Cranial Nerves
The cranial nerve controlling all tongue movements.
What is CN XII (Hypoglossal)?
It innervates ALL intrinsic and extrinsic tongue muscles!
A patient with PD shows repetitive anterior-posterior tongue rolling that fails to propel the bolus backward. What is this called and which phase is impaired?
Lingual rocking or lingual pumping — a hallmark of Parkinson's Disease. It is an oral phase impairment.
What does PAS stand for and what does a score of 8 mean?
Penetration-Aspiration Scale.
Score of 8 = material enters below the vocal folds and the patient does not react: silent aspiration, the worst and most dangerous score.
Disadvantages of alt means of nutrition like NG tube, ND tube, PEG etc.
Can still aspirate from bottom-up from tube feeding - Bedridden → aspiration risk goes up due to position
Can be dislodged or clogged - Twisted NG tube for example
Time consuming
Impacts quality of life
Caregiver burden
The difference between a compensatory strategy and a rehabilitative exercise.
Compensatory = modifies the swallow in the moment to make it safer right now but does not change underlying physiology.
Rehabilitative exercise = targets specific muscles with overload, specificity, and intensity principles to actually improve the physiologic impairment over time.
CN providing TASTE to the anterior 2/3 of the tongue.
What is CN VII Facial?
Anterior 2/3 = CN VII (Facial) taste
Posterior 1/3 = CN IX (Glossopharyngeal) for both taste and sensation.
A patient presents with nasal regurgitation immediately upon swallow initiation. What structure has failed and at what point in the swallow does this normally close?
The velum (soft palate) has failed to elevate and contact the posterior pharyngeal wall, leaving the velopharyngeal port open.
This normally closes at the very onset of the pharyngeal phase. Muscles responsible are levator veli palatini and palatopharyngeus, innervated by CN X and CN XI.
Which instrumental assessment can visualize the esophagus?
VFSS: it performs an esophageal sweep in the A/P view after the lateral pharyngeal assessment.
FEES cannot visualize below the UES.
The 3 pillars required for aspiration pneumonia to develop.
(1) serious illness or frailty reducing immune response
(2) poor oral environment with high bacterial load and dysbiosis
(3) impaired airway protection allowing bacteria-laden material to reach the lungs.
Aspiration alone does NOT cause pneumonia.
Postural strategy indicated for a delayed pharyngeal trigger.
What is Chin tuck (chin down)?
it widens the vallecular space giving the bolus room to wait safely during the delay, narrows the laryngeal vestibule making airway entry harder, pushes the epiglottis into a more protective posterior position, and moves the base of tongue closer to the posterior pharyngeal wall.
CN affecting a patient presenting with lateral sulcus pocketing and anterior bolus loss.
What is CN VII (Facial)?
Orbicularis oris controls lip seal causing anterior loss, and buccinator controls cheek tension causing lateral pocketing.
What is the difference between apraxia of swallow and lingual weakness, and how would each present differently on clinical exam?
Apraxia = motor planning deficit despite intact strength. You see multiple restarts, groping movements, inconsistency across trials, and normal strength on oral motor exam.
Lingual weakness = reduced force and ROM on CN XII testing, tongue deviation toward lesion side, reduced resistance against a tongue depressor, with consistent but insufficient propulsion rather than inconsistent attempts.
A patient is in the ICU on a ventilator with a tracheostomy and cannot be transported. Which assessment do you complete and why?
FEES: performed completely at bedside with no transport needed, no radiation, no scheduling with radiology, no barium aspiration risk, and can be paused or stopped immediately if the patient decompensates.
To be used instead of green oral swabs for oral care in patients with dysphagia and why?
Only a toothbrush physically disrupts or remove dental plaque and biofilm. Biofilm is a structured bacterial community resistant to simple rinsing and is a primary reservoir for respiratory pathogens.
Green swabs provide moisture and create false reassurance that oral care is complete when bacterial load has not been reduced.
Correct toolkit: toothbrush, toothpaste, mouthwash, and mouth lubricant.
2 exercises for a patient with reduced base of tongue retraction and significant vallecular residue.
Masako maneuver (tongue hold) — biting the tongue during a dry swallow forces the posterior pharyngeal wall to move further anteriorly, strengthening PPW and increasing pharyngeal pressure at the BOT level.
Effortful swallow — squeezing hard with the tongue against the palate during swallow directly increases BOT retraction force and clears vallecular residue. Both target the same deficit from complementary angles.
The CN nerve AND branch damaged after thyroid surgery in a patient presenting with a breathy voice and aspiration of thin liquids.
What is the RLN (Recurrent Laryngeal Nerve), a branch of CN X?
It innervates most intrinsic laryngeal muscles except the cricothyroid. Damage causes ipsilateral vocal fold paralysis, incomplete glottic closure, breathy voice, and aspiration of thin liquids.
Your FEES shows no pharyngeal dysphagia but the patient continues to report globus and food sticking in the chest. What instrumental study would you order next and why can't FEES alone rule out the suspected diagnosis?
Order VFSS with esophageal sweep, esophagram, or refer for upper GI endoscopy or esophageal manometry. FEES cannot rule out esophageal pathology because it only visualizes the pharyngeal phase — it cannot see below the UES.
You suspect unilateral pharyngeal weakness on the left side, which view on VFSS specifically confirms this and what would you see?
The anterior-posterior view confirms unilateral weakness. You would see asymmetric pharyngeal contraction: bolus channels down the stronger right side with residue pooling in the left pyriform sinus and left pharyngeal wall after the swallow. The lateral view alone overlaps both sides and would miss this.
What is the evidence-based response and ethical principles to apply in a patient with dementia failing to thrive and their family requests a PEG tube?
PEG tube placement does not reduce aspiration risk, mortality, or improve quality of life in dementia patients. They continue to aspirate their own saliva and secretions regardless of tube feeding. Families must be counseled honestly about what a PEG tube cannot do for this population.
Ethically: autonomy means the patient's previously expressed wishes via advance directive should guide decisions. Beneficence means recommending what actually helps, which is likely comfort-focused oral feeding with good oral hygiene and positioning rather than a tube.
Postural strategy and side to turn toward when treating a patient with unilateral right-sided pharyngeal weakness post-stroke.
Head turn toward the right (weaker) side.
Rotating toward the damaged side physically closes off that pharyngeal channel, directing the bolus entirely down the INTACT LEFT side. It also applies extrinsic pressure to the larynx increasing vocal fold adduction, and reduces resting UES pressure by pulling the cricoid cartilage away from the posterior pharyngeal wall.
Specific nerve branch is implicated in a patient has silent aspiration with no cough response, intact vocal fold movement, and normal tongue and facial function.
What is the internal branch of the SLN (Superior Laryngeal Nerve), a branch of CN X?
It provides sensory innervation to the larynx above the vocal folds. When damaged, the patient cannot feel material entering the airway so no cough reflex fires. Vocal fold movement is intact because that is RLN-mediated, and tongue/facial function involves CN XII and VII which are unaffected.
A patient with Myasthenia Gravis eats fine at breakfast but aspirates repeatedly at dinner and morning FEES looks essentially normal.
How do you explain this and how does it change your clinical approach?
MG attacks acetylcholine receptors at the neuromuscular junction. With repeated muscle use throughout the day, available receptors become depleted and neuromuscular transmission fails progressively. Early in the day after rest, enough receptors are functional but by dinner, cumulative use has exhausted them and the swallow breaks down.
Schedule instrumental assessment later in the day or after a period of oral intake to capture the deficit, a morning FEES misses the problem entirely. Plan rest breaks during meals and coordinate assessment and treatment timing around acetylcholinesterase inhibitor medications.
A patient post-cardiac surgery has suspected RLN injury. Before presenting any food or liquid, what specific FEES observation gives you critical diagnostic information that VFSS cannot provide?
Direct visualization of vocal fold movement during phonation. Ask the patient to say "ahh" and observe whether both folds adduct symmetrically.
A paralyzed or paretic fold will be visibly bowed, immobile, or sitting in a paramedian/lateral position. VFSS cannot show real-time vocal fold movement in isolation before the swallow.
A patient status post total laryngectomy is reporting difficulty swallowing 3 months post-op.
Name three reasons dysphagia can still occur and what your assessment would prioritize.
(1) cricopharyngeal dysfunction or UES spasm — CP muscle can be hypertonic or uncoordinated after larynx removal creating functional obstruction
(2) stricture or stenosis — scar tissue at the pharyngoesophageal segment post-surgery or post-radiation narrows the lumen physically
(3) pharyngeal weakness — radiation and surgical disruption damage pharyngeal constrictors reducing propulsive force.
Assessment priority: VFSS with esophageal sweep to visualize the pharyngoesophageal segment, assess CP opening, identify stricture, and evaluate pharyngeal constrictor function, since FEES cannot see below the UES and the dysphagia is most likely occurring at or below that level.
Contraindicated maneuver for a patient with COPD, uncontrolled hypertension, and reduced laryngeal vestibule closure needs a maneuver to improve airway protection.
Super-supraglottic swallow is contraindicated, it requires prolonged effortful breath hold creating dangerous intrathoracic pressure increases, causing air trapping in COPD and cardiovascular strain with uncontrolled hypertension.
Use the supraglottic swallow instead — it achieves voluntary vocal fold closure before and during the swallow without the extreme Valsalva-like bearing down effort.