Oromotor + CN Information

an oromotor + CNE starts ____ and moves ____

peripherally, interiorly

Why do we always start an oromotor + CNE with verbal instructions only?

difficulty with voluntary movement in the absence of a model is an indicator of AOS

What are we looking for when we observe the face + jaw at rest, as well as during movement?

-Abnormal muscle function: tone, strength, ROM

-Asymmetrical facial structures

What cranial nerves are we assessing during facial + jaw rest/movement? (2)

-CN V (trigeminal), CN VII (facial)

Describe what we’re assessing (CN/salient feature):

task: is face/mouth symmetrical?

-drooping (eyes, lips; UL or BL?)

Describe what we’re assessing (CN/salient feature):

Task: Does face have expressionless, mask-like appearance?

Parkinsonism

Describe what we’re assessing (CN/salient feature):

Task: When patient looks up, is there wrinkling on both halves of forehead? 

Neurologic damage of CN VII (UMN vs LMN)

Describe what we’re assessing (CN/salient feature):

Task: Abnormal movements?

-Location

-Able to inhibit these movements voluntarily or not?

Describe what we’re assessing (CN/salient feature):

Task: Difficulty controlling laughing or crying? 

Pseudobulbar affect (emotional lability) 

Describe what we’re assessing (CN/salient feature):

Task: Is smile symmetrical? 

Movement of muscles

Describe what we’re assessing (CN/salient feature):

Task: Can patient pucker & round lips?

Lip muscles, rounding (orbicularis oris)

Describe what we’re assessing (CN/salient feature):

Task: Can patient’s lips be forced opne?

Strength against resistance?

Describe what we’re assessing (CN/salient feature):

Task: Can patient puff out cheeks and hold air in oral cavity as you squeeze the cheeks

• labial seal (lip strength) 

• velopharyngeal closure 

Describe what we’re assessing (CN/salient feature):

Task: Does jaw hang loosely or deviate to one side when mouth is wide open? 

• Jaw control 

• One side stronger than the other? 

• CN V damage 

• Clenched jaw (UMN damage)

Describe what we’re assessing (CN/salient feature):

Task: Can patient keep jaw closed while examiner attempts to open it? 

Can patient keep jaw open while examiner attempts to close it? 

• Strength of jaw elevators 

• Submental muscle strength 

Describe what we’re assessing (CN/salient feature):

Task: Is patient able to move jaw to right and left?

Bilateral weakness of jaw muscles, groping

Describe what we’re assessing (CN/salient feature):

Task: Jaw at rest

Any involuntary movements (tremors, fasciulations?)

Describe what we’re assessing (CN/salient feature):

Symmetry of jaw movement

-opening/closing jaw

Describe what we’re assessing (CN/salient feature)

Task: range of jaw movement

Speech and nonspeech movements

Describe what we’re assessing (CN/salient feature):

Task: Voluntary versus spontaneous motor movement (i.e., coughing, click tongue, blow, bite lower lip, puff cheeks, smack lips, stick out tongue, lick lips)

Red flags for nonverbal oral apraxia: off-target approximations, frank errors, self awareness and corrections

Name the cranial nerve that we assess when we look at the tongue during rest and movement

CN XII (hypoglossal)

Describe what we’re assessing (CN/salient feature):

Task: does tongue appear normal at rest?

• Atrophy (deep grooves) – unilateral or bilateral 

• Involuntary movements (fasciculations LMN and tremors) 

• Secretions (xerostomia = dry mouth

Describe what we’re assessing (CN/salient feature):

Task: is tongue symmetrical?

Unilateral vs bilateral damage (**always note which side) 

Describe what we’re assessing (CN/salient feature):

Task: Is patient able to protrude tongue completely?

• Genioglossus, vertical/transverse lingual muscles 

• Unilateral damage: deviation towards weaker side 

• Bilateral damage: reduced ROM (describe to where) 

Describe what we’re assessing (CN/salient feature):

Task: Can patient keep tongue tip at midline while examiner pushes tongue to the left and right?  

• Strength: subjective OR objective (IOPI)

Describe what we’re assessing (CN/salient feature):

Task: Is patient able to touch upper lip/alveolar ridge with tongue tip?  

ROM of protrusion muscles and elevation of tongue tip 

Describe what we’re assessing (CN/salient feature):

Task: Can patient keep tongue tip pressed against inside of cheek as examiner pushes the cheek inward? 

Lingual strength

Describe what we’re assessing (CN/salient feature):

Task: Can patient move tongue from side to side? /tongue movement

-Speed, regularity, ROM

Name the cranial nerves we are assessing of velum + pharynx at rest/during movement (2/3)

CN IX, X (and V)

Describe what we’re assessing (CN/salient feature):

Task: Palate hang low in the mouth at rest?

Rest on the back of the tongue - this is normal, b/c it allows for unobstructed nasal breathing

Describe what we’re assessing (CN/salient feature):

Task: Symmetry of palatal arches at rest

Asymmetry (specify which side)

Describe what we’re assessing (CN/salient feature):

Task: Movement of velum during prolongation of /a/  

• Speed, regularity, ROM, symmetry of movement

• Palate should go up and backwards

• Insufficient lift = hypernasality

Describe what we’re assessing (CN/salient feature):

Task: Is there a gag reflex when back wall of pharynx is touched?  

• Gag reflex = CN IX and X (sensory and motor) 

• Abnormal: asymmetrical gag reflex

Describe what we’re assessing (CN/salient feature):

Task: Nasal airflow on mirror during vowel prolongation?   

• Should not see mirror fogging up 

• Fogging up = hypernasality

Describe what we’re assessing (CN/salient feature):

Task: Modified tongue-anchor test (puff cheeks while protruding tongue)

Assess velopharyngeal closure

Describe what we’re assessing (CN/salient feature):

Task: instrumentation during speech tasks

-Nasometer (used for voice disorders, cleft palate etc.)

-document % of hypernasality

Describe what we’re assessing (CN/salient feature):

Task: Can patient produce sharp cough?

• Strength of VF adduction (CN X) 

• Weak cough --> respiratory dysfunction, laryngeal dysfunction

Describe what we’re assessing (CN/salient feature):

Task: Can patient produce sharp glottal stop?

Strength of VF adduction (differentiate laryngeal vs respiratory defs)

Describe what we’re assessing (CN/salient feature):

Sustained /a/ (three trials of MPT)

-Vocal quality (infer status regarding function of vocal mechanism)

-Respiratory status

Describe what we’re assessing (CN/salient feature):

Task: S/Z ratio

-/z/ assess laryngeal function

-/s/ assess respiratory function

-Normative data - ratio about 1:1

What ratio for S/Z ratio would suggest laryngeal pathology?

>1.1

What ratio of S/Z ratio would suggest respiratory pathology?

< 0.9

Describe what we’re assessing (CN/salient feature):

Task: presence of inhalatory stridor

• Vocal folds adducted during inhalation (obstructing airflow)  

• VF paralysis

Describe what we’re assessing (CN/salient feature):

Task: quiet breathing / rate + depth of breathing

-Rate (16-20 cycles per min is WNL)

Describe what we’re assessing (CN/salient feature):

Task: Posture

Is posture adequate for optimal breathing?

-important b/c respiration is the driving force of our phonation

Describe what we’re assessing (CN/salient feature):

Task: presence of involuntary movements when breathing

Shoulder movement, neck extension, flaring of the nares