Oral Facial Exam Flashcards
why look at the ability to open the mouth voluntarily?
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
how to test bite reflex
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
how to test labial function
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/
how to test lip closure
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”
other labial function considerations
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
assessing anterior lingual function
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)
assessing posterior lingual function
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”
how to test chewing function
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
testing soft palate and oral reflexes
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
testing the palatal reflex
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
palatal-afferent portion of reflex
Glossopharyngeal (CN IX) and possible Vagus (CN X) nerve involvement
palatal-efferent portion of the reflex
Vagus (CN X) and possibly the Glossopharyngeal (CN IX) nerve
The Trigeminal nerve (CN V) is also believed to be involved in the reflex
gag reflex
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
gag- afferent portion of reflex
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
oral sensitivity
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
what to look for in labial assessment
Indicate any degree of facial paralysis
Indicate any problem with maintaining lip closure when food is placed within the oral cavity
what to look for in lingual assessment
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
assessing vocal quality
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
sliding up and down a vocal scale evaluates…
Cricothyroid muscle and intrinsic muscles of the vocal folds
Tests superior laryngeal nerve – innervates the Cricothyroid muscle
if patients laryngeal function is questionable..
use a supraglottic or super-supraglottic swallow
-Increases patient’s airway protection prior to the initiation of the swallow
what to review on patients chart
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
patient interview should collect info about..
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
swallow assessment consists of…
- dry swallow
- response to stimulation (pressure on lips and tongue, lemon swab on lips and tongue, thermal stim, empty spoon on tongue)
- response to food consistences (observe oral phase, drooling, mastication, bolus formation)
what to look for in oral phase..
Oral clearance
Anterior sulcus
Lateral sulci
Tongue body
reflexes during swallow assessment
Rooting
Biting
Oral defensiveness
what to look for in pharyngeal phase
Pharyngeal phase Promptness Laryngeal excursion Vocal quality Cough Cervical auscultation (listening for): Cessation of breathing Strong “clunk” Clear airway
materials/consistencies
Dry swallow Puree Ground Mechanical soft (cut up in 1-.5 inch pieces) Regular Liquid
advantages of bedside assessment
Natural setting
Normal food consistencies
Can observe caregiver
disadvantages of bedside assessment
Limited primarily to oral phase
Have to make inferences about pharyngeal and esophageal
Cannot detect silent aspiration
purposes of modified barium swallow
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
MBS food mixtures
Liquid (juice, water, etc.)
Puree
(pudding, applesauce or patient’s food)
Solid
(cookie, cracker or patient’s food items)
MBS positioning
Upright when possible
Habitual feeding position
Lateral view
A-P view
types of seating apparatus (MBS)
VESS
Hausted
MBS personnel
Speech pathologist Radiological technician Radiologist Respiratory therapist ICU/CCU nurse OT/PT
MBS order of material
most to least restrictive
MBS order of views
Lateral view ID penetration/aspiration
A-P view ID symmetry
MBS contra-indications
Decreased alertness
Decreased cooperation
Isolation requirements
MBS oral phase
Mastication
Oral retention
Bolus formation
Bolus management
Premature spillage
Oral retention
Bolus propulsion
Oral retention
Bolus clearance
Oral retention
MBS pharyngeal phase
Velar elevation
Nasal reflux
Epiglottic inversion
Penetration during swallow
Valleculae retention
Laryngeal elevation
Valleculae retention
Penetration
Pyriform retention
