Oral-Peripheral

Cranial Nerve Examination

What do we use these exams for as Speech Language Pathologist?

facial physical structure,
asymmetry,
adequate breath support,
range of motion, strength, and rate,
accuracy of hitting the speech target,
signs of weakness or atrophy of the muscles,
fasciculation,
involuntary movements
Phonation and resonance
oral and dental hygiene
Articulatory "groping"
ability to chew and swallow food.

Purpose

What is the Purpose for the Oral-Peripheral and Cranial Nerve Examination?

Oral-Peripheral Exam

The purpose for performing is to assess the anatomical and functional integrity of the structures that support speech and swallowing. Can be administered to clients of all ages. If there is inadequacy it may indicate concerns with complete or partial speech, language or swallowing.

Cranial Nerve Exam

The purpose for performing this neurological exam is to assess the sensory and motor integrity crucial for speech, voice, and swallowing functions. If there are inadequacies, it can negatively impact speech production. (e.g., damage to CN V or trigeminal nerve may disrupt sensory of the oral muscles)

Embry, E. & Molfenter, S. M.

Shipley, K. G., & McAfee, J. G. (2016)

Stein -Rubin et au (2012)

Oral Peripheral Assessment Areas and Task

BEFORE Exam:

Materials need: sterile gloves, a pen light, a tongue depressor, a mirror, and a stopwatch. Other materials may include a glass of water, lollipops, bubbles, and sterile cotton swabs.

Important to follow standard infection universal control precautions- (e.g., sterilizing all equipment, includes washing hands with soap and water for 20 seconds, before putting on gloves and after removal.) Find more information on https://www.cdc.gov/oralhealth/infectioncontrol/summary-infection-prevention-practices/standard-precautions.html Also Review any additional COVID-19 protocols such as mask and possible face shields.

Exam Tasks

Facial Exam

Structural: Note overall head size, shape of face, facial symmetry, and spacing of facial features

Functional: Facial motor: Observe Client's face at rest- Then evaluates rate, strength, and range of motion of the muscles of facial expression by asking the client to frown, pucker, smile, bare the teeth, and close eyes tightly.

Check for abnormal movements or spasms.

Lip Exam

Structural: Note client's lips at rest for structure, symmetry, posture (closed and open), and conditions

Functional: For range of motion; instruct client to protrude and retract the lips by asking them to either pucker their lips, smile, produce untensed vowel /u/ and tensed vowel /i/.

For closure and seal, ask client to purse the lips and then ask to seal month and puff out the cheeks. Clinician can ask to repeat and lightly provide pressure to assess strength.

Jaw (Mandible) Exam

Structural: Examine the size of the mandible in relation to the upper part of the face and how low the jaw hangs at rest

Functional: Assess the range, speed, accuracy, and symmetry of jaw movements. Clinician instructs the client to open and close mouth, then repeat but this time apply light pressure on the opposing downward or upward movement.

Teeth Exam

Structural: Examine for any occlusion or malocclusion, Dental alignment, and overall dental hygiene.

For alignment task ask client to bite down and smile. For overall dental hygiene have client open mouth and examen.

Assessment Areas

Includes area facial functional integrity/symmetry, coordination, closures and seal, range, speed, and accuracy of motion, swallowing and gag reflex.

Includes structures of the month (Lips, tongue, hard and soft palate, teeth, throat, jaw) AND the symmetry and shape of the client's face. Also, not head and neck muscle support.

Tongue exam

Structural: Examine the lingual size, surface, color, completeness, and symmetry at rest. Observe for fasciculations (involuntary lingual movement at rest). Ask client to elevate the tongue tip to the alveolar ridge to inspect the frenulum.

Functional: assess range of motion by instructing the client to protrude and the elevate and depress the tongue, rotate the protruded tongue. For strength, ask client to protrude the tongue and using the tongue depressor, press the flat side on the midline of the tongue and then against the lateral margin of the tongue.

Hard and soft palate exam

Structural: To assess the hard palate inspect the contour and width, if there is a presence of fistulas, scars, discoloration, or cleft. For the soft palate inspect the palate and the uvula or presence of a cleft or fistulas

Plarynx exam

Functional: Here we focus on the velopharyngeal closure, which separates the nasal cavity from the oral cavity. To assess (1) place mirror under clients nostrils and ask to produce /m/, /n/, /ŋ/ expectation is that the mirror will fog. OR (2) Clinician should close the client's nares with gently pinching and ask to produce nonnasal sounds. OR (3) Instruct client to stick out their tongue, ask the client to produce the /a/ sound and with a tongue depressor apply light pressure on the tongue blade and use the pen light observe the movement of the uvula at the phonation onset.

Embry, E. & Molfenter, S. M.

Shipley, K. G., & McAfee, J. G. (2016)

Stein -Rubin et au (2012)

Cranial Nerve Assessment Areas

There are 12 pairs of cranial nerves

3 have sensory branches only/ 5 have motor branches only/ 4 have both sensory and motor components.

Usually assessed top-down (from CN I to CN XII)

Shipley, K. G., & McAfee, J. G. (2016)

Embry, E. & Molfenter, S. M.

Cranial Nerves Tasks

Cranial Nerve I: Olfactory

Clinician requests Client to identify odors

Cranial Nerve II: Optic

Clinician tests visual acuity, color vision, visual fields, pupillary response to light. Request client to cover one eye and have them observe a pen light from middle to opposing side.

Cranial Nerve III: Oculomotor

Ask client to look up and down without moving head.

Cranial Nerve VI: Trochlear

Request client to follow object (e.g., pen light) up and down with eyes.

Cranial Nerve V: Trigeminal

Sensory: Request client to close eyes and describe location of where the clinician provides touch using cotton swab or gloved hand.

Motor: Ask client to clench teeth for palpation of the masseter and temporalis mucles and feel for symmetry. Request them to open or close against clinician resistance.

Cranial Nerve VI: Abducens

Evaluate the client's ability to open eyes from closure. Note any delay in opening an eye.

Cranial Nerve VII: Facial

Furrowing the brow, screwing up the eyes, sniffling, whistling, pursing the lips. Request client to smile then pucker lips or produce /i/ and /u/ alternating. Clinician may provide resistance manual lip opening

Cranial Nerve VIII: Vestibulocochlear

Can whisper in client’s ear to assess. Should refer to ENT/audiologist when concerns arise.

Cranial Nerve IX: Glossopharyngeal

Request client to cough, produce phonation, palatal elevation on phonation.

Cranial Nerve X: Vagus

Observe and evaluate Vocal characteristics; can perform a laryngoscopic examination. May also use a tongue depressor to lightly test gag reflex.

Cranial Nerve XI: Accessory

Request Client to move head and shoulder up and down.

Cranial Nerve XII: Hypoglossal

Request Client to protrude the tongue. Elevate tongue tip, evaluate strength against resistance. Tongue lateralization.

Note: During assessment we are describing observation only. If we observe or suspect impairments, make the appropriate referral for diagnosis.

Embry, E. & Molfenter, S. M.

Paul, R. & Cascella P. W.

Shipley, K. G., & McAfee, J. G. (2016)

Stein -Rubin et au (2012

Examples of Clinical Forms (click link for form):

Speech Team Sensory Oral peripheral exam form

Shipley & McAfee Orofacial Exam Form

Student to student guidelines OSME

The YouTube video is an example of performing a cranial nerve exam.

Normative Data:

Diadochokinetic Rates

Measured of a client's ability to make rapidly alternating speech movements.

Instructions:

Instruct client to repeat targets: /pʌ/, /tʌ/, /kʌ/ as quickly as possible until told to stop (Alternation Motion Rates)
Model the sequence and allow the client to practice
Say "go" and "stop" to indicate the time after 20 repetitions
Redo the sequence if client stops or intentionally slows down (i.e. not due to fatigue)
After assessing each syllable individually, evaluate the client for 10 repetition of /pʌtʌkʌ/ (Sequential Motion Rates)
Record all findings on the worksheet (sample found here https://chhs.fresnostate.edu/csds/documents/Diadochokinetic%20Syllable%20Rates%20Worksheet.pdf)

Measured by:

Counting the syllables produced within a predetermined number of seconds

The seconds it takes to produce a predetermined number of syllables.

Shipley, K. G., & McAfee, J. G. (2016)

Stein -Rubin et au (2012

Maximum Phonation Time (MPT)

The purpose for the MPT's task is a measure the glottic efficiency. Indicating how well the vocal folds close, open, and vibrate while producing speech.

MPT vary among speakers with normally functioning vocal folds.
It is assessed by asking a client to sustain a vowel
- Ex. technique:
  - ask the client to take to take a deep breath
  - exhale a "o" vowel (or "ah")
  - ask client to perform this at a comfortable pitch and loudness and to sustain it for as long as possible.
  - have a stopwatch to time
  - important to repeat for 3 trails
  - record the longest phonation

Normative Data

Typical adult males can sustain vowel sounds for 25 to 35 seconds

Typical adult females can sustain vowel sounds for 15 to 25 seconds.

Typical children can sustain the vowel sound for 10 seconds.

Glottic insufficiency may be of concern for speakers who sustain vowel sound for fewer than 10 seconds. This suggests air leakage through the glottis or improper breath support for voice

NOTE: low MPT would probably exhibit a high airflow rate on a pneumotachograph and may indicate breathiness.

Shipley, K. G., & McAfee, J. G. (2016)

Stein -Rubin et au (2012

Tavares, E. L. M. et au (2012)

S/Z ratio

The purpose of the s/z ratio is to assess the integrity of glottal closures upon phonation.

/s/ phoneme is produced at the alveolar position of the oral cavity and is Voiceless.

/z/ phoneme is produced also at the alveolar position of the oral cavity but is Voiced.

Procedure of task: The client should be sitting up in an upright position. The clinician asks the client to take a deep breath and prolong the /s/ sound for as long as possible and then to follow through with sustaining /z/. Stopwatch is needed to time each prolongation and then the longest /z/ is divided into the longest /s/.

Normative data: For adults the normal range is 1 -1.4 ratio; for Children a ratio over 1 is considered normal.

A ration above 1.4 is a marked reduction in vocal duration and air leakage through the glottis on /z/ (voiced phoneme)

Stein -Rubin et au (2012)

Tavares, E. L. M. et au (2012)

Information related to A&P/ (including visuals)

Central Nervous System:

-Composed of the brain and spinal cord

-Controls sensory output

-Information processing

-Controls motor output

Peripheral Nervous System:

-Nerves that branch off the spinal cord

-Controls involuntary functions of the body

-Relays information from the brain to the body

Cranial Nerves Related to Speech

CN X: Vagus- innervates the muscles of the soft palate, pharynx and palatoglossal muscle of the tongue and pharyngeal constriction during velopharyngeal closure during speech and swallowing

CN V: Trigeminal- opens eustachian tube and elevates the mandible

CN VII: Facial- innervates the submandibular sublingual and lacrimal glands; elevates the larynx and is responsible for the muscles of facial expression and the ear

CN IX: Glossopharyngeal- aids in laryngeal elevation and velopharyngeal closure

CN XII: Hypoglossal- controls tongue movements during speech and swallowing

CN VIII: Vestibulocochlear- responsible for transmitting sound and balance to the inner ear

The Four Lobes of the Brain

Frontal Lobe:

Controls Cognitive Function
Broca's Area
Speech Formation and Understanding

Parietal Lobe:

Processes Tactile Sensation
Somatic Sensory Cortex
Manages Taste, Hearing, Touch & Smell

Temporal Lobe:

Wernicke's Area
Speech Comprehension
Auditory Cortex
Processes Sound

Occipital Lobe:

Visual Analyses
Color Determination
Object & Face Recognition
Memory Formation

Brain lobes

Above Image has age range of eruption

Upper Jaw: Maxillary teeth

Lower Jaw: Mandibular teeth

Oral Cavity Anatomy

Four Classes of teeth:

Incisors, Canines, Premolars, and Molars

Image of the complere oral cavity

Brakebill et al.

Hoffman, M. (2020)

Shipley, K. G., & McAfee, J. G. (2016)

REFERENCES

Brain lobes. BrainFrame psychology for kids: Education. Retreived on September 23, 2021 from https://brainframe-kids.com/brain/facts-lobes.htm

Brakebill, L. and Vogl, L. The comprehensive oral peripheral mechanism evaluation and the school SLP: What to do when TOTs and/or tongue thrust is suspected?. Oregon Speech and Language and hearing association. Retrieved on september 22, 2021 from https://www.oregonspeechandhearing.org/resources/Documents/2019%20Fall%20Conference/Speaker%20Handouts/Vogl,%20Brakebill%20TOT%20and%20Tongue%20Thrust_OSHA%202019.pdf

Diadochokinetic syllable worksheet. Resouces for assessing communication disorders. Fresnostate. retreived on September 24, 2021 from https://chhs.fresnostate.edu/csds/documents/Diadochokinetic%20Syllable%20Rates%20Worksheet.pdf

Embry, E. and Molfenter, S. M., Components of a comprehensive diagnostic evealuation and report: The cranial nerve oral sensory motor examination (OSME). 2NYU. https://2nyu.speech.steinhardt.nyu.edu/ap/courses/1026/sections/1bbc11cd-f45c-4b62-8344-596b52e260f9/coursework/module/21057be9-5c4a-463c-a3c3-37ebcd702f39/segment/c9576205-2d80-41dd-91fd-b20560bb15dc

Hoffman, M. (June 2020). Picture of the teeth: Human Antatomy. WebMD. Retreived on September 24, 2021 from https://www.webmd.com/oral-health/picture-of-the-teeth

Oral health. (June 2018). Centers for disease control and prevention (CDC) https://www.cdc.gov/oralhealth/infectioncontrol/summary-infection-prevention-practices/standard-precautions.html

Paul, R., & Cascella, P. W. (2007). Introduction to clinical methods in communication disorders (2nd ed.) Paul H. Brookes publishing co.

Shipley, K. G., & McAfee, J. G. (2016). Assessment in speech-language pathology: A resource manual (6th ed.). Boston, MA: Cengage.

Stein-Rubin, C., & Fabus, R. (2012). A guide to clinical assessment and professional report writing in speech-language pathology. Delmar.

Tavares, E. L. M., Brasolotto, A. G., Rodrigues, S. A., Pessin, A. B. B., & Martins, R. H. G. (2012). Maximum phonation time and s/z ratio in a large child cohort. Journal of Voice, 26(5), 675-e1. DOI: 10.1016/j.jvoice.2012.03.001

Reinstein, A. (2020). Brain and cranial nerves. Amy Speech & Language Therapy, Inc. Retrieved September 24, 2021, from https://www.amyspeechlanguagetherapy.com/brainandcranialnerves.html.