Oromotor Questions

What nerve are we considering when observing the face at rest and on excursion?

The facial nerve (CN VII) - responsible for motor innervation to the muscles of facial expression, as well as sensory and parasympathetic functions, such as taste sensation from the anterior two-thirds of the tongue

You notice loss of saliva from the right side of the mouth. It remains un-cleared. What does this suggest to you?

Suggests loss of sensation around mouth - impaired mandibular branch of trigeminal nerve (CN V)

Weakness or paralysis of the facial muscles on that side - impaired facial nerve (CN VII)

You notice a marked left-sided facial weakness during the exam. What does this tell you about the neurological deficit?

Neurological deficit affecting the right hemisphere of the brain - motor control for the face is contralateral (right side of brain controls left side of face)

If weakness involves the entire left side of the face, it suggests a LMN lesion affecting CN VII. If only the lower part of the face is affected, it points to an UMN lesion

Your patient is wiping saliva from the side of their mouth during your assessment. What might this tell you?

Weakness or paralysis of the facial muscles can impair the ability to keep saliva contained within the mouth, poor lip seal - impaired facial nerve (CN VII)

Your patient’s upper lip is retracted due to hypertonicity. What might be the impact on their day to day function?

Speech - difficulty clearly articulating bilabial sounds

Eating and Drinking - impaired ability to create strong lip seal, challenge to manage food and liquids, potentially leading to spillage or difficulty swallowing

Facial Expression - limit the range of facial expressions, affecting non-verbal communication and social interactions

Oral Hygiene - difficulty managing saliva and food, can increase risk of dental issues, such as cavities or gum disease

Comfort and Appearance - may cause discomfort or self-consciousness about facial appearance, impacting emotional well-being

Your patient tells you that they lose fluids from their mouth. What might this indicate about function?

Impaired swallowing function - fluids pooling in mouth and spilling out

Weakness of muscles around mouth can make it difficult to maintain a proper lip seal - impaired facial nerve (CN VII)

Lack of sensation in oral cavity prevents patients awareness of fluid leakage - impaired trigeminal nerve (CN V)

You observe dry saliva on the patient’s chin, what might this indicate?

Suggests loss of sensation around mouth - impaired mandibular branch of trigeminal nerve (CN V)

Your client cannot follow these complex commands, what actions might you take?

Simplify instructions and adapt communication

Use visual or physical cues

Assess cognitive function

Speak to caregivers or family members

Why does tongue strength matter? How would you assess it in person?

Tongue strength is crucial for speech, swallowing, chewing, weak tongue strength can lead to difficulties, potentially impacting quality of life

Observe movements, test resistance, observe EDS

What is the likely impact of a weak, flaccid tongue on communication and swallowing?

Slurred or imprecise speech, strained nasal voice quality, reduced intelligibility

Poor bolus control - increased risk of choking, residue in oral cavity - dental issues, delayed or inefficient swallow

Why does oral health/condition matter?

Bacteria in mouth can enter bloodstream and cause heart disease, diabetes, respiratory infections, aspiration pneumonia

Tooth decay or gum disease can make eating painful - poor nutrition

Poor oral health can affect pronunciation and confidence in communication

Prevention of cavities, gum disease, abscesses which can escalate if untreated

You notice food residue stuck in the lateral sulcae. What might this indicate?

Weak tongue muscles - impaired hypoglossal nerve (CN XII)

Lack of sensation within mouth - maxillary and mandibular branches of trigeminal nerve (CN V)

What is the neurological basis of tongue movement and sensation?

Hypoglossal nerve (CN XII) - innervates intrinsic and extrinsic muscles, responsible for movement

Vagus nerve (CN X) - innervates palatoglossus muscle, elevates back of tongue

Trigeminal nerve (CN V) - sensory innervation to anterior 2/3 via mandibular branch

Glossopharyngeal nerve (CN IX) - general and special sensory innervation (taste) to posterior 1/3 of tongue

Facial nerve (CN VII) - carries taste sensations from anterior 2/3 of tongue

Why observe the tongue at rest?

Assessing baseline condition - muscle tone, position, structural abnormalities

Abnormalities may indicate CN dysfunction, especially hypoglossal nerve (CN XII), can have impact on oro-motor functions

Your client’s tongue appears asymmetrical, what does this suggest?

Dysfunction of hypoglossal nerve (CN XII)

Why does it matter if someone can wriggle their tongue?

Reflects motor control, coordination, and strength of tongue muscles - essential for speech, swallowing, etc.

May indicate impaired hypoglossal nerve (CN XII)

You observe copious, watery saliva. What might you consider?

Impaired facial nerve (CN VII) - stimulates submandibular and sublingual glands

Impaired glossopharyngeal nerve (CN IX) - innervates parotid gland

The oral mucosa is dry and inflamed. What impact might this have on your client?

Difficulty eating and drinking - nutritional deficiencies

Increased risk of infections

Difficulties in articulation

Whose role is it to carry out oral hygiene?

Depends on circumstances but: personal, caregivers, healthcare professionals, multidisciplinary teams

What relevance does dentition have for communication? How about for swallowing?

Speech articulation - labiodental, alveolar fricatives

Resonance - impacts voice quality

Confidence

Chewing efficiency

Forming cohesive bolus

Prevent food residue accumulating - reduces risk of aspiration or infections

You notice your client has several missing teeth and multiple caries. Why is this important to take into your account during your assessment?

Indicator of poor oral health, impact on eating, speech, risk of aspiration pneumonia or other infections

What is the gag reflex?

Protective reflex, clears obstructions from upper pharynx and airway

Absent gag reflex - impaired glossopharyngeal nerve (CN IX), translates sensory info from upper pharynx, translates into motor innervation via Vagus nerve

On protrusion, you notice the tongue is deviating to the left side. What does this tell you?

Left sided weakness from unilateral damage to hypoglossal nerve (CN XII)

What are the different presentations of facial weakness in UMN and LMN lesions?

UMN lesion indicated by weakness at the lower face, on one side, this weakness is contralateral to lesion

LMN lesion presents in the whole half of face, weakness is ipsilateral to lesion

Difference is because bilateral innervation at top of face, unilateral innervation at bottom

If your patient was unable to identify when you were touching their lips, what are the implications of this loss of lip sensation?

Unable to detect temperature of food or drink, can’t determine if something is a safe temperature to consume

Unable to feel anterior loss of saliva/food residue, social impact