Cranial Nerves
Assessment
Neurological Disorders & Swallowing
Head & Neck Cancer
Respiratory & Iatrogenic Disorder
Treatment
Instrumental Assessment
FOIS
Other Stuff
PA Scale Score
100

Cranial Nerve V, VII, IX, X, XII

nerves involved in the swallow

100

any perceptible change in bodily function that a patient notice

symptom 

100

Cortical, Diffuse neurological deficits 

•Affects behavioral control • Prevalence 60 – 90% •Both oral and pharyngeal deficits
•Recovery of function is good
• Severity is strong predictor of recovery in the next 3-4 months
•High PNA rate

TBI

100

surgery
radiation therapy (RT)
chemotherapy

primary treatment options
100

a vertical incision is made between the second and third tracheal rings so that the tube is below the level of the VF to allow the team to access the lungs for suctioning.

Tracheostomy Tube

100

●Education of case management member, family, and client
●Improving the quality of life
● Special food prep, diet restriction, supervision, posture, and mealtime environment change
●Feeding tubes do not promote quality of life, compassion, or significant benefit to most patients with aphasia

Treatment for Dementia 

100

direct view of upper airway structures, including vocal cords
done at bedside
can see in all directions while scoping
immediate results: can patient eat safely or not?
easy to repeat often
no exposure to radiation

FEES Strengths 

100

total oral diet with multiple consistencies but requiring special preparation/compensation

Level 5

100

(1) Thicken liquids result in less aspiration among patients (2) thicker liquids have a physiologic effect on swallow mechanism (3) delay onset of swallowing and impaired oral control of thin liquids

Why do we thicken liquids 

100

Contrast enter the airway, contacts the VFs, and is not ejected from the airway

Score 5

200

If damaged loss of sensation, inability to move mandible (lower jaw)

damage Trigeminal Nerve (5) 

200

malnutrition, failure to thrive, fatigue, aspiration, death

symptoms

200

Oral stage
- Lingual Tremors    
- Repetitive tongue pumping

Pharyngeal stage  
- Vallecular retention    
- Aspiration
Sensory Deficits    
Pharyngoesophageal segment dysfunction

Parkinson 

200

removal of <50% of stricture the patient will not have permanent significant swallowing problems

50% rule

200

a short-term - long plastic, flexible tubes that are inserted through the mouth, through the vocal folds, and into the trachea to aid the patient in respiratory distress. Designed to be connected to a respirator to help the patient breathe

ET

200

Throat clear, chin tuck, head turn, head tilt found effective at reducing penetration and/or aspiration in 79% of ALS patients

-Other strategies: liquid wash, double swallow, effortful swallow

Longer mealtime duration- Take smaller, more frequent meals throughout the day, add high-calorie snacks

Difficulty chewing- moisten foods with gravies and/or sauces, smaller bite sizes, downgrade to a softer consistency

Treatment/management for ALS 

200

exposure to radiation (minimal)
patient size may be an issue
transport to radiology
cost (more expensive than FEES)
barium (taste)
secretion management (hard to see)
interrater reliability
variability clinician to clinician
patient medical status may be an issue

MBS Weaknesses

200

FOIS

Functional Oral Intake Scale

200

IDDSI

International Dysphagia Diet Standardization Initiative

200

Constrast enters the airway, remains above, the VFs, and it not ejected from the airway (is seen in airway after swallow) 

Score 3

300

Controls sensation of the larynx, base/back of tongue, pharynx, palate, and muscles 

Vagus nerve (10) 

300

what is objective, measured, or observed;

dysphonia, dysarthria, abnormal gag reflex, cough after the swallow

signs

300

●Unexplained weight loss
●Oral-stage dysfunction (oral prep and oral phase)
●Pharyngeal-stage dysfunction (slowed or delayed) 
●Major and minor aspiration
●Feeding limitations

Dementia 

300

swelling of mouth, throat, difficulty breathing, difficulty with mastication, difficulty with swallowing, facial disfigurement, numbness face, neck, throat, decreased mobility in the neck and/or shoulders, decreased function of the thyroid

side effects of surgery 

300

has holes in tubing

Fenestrated

300

Effortful swallow- increased base of tongue retraction,
reduced pharyngeal residue

Chin tuck- improved airway protection, reduced penetration aspiration

Expiratory muscle strength training- forcefully exhaling into a small portable handheld device set to a specific resistance level. -improves cough and airway protection

-taking smaller meals throughout the day to help with fatigue, adding supplemental nutrition Ensure/Boost

Lee Silverman Voice Treatment

Treatment for Parkinson 

300

Pt cooperation for scoping procedure
facial trauma, difficult airway
whiteout at exact moment swallow occurs
must rely on pre and post swallow info to speculate why dysphagia present (cannot see pharyngeal function)
safety issues: vasovagal response (fainting)
complications (blood)

FEES Weaknesses 

300

tube dependant with minimal attempts of food/liquid

Level 2

300

For: reduced laryngeal elevation plus reduced UES opening plus timing How: Swallow normal, feel larynx lift to height of swallow; push tongue forcefully against roof of the mouth, feel and hold larynx up after it lifts, finish swallow (longer elevation of larynx normalizes timing of pharyngeal swallow)

mendelsohn maneuver 

300

Constrast enters the airway, remains above the VFs, and is ejected from the airway (not seen in the airway at the end of the swallow) 

Score 2

400

Transmits sensation to the tongue, pharynx and soft palate provides a sensation of taste to back 1/3 of tongue, related to dry mouth

What is glossopharyngeal nerve (9) 
400

Interview/medical chart, oral mech exam/physical inspection, the trial of food/liquids, subjective with valid measures

Components of CBSE

400

reduced ability to initiate a saliva swallow delayed triggering of pharyngeal swallow, incoordination of oral movement, increased pharyngeal transit time, reduced pharyngeal constriction, aspiration, impairment lower esophageal sphincter relaxation

*HINT: these happen after what occurs 

AFTER a hemisphere stroke

400

acute toxicity, late effects, late toxicity, mucositis (painful), Xerostomia (dry mouth), sensory change (taste/smell), fibrosis (tight), trismus (hard to open), neuropathy, stricture (narrowing), loss of appetite, edema, fungal infection, dental change

Side effects of RT 

400

solid tubing without cuff

Non Fenesrated

400

short term, adjust not change, maintain status quo

compensation 

400

gold standard

-evaluating effectiveness of swallowing postures/maneuvers
-view of oral, pharyngeal, upper esophageal phase
-evaluates the integrity of airway protection before, during, and after the swallow
-best at detecting micro-aspiration (laryngeal closure)
best at determining why a patient is having dysphagia

MBS Strengths 

400

total oral diet with multiple consistencies without special preparation, but with specific food limitations

Level 6

400

For: Reduced BOT retraction and pressure in pharyngeal phase, anterior/superior hypolarnygeal movement Food residue in valleculae How: Swallow hard w tongue pushed up on roof of mouth increases BOT movement to clear bolus from valleculae

Effortful swallow

400

Contrast enters the airway, crosses the plane of the VFs, and is not ejected from the airway 

Score 6 

500

If damaged paralysis of facial muscles. Poor lip strength. Dry mouth. No taste from 2/3 of tongue 

Facial nerve (7) 

500

To define the potential cause, to establish a working hypothesis to define the disorder, to develop a tentative tx plan, to develop a potential list of ?’s for further study, to establish the readiness of the patient to cooperate with any further testing.

Reasons to complete a bedside swallow

500

Oral Stage: Leakage, mastication, bolus formation, bolus transport, residual pooling

Pharyngeal State: nasopharyngeal regurgitation, valleculae pooling, piriform sinus pooling, airway spillage, ineffective airway clearance, shortness of breath 

oropharyngeal swallowing deficits ALS

500

air cannot get to VF aspiration is less likely

cuff inflated 

500

safety (aspiration)
adequate (nutrition)
expand (consistencies)
prevent
socialization
QOL
recurrence (cancer)
limit functional deterioration
facilitate recovery

objectives of treatment 

500

standardized barium (contrast)

thin (mix with water)
nectar
honey
pudding
cracker (use pudding past)

500

total oral diet with single consistency

Level 4

500

No contrast enters the airway 

Score 1

600

If damaged inability to position food for chewing resulting in food getting pocketed in cheeks

damage to hypoglossal nerve (12) 

600

drooling, wet vocal quality, weight loss, abnormal cough 

signs and symptoms

600

allows more air leakage around trach, may get some voicing, decreased airway protection          

cuff deflated 

600
  • long-term, make a functional change, improve function y applying technique

Rehabilitation

600

nothing by mouth

Level 1

600

Contrast enters the airway crosses the plane of the VFs, is not ejected from the airway and there is no response to apsiration. 

Score 8 

700

Barnes Jewish Hospital Stroke Dysphagia Screen
Modified Mann Assessment of Swallowing Ability (MMASA)
Toronto Bedside Swallowing Screening Test (TOR-BSST)
Emergency Physician Swallowing Screening (not us)
Water Test

screenings to detect aspiration

700

swallowing postures compensatory strategies

  • Head back
  • Chin down
  • Head rotation
  • Head tilt
700

normal no restrictions

Level 7

700

Contrast enters the airway, crosses the plane of the VFs, and is not ejected from the airway despite the effort

Score 7 

800

Swallowing maneuvers compensatory strategies 

1.Supraglottic Swallow 

2.Super-supraglottic Swallow 

3.Effortful Swallow 

4.Mendelsohn Maneuver 

5.Tongue Hold Maneuver 

800

Aspiration occurs 

6, 7, 8

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