Oral Facial Exam

Question 1

why look at the ability to open the mouth voluntarily?

Answer 1

Patients with head injuries (TBI) or other severe neurological/cognitive deficits may have significant deficits for the ability to voluntarily open the mouth.

These patients may need more oromotor stimulation and facial message than actual “feeding” therapy – pre-feeding therapy

Question 2

how to test bite reflex

Answer 2

Once the mouth is open use a 4” X 4” gauze (rolled)
Touch the teeth and alveolar ridge

For patients with a tonic bite:
Use a coated spoon or a spoon that will not splinter

Question 3

how to test labial function

Answer 3

Once the ability to open the mouth has been assessed

Spread the lips as widely as possible
Use the vowel /i/

Round the lips as much as possible
Use the vowel /u/

To assess coordination
Rapidly alternate the combination of /i/ and /u/

Question 4

how to test lip closure

Answer 4

Use /pa/ to determine the adequacy of intraoral pressure and the possible presence of velopharyngeal incompetence

Diadochokinetic Rate
Use /pa/ repeatedly

May use a sentence filled with plosives
i.e., “Put the papers by the back door”

Question 5

other labial function considerations

Answer 5

Assess ability for jaw strength and potential for chewing
Lip closure during such activity

Consider patient’s ability to be able to shape lips for use of straw drinking, cup drinking and use of spoon and/or fork

Assess the ability to tolerate nasal breathing

Question 6

assessing anterior lingual function

Answer 6

Extend the tongue out of the mouth as far as possible and retract it as far backward as possible
Touch each corner of the mouth and then rapidly alternate the lateral movements
Attempt to clear the lateral sulcus on each side of the mouth (as if there was material that needed to be cleared)

Open the mouth and then elevate the tongue tip to the alveolar ridge
Rapidly repeat the syllable /ta/ to determine diadochokinetic rate
Utilize a sentence i.e., “Take time to talk to Tom”
Tongue slide across the palate (from alveolar ridge to the back)

Question 7

assessing posterior lingual function

Answer 7

Open mouth and lift the back of the tongue as if saying /k/
Hold the position for a few seconds
Repeat the syllable /ka/ to determine diadochokinetic rate
Utilize a sentence i.e., “The king gave a ring to the queen”

Question 8

how to test chewing function

Answer 8

Not ideal during the bedside evaluation

Use a 4”x4” dipped into something tolerable
Squeeze out excessive material
Place the flavored end of the gauze on the midline of the patient’s tongue
Have the patient transfer the gauze onto molar
Have patient chew
Have patient then transfer to other side and repeat

Question 9

testing soft palate and oral reflexes

Answer 9

Have the patient produce a strong, loud /a/
This may be sustained for a few seconds as well as performed in a sequence
Assess the Levator muscle in elevation of the palate
Assess the Palatopharyngeus muscle in retraction of the palate
Assess any lateral or posterior wall movement

This is a good way to assess possible VPI

Question 10

testing the palatal reflex

Answer 10

Use either a tongue blade or a 00 laryngeal mirror
Contact is made against the juncture of the hard and soft palate or the inferior edge of the soft palate and uvula

Movement
Should elicit an upward and backward movement of the soft palate
No retraction of the pharyngeal walls

Question 11

palatal-afferent portion of reflex

Answer 11

Glossopharyngeal (CN IX) and possible Vagus (CN X) nerve involvement

Question 12

palatal-efferent portion of the reflex

Answer 12

Vagus (CN X) and possibly the Glossopharyngeal (CN IX) nerve

The Trigeminal nerve (CN V) is also believed to be involved in the reflex

Question 13

gag reflex

Answer 13

Should be tested
Use a tongue blade or the head of a laryngeal mirror
Contact is made against the base of the tongue or the posterior pharyngeal wall

Movement
A strong, symmetrical contraction of the entire pharyngeal wall and soft palate should be observed
If asymmetry is observed – indicative of a unilateral weakness

Question 14

gag- afferent portion of reflex

Answer 14

Vagus (CN X) nerve involvement and Glossopharyngeal (CN IX)

The gag reflex is triggered from surface tactile receptors and noxious stimulus (i.e., vomit/reflux)

IT IS POSSIBLE TO HAVE REDUCE OR ABSENT GAG AND STILL HAVE NORMAL SWALLOW

Question 15

oral sensitivity

Answer 15

Includes light tough to determine any degree of reduced sensitivity

Use a long stem Q-tip and touch various points along
Tongue (anterior-posterior)
Buccal mucosa
Faucial pillars (base to top)

If no gag is elicited – do the same to the post pharyngeal wall

Reduced sensitivity may determine placement of food in the oral cavity

Reduced sensitivity in the pharynx may indicate poor awareness of any pharyngeal residue

Question 16

what to look for in labial assessment

Answer 16

Indicate any degree of facial paralysis

Indicate any problem with maintaining lip closure when food is placed within the oral cavity

Question 17

what to look for in lingual assessment

Answer 17

Identifies limitation in tongue function that may affect the ability to propel food posteriorly or hold a cohesive bolus
Helps to identify probable consistency of best management

Question 18

assessing vocal quality

Answer 18

Wet/gurgly, audible vocal quality and/or bruits is indicative of possible pooling of secretions in the valleculae and/or pyriform sinuses and/or laryngeal vestibule

Use cervical auscultation to assess respiration

Have the patient cough to try and clear debris

Have the patient produce and prolong an /ah/ or /ha/
Have the patient slide up and down a vocal scale

Question 19

sliding up and down a vocal scale evaluates…

Answer 19

Cricothyroid muscle and intrinsic muscles of the vocal folds

Tests superior laryngeal nerve – innervates the Cricothyroid muscle

Question 20

if patients laryngeal function is questionable..

Answer 20

use a supraglottic or super-supraglottic swallow

-Increases patient’s airway protection prior to the initiation of the swallow

Question 21

what to review on patients chart

Answer 21

Medical status
Reason for admission
Past medical history (PMH)
Neurological history
History of head and neck (H&N) cancer (Ca)
Tumor
Node
Metastasis
Previous pneumonias
Respiratory difficulties
Need for O2  
Presence of Trach
Levels of alertness
GI history

Nutrition status
Current Diet
Nutrition status
Weight
Calorie/protein intake
Nutrition labs
Medications
Psychotropic medications
Sedatives

Radiological reports
Head CT or MRI
Chest X-Ray
Infiltrates
Pleural effusions
Increased fluid in pleura, takes up space in lung
Barium esophagram
Upper GI Series
Surgical procedure reports
ENT reports
Endoscopy reports

Reports from other therapies

Nursing reports
Alertness
Difficulty eating/drinking

Question 22

patient interview should collect info about..

Answer 22

Nature of problem
Onset and duration
Progression (gradual vs. sudden)
Constant vs. intermittent
Sticking sensation
Where
With what
Coughing/choking
With what
Pain
Where
When
Liquids easier than solids
Heartburn/reflux
Nasal reflux
Dry mouth
Weight loss
Appetite change
Food preferences
Voice change

Question 23

swallow assessment consists of…

Answer 23

1. dry swallow
2. response to stimulation (pressure on lips and tongue, lemon swab on lips and tongue, thermal stim, empty spoon on tongue)
3. response to food consistences (observe oral phase, drooling, mastication, bolus formation)

Question 24

what to look for in oral phase..

Answer 24

Oral clearance
Anterior sulcus
Lateral sulci
Tongue body

Question 25

reflexes during swallow assessment

Answer 25

Rooting
Biting
Oral defensiveness

Question 26

what to look for in pharyngeal phase

Answer 26

Pharyngeal phase
Promptness
Laryngeal excursion
Vocal quality
Cough
Cervical auscultation (listening for):
Cessation of breathing
Strong “clunk”
Clear airway

Question 27

materials/consistencies

Answer 27

Dry swallow
Puree
Ground
Mechanical soft (cut up in 1-.5 inch pieces)
Regular
Liquid

Question 28

advantages of bedside assessment

Answer 28

Natural setting
Normal food consistencies
Can observe caregiver

Question 29

disadvantages of bedside assessment

Answer 29

Limited primarily to oral phase
Have to make inferences about pharyngeal and esophageal
Cannot detect silent aspiration

Question 30

purposes of modified barium swallow

Answer 30

Define the abnormalities in anatomy and physiology causing the patient’s symptoms

Identify and evaluate treatment strategies that may immediately enable the patient to eat safely and efficiently

Question 31

MBS food mixtures

Answer 31

Liquid (juice, water, etc.)

Puree
(pudding, applesauce or patient’s food)

Solid
(cookie, cracker or patient’s food items)

Question 32

MBS positioning

Answer 32

Upright when possible
Habitual feeding position
Lateral view
A-P view

Question 33

types of seating apparatus (MBS)

Answer 33

VESS

Hausted

Question 34

MBS personnel

Answer 34

Speech pathologist
Radiological technician
Radiologist
Respiratory therapist
ICU/CCU nurse
OT/PT

Question 35

MBS order of material

Answer 35

most to least restrictive

Question 36

MBS order of views

Answer 36

Lateral view ID penetration/aspiration

A-P view ID symmetry

Question 37

MBS contra-indications

Answer 37

Decreased alertness
Decreased cooperation
Isolation requirements

Question 38

MBS oral phase

Answer 38

Mastication
Oral retention

Bolus formation
Bolus management
Premature spillage
Oral retention

Bolus propulsion
Oral retention

Bolus clearance
Oral retention

Question 39

MBS pharyngeal phase

Answer 39

Velar elevation
Nasal reflux

Epiglottic inversion
Penetration during swallow
Valleculae retention

Laryngeal elevation
Valleculae retention
Penetration
Pyriform retention