HC 3: Assessment: non-instrumental CSE

Question 1

Out of which components does the CSE exist?

Answer 1

• (Head/neck) physical examination
• clinical observation
• direct physical evaluation of motor and sensory function -> cranial nerves
• Functional observation swallow
• instrumental evaluation

Question 2

What is a successful swallow? What does it require?

Answer 2

= safe transport from mouth to stomach (nothing enters the airway)

• > head & neck structurs
• > coordination (sequence of events)

Question 3

What are head & neck examination’s limitations?

Answer 3

• does not provide enough information to gain a complete understanding of the pathophysiology -> usually FEES or a dynamic videofluoroscopic swallow study required
• subtle abnormalities of sensation & motor functions: not noticeable
• complex coordination: not all of it is examined

Question 4

What does the head/neck physical examination consist of?

Answer 4

• face: asymmetries, signs of trauma, facial musculatore & sensation
• nose
• lips (as it is the 1st valve): saliva leakage? complete closure at rest? evaluate sensation & competence
• 2/3 chambers of the swallowing mechanism: oral cavity & oropharynx
• neck: palpation (for abnormal masses, large thyroid goiters, adenopathy)
• larynx: palpation (normal laryngeal structure, tethering?)

Question 5

What do we examine in the oral cavity?

Answer 5

• interincisal distance (trismus?)
• move and look at the structures
• dentition (caries, broken, missing teeth? -> difficulty with bolus preparation)
• mucosal surfaces: no irregularities or lesions, moisture?
• saliva quantity & quality? Lack of saliva: no adequate bolus lubrication + oral/pharyngeal residue
• tongue: mobility & strength, surface irregularities, fasciculations, atrophy, tethering, palpation for masses
• cheeks: pocketing if weak

- hard palate: defects causes escape of air/bolus

• floor of mouth: lingual sulci -> tethering tongue?

Question 6

What’s the role of the tongue in effective swallowing?

Answer 6

• during bolus preparation:
• base of tongue contact soft palate => prevents premature movement of the bolus to the pharynx
• moves the bolus between the teeth during mastication
• moves bolus into the pharynx

Question 7

What’s the role of the soft palate in swallowing?

Answer 7

• prevents premature movement of the bolus into the pharynx (together with tongue base)
• aids in pressure generation to start bolus movement into the pharynx
• closes off the nasopharynx during the pharyngeal phase of swallowing

Question 8

What do we examine in the oropharynx?

Answer 8

• visual inspection of:
• mucosal surfaces (masses, ulceration?)
• tonsils (enlarged?)
• symmetrical elevation of soft palate
• hypopharynx inspection by indirect or flexible laryngoscopy

Question 9

What does the head and neck physical examination gives you information about?

Answer 9

• Obvious tumor, surgical changes, anatomic abnormalities
• Abnormalities of tongue, palatal and vocal fold mobility
• Inadequate sphincteric functions (oral, velopharyngeal and laryngeal)
• Loss of sensation
• Pooling of secretions

Question 10

What will we be observing during the CSE? Why?

Answer 10

Because this information is needed for instrumental evaluation:

• overall condition & cognition
• level of awareness, alertness and cooperation, accept food voluntarily -> ready for instrumental study?
• apparent strength and potential for fatigue
• Body tone, oral tone, sitting position (postural support required? -> important for radiography)
• airway status: tracheostomy tube? breathing audible?
• ability to follow instructions
• self feeding potential: independently? special utensils needed?

Question 11

What will we evaluate directly in the oral phase?

Answer 11

• structures
• sensation
• reflexes and responses/nonvolitional movements
• volitional movement
• oral sensorimotor integrity
• secretions
• articulation
• resonance

Question 12

Explain direct physical evalution of the structure in the oral phase?

Answer 12

−Jaw, dentition (!molars), lips, tongue, buccal cavity, gum, faucial pillars, palate and velum à observe carefully

−Tissue condition: color, configuration, shape, size, symmetry, scarring or tethering

−Tonsils: presence/absence, size, placement and condition

Question 13

Explain direct physical evalution of the sensation in the oral phase?

Answer 13

• assessing by applying light touch to lips, tongue, buccal cavity, gums,…
• hypersensitivity?
• reduced sensitivity?
• unilateral differences?

=> consequences for bolus management and trigger for swallow

Question 14

Which nerves are involved for the taste and sensation in the oral phase?

Answer 14

• anterior 2/3 tongue:
• taste: VII
• sensation: V
• posterior 1/3 tongue: taste + sensation: IX
• facial sensation: V
• pharynx: IX (glossopharyngeus)

Question 15

Explain direct physical evalution of the reflexes and nonvolitional movements/responses in the oral phase?

Answer 15

• gag reflex = normal oral reflex
• > check presence
• > check symmetry
• suggestion for neurological problems if
• impairment of reflexes
• presence of primitive reflexes

Question 16

Which nerves are involved in the motor functions of volitional movements?

Answer 16

• V : motor control of mastication
• VII : facial expression
• IX - X : palatal, pharyngeal and laryngeal movement
• XII : lingual movement

Question 17

Explain direct physical evalution of the volitional movements in the oral phase?

Answer 17

In terms of strength, rate, accuracy and range of motion.

• Jaw: open/close, ease, trismus, clench teeth
• lips: closure at rest/swallowing, breathe through the nose during eating, pursing & retraction, symmetry of smile and showing of teeth
• tongue: anterior and posterior movement
• velum: sustained /a/: strenght, symmetry?

Question 18

How would you assess anterior and posterior lingual movement?

Answer 18

• anterior: note symmetry, strenght, range of motion and accuracy when asking to:
• extend, lateralize, elevate and depress the tip
• sweep tongue from front to back
• posterior:
• produce /k/
• push tongue agains tongue depressor
• push tongue into cheek on both sides

Question 19

Explain direct physical evalution of the oral sensorimotor integrity in the oral phase?

Answer 19

we have assessed isolated sensory and oral-motor skills -> now we want to know how they work together, because the sensation will allow (in)adequate oral manipulation or (not) trigger the swallow response

Question 20

Explain direct physical evalution of the secretions in the oral phase?

Answer 20

• quantity, type
• management: swallowing or actively/passively expectorating?
• changes in secretion type, amount or management?

Question 21

Explain direct physical evalution of the articulation and resonance in the oral phase?

Answer 21

Articulation:

• offers much information about oral function
• diadochokinetic tasks to note agility and speed
• connected speech gives an indication of the timing and precision of movement

Resonance:

problems with velar function -> problems with bolus containment and pressure generation

Question 22

Explain direct physical evalution in the pharyngeal and laryngeal phase?

Answer 22

• Vocal quality or changes: hoarseness or breathiness (may indicate problems of laryngeal closure to protect the airway)
• Pitch control or range: glide up and down to assess laryngeal agility (laryngeal control and elevation)
• Breathing (respiratory compromise)

− Stridor or audible breath sounds at rest

− Weak vocal intensity or “running out of air” or becoming short of breath with/without speech

• Volitional cough or throat clear: ability to volitionally expectorate aspirated material
• Saliva swallow and laryngeal management: Wetness? Coughing or clearing during CSE? Dry swallow with cough, throat-clear with voice quality noted.
• Liquid and/or food swallow (under safe circumstances!)
• Check the ability to contain the bolus in oral cavity
• observe timing and effortfulness
• check presence or absence cough/throat-clearing
• check voice quality after swallow

Question 23

Which signs urge for a functional observation swallow?

Answer 23

−Delayed onset

−Reduced elevation

−Reduced closure lips

−Difficulty bolus preparation

−Prolonged oral phase

−Residue/stase

−Pocketing

−Nasal regurgitation

−Several swallow attempts

−Changes in voice quality

−Coughing

−Shortness of breath

−Pace

−Head posture

Question 24

Which test criteria do we ask for in standardized CSE tests? Which tests do we use?

Answer 24

−Sensitive (detecting risks when presented)

−Specific (negative result when there is no risk)

−Not too many false positives/negatives

−Consistent:inter and intra judgemantal reliability

−Easy to use

−Acceptable to patient

−Non-invasive

−Time & equipment

•Mann Assessment of Swallowing Ability (MASA)

•MASA-C (MASA adapted for patients with head neck cancer)

•McGill Ingestive Skills Assessment (MISA)

Question 25

Explain: MASA

Answer 25

• 3 parts:
  1. evaluation of motor and sensory skills + basic terms (-> link cranial nerves and swallowing)
  2. funtional examination swallow
  3. dietary recommendations and risk assessment
• 24 items, weighted score
• interjudgmental reliability: good for dysphagia, moderate for aspiration
• severity rating

Question 26

Explain MISA

Answer 26

−Medical history

−Clinically assess patients’ functional eating skills in a natural environment

−Designed for clinicians working with older patients

−5 areas of eating performance

• Positioning
• Self-feeding potential
• Liquid ingestion
• Solid ingestion
• Texture management