Screening

Modified Tongue Anchor Test

• Consists of having patient puff cheeks and protrude tongue simultanesouly. Push on cheeks. If their velopharyngeal functioning is within normal limits, their cheeks will remain puffed up

• Not valid if there is significant tongue or facial weakness

• Rationale is that patients cannot use back of tongue to aid in velopharyngeal closure

  • Compensatory strategy

• Velopharyngeal closure can only be examined through videofluoroscopy or nasoendoscopy

Larynx

• Adduction tested through two tasks

  • Cough–assess cough sharpness, not loudness

    • Weak/breathy cough can reflect adductor weakness/poor respiratory support/both 

• Coup de glotte/glottal coup - sharp glottal stop or a grunt

  • Does not require respiratory force or sustained airflow – assess sharpness

• Weak cough with a strong glottal coup indicates respiratory weakness

• Weak coup/normal cough or equally weak coup/cough indicates laryngeal weakness or combined laryngeal/respiratory weakness

Impairments

• Several abnormalities (polyps or nodules) can alter mechanical properties of cords

• Weakness/Paralysis can alter cord mobility

• Note if there’s significant abnormal movements of the cords

When should Relaryngeal exams be conducted

When structural or LMN lesions are suspected

Respiration Questions:

• Assess patient’s quiet breathing

• Is patient’s posture normal?

• Is patient slouched or bent forward or to side?

• Does patient gravitate to abnormal posture during interview?

• Is patient’s head drooped forward?

• Does patient’s head rest on chest?

• Is patients braced in wheelchair for normal posture?

• Does patient complain of shortness of breath during rest, speech, or exertion?

• Is breathing shallow, rapid, or labored?

  • Normal rate is 16 to 18 cycles per minutes and lasts for 2 to 3 seconds

• Are abnormal/thoracic movements limited?

• Is breathing accomplished by abnormal movements?

  • Pulmonary testing can be conducted to determine if respiration is sufficient for speech?

  • Must distinguish between sharpness of couch or coup in order to separate laryngeal and respiratory weakness

Reflexes

• Confirmatory information about presence of neuropathology and localization (CNS vs. PNS) 

• Normal reflex – occurs as a reflection of normal nervous system function

  • Absence of normal reflex reflects PNS pathology

• Primitive reflex - is present during infancy but tends to disappear during nervous system maturation

• Presence of these associated with CNS pathology, especially frontal lobe, cortical and subcortical regions 

• Release Phenomena - reduction in cortical inhibitory influence on lower centers of brain and can reappear with age

• Use caution when interpreting findings as they can be confused by release phenomena

Release Phenomena

Reduction in cortical inhibitory influence on lower centers of brain and can reappear with age

Primitive Reflex

Present during infancy but tends to disappear during nervous system maturation

Normal Reflex

Occurs as a reflection of normal nervous system function

Gag/Pharyngeal Reflex

• Elicited by bottom of uvula, stroking back of tongue, posterior pharyngeal wall or faucial pillars on both sides

• Sensory = glossopharyngeal nerve (IX)

• Motor = vagus (X) 

• Response is elevation of palate, retraction of tongue, sphincteric contraction of pharyngeal walls 

• Gag reflex is only significant if asymmetry is noted 

• Ask if it feels different on the two sides- a lack of sensation could be responsible for decreased gag reflex

Jaw Reflex

• Maxillary reflex

• Primitive deep muscle stretch reflex that may be pathologic in adults

• Patient should be relaxed with lips parted and jaw half way open

• Tongue depressor (finger) is placed on chin and is tapped with other hand or a reflex hammer

• Response is pathologic if jaw closes quickly

• Present in approximately is 10% of normal adults

• May be confirmatory sign of bilateral UMN lesions at level above mid-pons

Sucking

• Primitive reflex

• Elicited by stroking lip from lateral aspect towards philtrum on both sides

• Pathologic response is pursing of lips 

• Can be a confirmatory sign of UMN damage, especially to premotor cortex

• Frequently elicited in demented patients

• Rooting reflex occurs as an exaggerated reflex when an object approaches mouth

Snout Reflex

• Similar to sucking reflex

• Elicited by a light tap of finger on philtrum or tip of nose or backwards pressure on midline of upper lip and philtrum 

• Pathological - puckering or protrusion, along with elevation of lower lip and depression of lateral angles of mouth

Cognitive-Communicative Ability

• Can patient follow simple directions?

  • Oral motor and dysphagia exercises

• Can patient remember and re-state a technique? 

  • Determine if patient can participate in treatment

• Can patient follow and remember directions independently for functional swallow?

Trail Feeding

• Present small amounts of variety of textures for both liquids and solids

• Begin with ice chips, small sips of water, puree, mechanical soft and regular consistencies 

• Observe for any problems with specific consistency or for oral phase issues 

• If patient exhibits difficulty, attempt compensatory technique

Determine which placement facilitates safest swallow

• Anterior placement - prone to aspirate but good bolus control

• Posterior placement - mastication/AP transit problem; no pharyngeal issues

• Left placement - R weakness

• Right placement - L weakness

• Midline placement - reduced sensitivity

Placement Guidelines

• Place food on stronger side to increase sensation and stimulability to food and to reduce pocketing

• Use smooth stroke to press down on tongue as food is placed 

  • Stimulates oral stage

• Anterior placement for patients experiencing premature spillage into pharynx and who have good lip closure

Placement Guidelines

• Posterior placement for patients who have delayed oral transit time or who have poor lip closure

• Lateral placement (strongest side) in patients with unilateral tongue weakness

• Midline placement with patients with good tongue control and lip closure

3oz. Water Swallow Test

• A 3-ounce (approximately 90 milliliters) volume of water is measured and poured into a cup.

• Patient is instructed to take small sips of the water and swallow it in a controlled and CONSECUTIVE manner. 

• SLP observes the patient’s swallowing, looking for signs of difficulty or abnormalities (coughing, choking, throat clearing)

Alternative Procedures

1. A specific volume of liquid (typically water) is measured, and patient is instructed to take a sip of the liquid and swallow it as quickly and safely as possible. 

2. The goal is to complete the swallow without coughing, choking, or experiencing any other signs of aspiration 

3. SLP uses a stopwatch or timer to measure the time it takes for the individual to initiate and complete the swallow, from the moment the liquid enters their mouth to the moment they signal that the swallow is complete.

4. The test may be repeated several times with different volumes of liquid to assess the individual's swallowing abilities across different conditions.

Alternative Procedures

• Cervical Auscultation

• Blue Dye Test

• Pulse Oximetry- monitors oxygen saturation levels (the percentage of hemoglobin in the blood that is carrying oxygen, compared to the total amount of hemoglobin available)

• Reflex Cough Test- A small amount of a substance known to induce coughing is applied to the back of the patient's throat (often citric acid, tartaric acid, distilled water, or a similar irritant). Individual's response to the test substance is observed (i.e., coughing, throat clearing, or other signs of discomfort).

Pulse Oximetry

Monitors oxygen saturation levels (the percentage of hemoglobin in the blood that is carrying oxygen, compared to the total amount of hemoglobin available)

Reflex Cough Test

A small amount of a substance known to induce coughing is applied to the back of the patient's throat (often citric acid, tartaric acid, distilled water, or a similar irritant). Individual's response to the test substance is observed (i.e., coughing, throat clearing, or other signs of discomfort).

What happens after the bedside?

• What happens if the SLP recommends NPO?

• Information is placed in patient’s chart

• Patient provided with an NG tube or TPN until an instrumental exam can take place

• > 24 hours before exam = NG tube

• < 24 hours = Placed on TPN or NG tube

Non-surgical Enteral Procedures

• Oral nutrition – p.o. intake via diet modification

• Enteral tube feeding – through tube or catheter that delivers nutrients bypassing oral intake

  • NG tube (nasogastric tube) through nose and inserted down esophagus into stomach – usually for less than 30 days

  • NJ tube (nasojejune) intestinal tract – less than 30 days

Oral Nutrition

P.O, intake via diet modification

Surgical Procedures

• Gastrostomy – PEG (percutaneous endoscopic gastrostomy) 

  • Tube inserted directly through a surgically produced stoma in stomach  

  • Used for greater than 30 days duration

• Jejunostomy – PEJ (percutaneous endoscopic jejunostomy) 

  • Tube inserted directly into intestines through an incision

    • Used for greater than 30 days duration

    • Often used if PEG tube fails or becomes infected

Gastrostomy

PEG (percutaneous endoscopic gastrostomy)

Tube inserted directly through a surgically produced stoma in the stomach

Used for more than 30 days

Jejunostomy

PEJ (percutaneous endoscopic jejunostomy)

Tube directly into intestine trough an incision

Used if PEG tub fails/becomes infected

Used for more than 30 days

Parenteral Feeding

• Provision of some or all nutrients by means other than gastrointestinal tract (usually IV)

  • Peripheral – delivered thorough a peripheral vein (hand or forearm) through IV

  • Central – delivered through a large diameter vein (superior vena cava via the jugular vein)

    • “Central line”