Lecture 5 Flashcards
(40 cards)
What are the goals of a clinical swallowing assessment?
x6
Determine the presence, nature, severity of dysphagia
Collect baseline data
Judge swallowing safety & potential risks
Enable the development of a management plan
Consider impact of dysphagia on QoL
Determine need for onward referral
What are the benefits of a bedside evaluation?
Cheap, quick, less invasive, ethical, fewer resources required
What are the limitations of a bedside evaluation?
Does not detect silent aspiration, less detailed, more subjective
What are the elements of a clinical swallowing assessment?
(x9)
BGCCOOIRR
Background information General observation Communicaiton, cognition, behaviour Case history OME Oral trials Overall impression and diagnosis Recommendations/management plan Referral for other assessments
Background information - generally obtained from medical file or MDT team
Age and gender Relevant medical history/diagnosis Current medical and chest status Nutritional status Medications Cultural/client-specific information
General observation
Alertness - can they be roused? Mobility status and posture Ability to manage secretions (are they drooling) Ability to self feed (are there movements e.g. paralysis, chorea, cognitive impairments) Respiratory status (is patient wheezing) Client state (comfort/distress) Support system/family Do they appear healthy/nourished?
Communication
Ability to follow instructions
Insight and awareness into role of SP
Need for communication support/device
What are the goals of a dysphagia case history interview?
MDCBCS
- Gather information: medical diagnosis/status, nutritional status, complexity of the problem
- Determine if dysphagia is present (nature & extent)
- Determine causal factors
- Area of breakdown: Determine functional abilities and impairments
- Gather information about client (cultural, religious etc.)
- Determine level of stress/concern regarding swallow
Areas to probe via case history
OSPDCMP
- Onset of the problem (gradual/sudden, progressive/improving, fluctuating/stable)
- Symptoms of dysphagia (main difficulties, factors that exaccerbate/improve)
- Pain associated with the swallow
- Duration of meals
- Consistencies that are difficult/easy to swallow (inc. medications)
- Modified diet (food currently being avoided/modified to aid swallowing)
- Food preferences (cultural, religious, personal).
What is the purpose of an OME?
- Provide information about the appearance, strength, speed, coordination, and range of movement of the facial musculature (and associated cranial nerves)
- Opportunity to assess receptive language abilities (following directions)
- Allows clinician to determine patient state (cooperative/agitated)
What are the characteristics of an UMN lesion?
With an UMN lesion, voluntary control of ONLY the LOWER muscles of facial expression on the side CONTRALATERAL to the lesion will be lost.
The ability to raise the eyebrows suggests an UMN lesion
Voluntary control of muscles of the forehead will be spared due to the bilateral innervation of the portion of the motor nucleus of CN VII that innervates the upper muscles of facial expression.
The lower face receives UMN from the contralateral cortex, whereas the upper face receives bilateral UMN innervation
Which approach is appropriate for an OME? What does this involve? Which areas do we assess, in what order?
The “up-down-front-back” approach starts at the top of the face and works down, progresses to the inside of the mouth and then works to the back of the mouth.
- Upper face
- Lower face (lips and cheeks)
- Jaw
- Oral cavity inspection
- Tongue
- Oropharynx
- Soft palate
- Vocal folds
- Hyolarngeal excursion
How would you assess the motor function of the upper face region? What cranial nerve(s) are involved?
- Observe symmetry at rest/facial droop
- Ask the patient to raise their eyebrows, frown, open and close their eyes (model these if difficulty understanding)
- CN VII (Facial) - motor function of facial muscles (gives information about chewing ability)
How would you assess the motor function of the lower face region (lips and cheeks)? What cranial nerve(s) are involved?
(Symmetry, strength, range, coordination)
- Observe symmetry at rest/facial droop
- STRENGTH: puff up cheeks (lip seal), hold tongue depressor between lips
- RANGE: Retraction (smile/”ee”) and pucker (“oo”)
- COORDINATION: alternate between ee-oo
- CN VII (Facial) - motor function of facial muscles (gives information about chewing ability)
How would you assess the sensory function of the face? What cranial nerve(s) are involved?
Use a light touch with a cotton swab with the patient’s eyes closed. Have the patient tell you where they are being touched (e.g. right cheek).
- CN V (Trigeminal) - sensory function = general somatic sensation of the face, cheeks, jaw, lips.
What is the importance of the jaw in swallowing?
The jaw is important for containing the food/liquid/saliva bolus. In addition, when the jaw is closed correctly, the tongue can be brought into a position to manipulate the bolus for chewing/reaching the palate.
How would you assess the motor function of the jaw? What cranial nerve(s) are involved?
(Symmetry, strength, range)
- Observe habitual position at rest (Is it hanging open? Is it symmetrical?) - an open mouth position may indicate weakness.
- STRENGTH: Ask patient to bite their teeth together and palpate the masseter. Place your hand under jaw and ask the patient to open against your resistance.
- RANGE: have patient move their jaw up and down/side to side/rotatory movement.
- CN V (Trigeminal) - jaw movement is governed by the motor component of the trigeminal nerve (i.e. CN V controls the “muscles of mastication” e.g. masseter).
- During chewing, involvement of CN V will show a deviation of the jaw TOWARDS the side of the lesion when the mouth is opened.
How would you assess the oral cavity? What cranial nerve(s) are involved?
- General inspection (should be moist and pink).
- Look at the symmetry of the tongue in the mouth at rest (CN XII). Are there any white patches (may = oral thrush) or fissuring (may = dehydration) on the tongue
- Look at the symmetry of the soft palate in the mouth at rest (CN X).
- Are the tonsils evident? Are they impinging on the amount of opening to the oropharynx?
- Is there any food residue? Could indicate sensory issue (CN IX).
- Look at state of gums and dentition. Are teeth discoloured/broken/display holes?
- Type and quantity of saliva (could indicate dehydration and/or poor oral hygiene).
What is the importance of the tongue in swallowing?
The tongue is critical for oral manipulation and containment of the bolus (glossopalatal seal).
It is the primary force for projecting the bolus into the pharynx (oral transit)
It is important for initiating the pharyngeal swallow (BOT to PPW approximation).
How would you assess the tongue? What cranial nerve(s) are involved?
(Symmetry, bulk, strength, range, coordination)
- SYMMETRY: Ask the patient to stick out their tongue. Observe symmetry.
- BULK: Observe presence of atrophy/fasciculations (brief spontaneous muscle movements, may indicate MND).
- STRENGTH: Ask patient to push each cheek out using their tongue (feel the strength and symmetry of the movement). Ask the patient to press against the tongue depressor.
- RANGE: Have the patient point their tongue upwards towards their nose, down towards their chin, and then lick all around their lips.
- COORDINATION: have patient say “ka la ka la” to observe alternating movement.
- CN XII (hypoglossal) provides motor function for the extrinsic and intrinsic muscles of the tongue.
You have asked the patient to stick out their tonge. It sticks out to one side.
If the tongue deviates to the SAME side as the known lesion, does this represent a UMN, unilateral LMN, or bilateral LMN dysfunction?
Unilateral LMN (ipsilateral innervation)
You have asked the patient to stick out their tonge. It sticks out to one side.
If the tongue deviates to the OPPOSITE side to the known lesion, does this represent a UMN, unilateral LMN, or bilateral LMN dysfunction?
UMN (contralateral innervation)
You have asked the patient to stick out their tonge. It has very limited protrusion and does not deviate to either side.
Does this represent a UMN, unilateral LMN, or bilateral LMN dysfunction?
Bilateral LMN
What is the importance of the soft palate in swallowing?
Plays a role in separating the oral and nasal cavities during swallowing. It creates a tight seal in the oral chamber and prevents nasal regurgitation.
