A cinef luorographic technlqiie for the study of velopharyngeal closure. JSHD, 17, 1952, 22^-228. Cooper, H.K. Cinefluorography v;ith image intensification as an aid in treatment planning for some cleft lip and/ or cleft palate cases. An. J. Orth o d ontics, i^2, 1956. 815-826. Fletcher, S.G. Analysis of cine film in diagnosis and research, J. bio l . photogr. Assoc . 26, 1958, 29-33. Fletcher, S. G. , Shelton, H.L. , Jr., Smith, C.C., Bosna, J.?. Radiography in speech patholo-y. JSHD, 25, I960, 135-1^^. Graber, T.il. New horizons in case analysis--clinical cephalome tries. An. J. Orthodontics . 38, 1952, 603-62i(-. Graber, T.i4,, Bzoch, K.R., and Aoba, T. A functional study of the palatal and phai^yngeal structures. Angle Orthodontist . 29, I959, 30-^-0. Green, H.I. The radiology of speech defects. Rac iography , 27, 1961, 33I-33S. Hagerty, R.?., Hill, H.J., Pettit, :. .3., and Kane, J.J. Soft palate movement in normals. JSHR 1, 1953, 325-330. Harrington, R. A study of the mechanism of velopharyngeal closure. JSHD. 9, ISk-^-, 325-3^^5. Hixon, i^.ii. An X-ray study comparing oral and pharyngeal structures of individuals xvith nasal voices and individuals with superior voices, M.S. Thesis,

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67 state University of Iov:a, 19^9. Kelly, J, P. Studies in nasality. Archives of Speech , 1, 1934, 26-43. Kirkpatrick, J. A. Hoent£;en evaliiation of velopharyngeal closure. Cleft Palate J . . 1, 1964, 388-390. Kirkpatrick, J. A. and Clnstead, R.\-J. Cinefluorographic study of pharyngeal function related to speech. Radiolo.gy. 73. 1959, 557-559. Lubker, J.F. An electro3iyographic-clnef luorographic investigation of velar function during normal speech production. Cleft Palate J . . 5, I968, 1-18. I'lacnillan, A.S, and Kelenen, G. Radiography of the supraglottic speech organs. A.M. A. Archives of Ctolaryngology. 55, 1952, 67I-88. I-icDonald, 3.T. and Baker, H.K. Cleft palate speech: an integration of research and clinical observation. JSHD, 16, 1951, 9-21. Hazaheri, i'i. and liofniann, F.A. Cineradiography in prosthetic speech appliance construction. J, Pro s . Den.., 12. 1962,^571-575. rlazaheri, H. , Killard, R. , and Srlckson, D.M. Clneradiographic comparison of norir.al to noncleft subjects with veloDharyn~eal inadequacy. Cleft Palate -J. , 1, 1964. 199-209. Moll, K.L. Cinefluorographic techniques In s-oesch research. J3HR. 3, i960. 227-241. . Velopharyngeal closure on vowels. JSHH, 5, 1962. 30-37. , Photographic and radiographic procedures in speech research. Proceedings of the Conference: Cormnunicative Problems in Cleft Palate. A5EA Reoorts. 1, 1965. 129-139. i'loll, iv.j_-. and Shriner, T. . Prelirainary investigation of a ne-rt concept of velar activity during speech. C left Palate J . . 4, I967, 59-c9. Ivorgan, R.H. The perf or-'iance of screen intensification and cinefluorographic systems. Am. J . Roent genol ogy, Radium Therapy and Nuclear Ked .. 86, 19^1, 10271039.

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68 Podvinec, S. The physiology and pathology of the soft palate. J. Laryn.s;ology and Otology, 66, 1952i ^52~'^6l. Powers, G.H. A cinef luorographio study of the articulatory movenents of selected individuals with cleft palates. Ph.D. Thesis, State Univ. of lov/a, I960. Hlcketts, R.M. The cranial base and soft structures in cleft pa.late speech and breathing. Plast. R econstr. Surg. . 14, 1954. 47-61. Shelton, R.F., Brooks, A.R., and Youngs trom, K.A. Articulation and patterns of palatopharyngeal closure, JSHD . 29, 1964, 390-408. Shelton, R.L., Brooks, A.R., Youngstroin, K.A., Diedrich, VJ. M. , and Brooks, R.S. Filniing speed in cinefluorographic speech study. JSHR, 6, I963. 19-26. Sloan, R.F., Brummett, S.W., V/estover, J.L., Ricketts, R.M., and Ashley, F.L. Recent cinef luorographic advances in pala.topharyngeal roentgenography. Am. J . R ent _genolqgv , Ra dium Therapy and Nuclear Med . , 92 , 1964,' 977-935. Sloan, R.F., Ricketts, R.M., Bench, R.'i., Rahn, S, , /.'estover, J., and Brunmett, S. The application of cephalome tries to cinefluorography . Angle Ortho don tist . 33-34, 1963-64, 132-141. Smith, C.C., Fletcher, S.G., Shelton, R.L. , Jr., and Bosaa, J.F. Utilization of radiology in study of speech mechanisms . Am. J . Roe nt"enolo-~y , Radium Ther apy, and Nuclear Ked .. 84, I96O. Sparrov;, S.S., Brogdon, B.G., Bzoch, K.R. The effect of filming rate and frame selection in cin8f?.uorographic veloDharynareal analysis. Cleft r a late J . . 1, 1964, 419-429. Strong, L.n. Muscle force components in the occlusive mechanism of the nasopharynx. Anat. Rec . , I03, 1949, 510. Subtelny, Joanne D. Fhysio-acous tic considerations in the radiographic study of speech. Cl eft Palate J . . 1, 1964, 402-410. Subtelny, J.D. and Baker, H. Koepp. The significance of adenoid tissue in volooharyn:-eal function. Flast. Reconstr. Surg .. 17, 1956, 235-250.

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69 Subtelny, J.D., Pruzansky, S. , and Subtelny, J. The application of roentgenography in the study of speech, In Kaiser, L. (I:;d.) Manual of Phonetics . Amsterdara: North-Kolland, 1957,' I66-I79. V/arren, D.k'. and Hofmann, F.A. A cineradiographic study of velopharyngeal closure. P last. Reconstr. Surg . , 28, 1961. 656-659. warren, D.v;., Hofmann, F.A. , and Miller, R.M. A study of velopharyngeal closure using cineradiography with image intensification. Abstract. J . D . Re s . . ^0, 1961, 733-73^. U'estlake, H. and D. Piutherford. Cleft Palate . Snglewood Cliffs, N.J.: Prentice-Hall, Inc., I966. Wildaan, A.J. Tongue, soft palate, and pharyngeal wall movement. Am. J. Orthodontics. ^4-7, I96I, ^39-^61.

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70 BIOGRAPHICAL SKETCH Dorothy Vivian McDuffe KcKerns vras born in Brandon, Manitoba, Canada, on Hay 3, I923. Her priraary and secondary eduction v;ere received in Canada. She and Kenneth i'lcKerns were married in 19-^3 and have tvro daughters, Maureen and Leslie, and a little sranddau^hter, Laura. The i'icKerns family has lived in Edmonton, Montreal, and Toronto in Canada, and St. Andrevjs, Scotland before coming to the United States in 1956 to make their home in New Jersey. ..'hile living in New Jersey, Dorothy attended Paterson State College In Wayne, M.J, and graduated cum lairds in June, i960 v^ith a Bachelor of Arts in Elementary Education. She entered the University of Florida in September, I960, when she and her family m.oved to Gainesville, and received a Master of Education degree in Secondary Education (English) in December, I962. viork tovrard a doctorate in Speech Pathology was begun in September, I963. American citizenship v;as granted in October, I963. Special interests aside from those involved in the field ofspeech include those shared with her husband in his work In endocrinology, and in their home, garden, and family.

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This dissertation vjas prepared under the direction of the chairman of the candidate's supervisory comraittee and has been approved by all members of that committee. It was submitted to the Dean of the College of Arts and Sciences and to the Graduate Council, and was approved as partial fulfillment of the requirement for the degree of Doctor of Philosophy. June, 1908 s and Sciences Dean, Graduate School Supervisory Committee: Chairman ^:^2i6d-iZ U^3t

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59 91 ^^'