Course Alert-Cranial Nerves and Sensory Treatment

cranial nerves

I have always loved SpeechPathology.com.  I love the fact that it costs me very little for UNLIMITED CEUs!!!  What could be better?

I was extremely excited when they asked me to do not 1 but 2 webinars!!  The first is on Cranial Nerves and the second is Sensory Treatment options.

I’d love if you would check these out!

Cranial Nerves and Dysphagia:  Making the Connection

A Sensory Approach to Dysphagia Treatment:  After the Cranial Nerve Exam

The Swallow in Detail

The Swallow in Detail

 

Taken from: *Dysphagia Foundation, Theory and Practice by Julie Cicheroand Bruce Murdoch*

 

Hunger

Smell of food, empty stomach or electrolyte imbalance informs hypothalamus of the need to eat.

Brainstemactivates nucleii of CN VII and IX to promote secretion of salivary gland juices to prep for bolus

 

Chewing 

Bolus in mouth.  CN VII ensures good lip seal (orbicularisoris) while CN V relays sensory info to brainstem to constantly modify the fine motor control of bolus prep.

Motor activity to CN V, VII, IX, X, XII to create an enclosed environment within the mouth to prepare the bolus.

Cheeksprovide tone (buccinator CN VII).

Soft palate tense and drawn down towards tongue (tensor velipalatini CN V and palatopharyngeusCN IX)

Tongue is drawn up towards the soft palate (palatopharyngeusCN X, styloglossus CN XII).

Hyoidbone is stabilized (infrahyoid muscles CN XII and C1-C3) to allow movement of the mandible).

Bolus prepared by closing (temporalis, masseter, meial pterygoid,lateral pterygoid, CNV) and opening (mylohyoid and anterior belly of digastric CNV, geniohyoid CNXII &C1-C3.)

Bolus pushed around the mouth by actions of the tongue to create a consistent, homogenous texture (hypoglossus, genioglossus,styloglossus and 4 groups of intrinsic muscles of the tongue CN XII). Taste sensations (CN VII and IX) provide info to cortex to stimulate areas of brain required to coordinate the swallow (insulaand cingulatecortex).

 

Voluntary initiation

Once bolus is adequately prepared.

Soft palate elevates slightly (levator veli palatini and palatopharyngeusCN X).

Slight elevation of hyoid bone (suprahyoid muscles contracting on rigid mandible with slight relaxation of infrahyoid muscles.

Pharyngeal tube is elevated (stylopharyngeus CN IX, palatopharyngeusand salpingopharyngeus CN X).

Tongue delivers bolus to force bolus distally towards posterior wall of the pharynx in a “piston-like” manner using hard palate for resistance. Sensation by CN XI and by CN X (pharyngeal plexus).

 

Larngeal elevation

1st motion for tongue to propel bolus into oropharynx is elevated anterior direction toward roof of mouth (mylohyoid and anterior belly of digastric, CNV; stylohyoid and posterior belly of digastric CNVII; palatoplossusCN X; genioglossus, hyoglossus and styloglossusCN XII; geniohyoid CN XII and C1-C3) affects hyoid elevation in an anterior direction.

Soft palate seals off nasopharynx.

Superior constrictors begin medialization of the lateral walls.

Larynx elevated and moved anteriorly in relation to hyoid bone by thyrohyoid CNX.

 

Laryngeal closure

During laryngeal elevation-vestibule closes and rises relative to thyroid cartilage (cricothyroid and intrinsic laryngeal muscles CN X).

Opposition and elevation of arytenoid cartilages provide “medial curtains” of pyriform recesses (aryeppiglottic folds).

Pressure exerted on base of epiglottis causing it to tip and cover the laryngeal vestibule.

Medial constrictors (CN X) “strip” the pharynx by medialization following on from superior constrictors.

Palatedescends (palatopharyngeus CN X), constrictors “strip” and tongue moves posteriorly (styloglossus CN XII) to close oropharynx.

Once the bolus has reached pharyngeal areas innervated by the internal branch of the superior laryngeal nerve swallow reflexive and cannot be stopped.

Anterior and elevated movement of larynx allows cricopharyngeus to be stretched (UES) and opened.

Inferior constrictor finishes medialization and bolus in esophagus.

 
 

Resting state

CNX

Cricopharyngeus resumes tonic state.

Glotticopens and larynx lowers.

Ifbolus present should cough.

Tongue and hyoid and palate return to resting position.

**Oral phase for liquid boluses should take 1 second and the pharyngeal phase with all consistencies should take 1 second.**The ability to contain a bolus is prognostic.**The swallow is a positive pressure phenomena where the pressure is always on the tail of the bolus.

 
 

Triggering the pharyngeal swallow response:

 

        The bolus stimulates CN IX, X, XI in the medullary reticular formation

        (nucleus tractus solitarius) (NTS).

 

        Incoporates (NTS) input from V, VII, XII

 

        NTS signals motor nuclei in teh nucleus ambiguus to help fire IX, X,

        XI.

 

        Nucleus ambiguus innervates muscles of the velum, pharynx, larynx,

        and upper esophagus (IX, X, XI) producing the pharyngeal swallow

        response.

 

       Strongest ties to the NTS=anterior faucial arches, posterior tongue at

       the lower edge of the mandible, valleculae, pyriform sinuses and

       laryngeal aditus.

 

       The anterior faucial arches have a strong connection between the

       sensory receptors and NTS via afferent fibers of the glossopharyngeal

       nerve (IX) creating a trigger point for younger adults.  (Swallows in

       older adults may trigger lower.)

Cranial Nerves: App Review

App:  Cranial Nerves:  Pocket Clinical Resource

Price:  $2.99

What it is:  An incredibly simple app to use to learn and look up information on cranial nerves.

System:  iOS (iPhone and iPad)

Version:  1.2.4

Let me start off by saying:  I LOVE THIS APP!

I was referenced to a cranial nerve app which was $60.  I thought to myself there has to be a less expensive version that I can utilize just as easily.

I found the app!

We’re told often to complete a cranial nerve assessment, especially looking at neuro patients including CVA and patients with dysphagia.

Cranial nerves can be daunting and scary.  They don’t have to be!

Along the left side of your iPad (for that version of the app), you have a list of the nerves by roman numeral.  Touch the roman numeral corresponding to the cranial nerve you are trying to find.

You will find a full description of that nerve:  function, nerve tract, integrity tests, symptoms and signs and images.

Yes!  This app will tell you how to test the nerve and symptoms signs if the nerve is not intact.

Sometimes there just is not enough information.  If you are a Google/Wikipedia fan like me, then this app was designed for you.  You might notice at the top of the description of the nerve in the above picture, there is a box icon, a G icon, a globe icon and a picture icon.  If you have internet access, touch the G icon.  Amazingly you will be directed to a Google search of that nerve.  Similarly, touch the globe icon (third from the left) and you will be directed to a Wikipedia search of that nerve.

This app can be used as a learning tool and a quick reference when you just can’t remember what that nerve is for or how to test it!

This is a 5-star app in my book!

Dysphagia Assessment

So many people assess dysphagia in the same manner, at least from my observations. Sit with them while they eat a meal, feel laryngeal elevation and trial diet modifications. I have rarely seen people do a thorough dysphagia bedside evaluation.

 I’m trying to standardize the manner in which I complete my bedside evaluation. I have started using the SOPE, the MASA and the Sage during every assessment, along with a thorough chart review and assessing aspiration risk factors. I can complete a fairly thorough assessment. The SOPE assesses cranial nerves, taste buds and some muscle function. The Sage assesses oral cleanliness and need for oral care. The MASA has been a fairly accurate indicator of dysphagia from my standpoint. I also do the traditional feel for laryngeal elevation, but I also feel for hyoid protraction. I have started assessing with water and graham crackers. If I need to, I will thicken the liquids, but usually wait for an instrumental assessment. I also have started using the 3 ounce water swallow challenge, which has been a good indicator for aspiration from what I have done so far.

 It is important to assess cranial nerves and to understand the cranial nerves. For instance CN XII, the hypoglossal nerve has no sensory pathways, only motor. This definitely affects the means by which you will treat. Another point that has been drilled into my head is that sensory input drives motor output. If you can increase the sensory input a person receives you can increase the amount of output in the muscle functions. Cranial nerve assessment is vital in understanding dysphagia. Sensory input such as olfactory and optical help to prepare the person for the swallow by increasing saliva and telling the body that it is going to masticate and swallow food/drink. Sensory input can also be established through tactile, thermal, or NMES input. In fact, Vitalstim placement 1 has the highest sensory input of all the Vitalstim placements. DPNS is highly driven by sensory input to the cranial nerves through use of frozen lemon swabs, along with thermal, tactile stimulation (TTS).

 You can actually tell a lot about a person by their oral hygiene. You can tell who will qualify for Frazier Water Protocol. Also, by oral hygiene, you can make an assumption that the person is at higher risk for aspiration pneumonia because of the poor hygiene of the oral cavity. It is important to let nursing and nursing staff know how often to complete oral cavity for patients that are unable to complete this task with independence.

 It is vital to assess motoric function. You treat the motor dysfunction, not the symptoms, i.e. aspiration. If you assess a person and can only tell that they are aspirating, but not WHY they are aspirating, you are no better off than you were before the assessment. There are many areas of function that are vital to swallowing, labial closure, lingual to palate contact, bolus management and propulsion (lingual strength), velar elevation, tongue base retraction, pharyngeal sqeeze, hyolaryngeal excursion (laryngeal elevation, hyoid protraction and hyoid thyroid approximation) and UES opening. I am extremely excited about the MBSImP which will be published next year with certification courses to follow!!

 The 3 ounce water swallow challenge is fairly new. It is an indicator of aspiration as it is believed, people that silently aspirate small amounts of liquid will choke with larger volumes. 3 ounces of water is enough to make a person choke, as it is stated per this protocol that silent aspiration is volume dependent. With this challenge, the person is given 3 ounces of water, either by straw or cup sip. They drink the water continuously. Any coughing, throat clearing or inability to drink all 3 ounces at one time is considered a fail. If the person can continuously drink the water and not cough during or for a minute after the challenge, they pass. Those that fail are then assessed instrumentally.

 Watching a person eat is also very critical to the evaluation. One predictor of aspiration is inability to self-feed. Medication can often affect a person’s ability to swallow, affect amount of saliva a person has to help break-down the food orally or affect the person’s alertness.

 A thorough dysphagia exam is vital and necessary for treatment. A good bedside examination with instrumental assessment will aid you in accurate assessment for thorough and appropriate treatment for dysphagia.

Screening and CVA

Our hospital recently became Stroke Certified.  My initial reaction was sheer joy.  How many evaluations would that create for me!?!?!?!

My new reaction is HOW many more evaluations do I have to do on patients  that did not really have a stroke!?!?!?!

In working on Stroke Certification, nursing staff was educated on administration and interpretation of the 3 Ounce Water Swallow Challenge.   Having the nursing staff give the patients 3 ounces of water to swallow was one of the easiest ways to incorporate screening in their assessment.  It is also backed by research.

http://www.ncbi.nlm.nih.gov/pubmed/18058175

http://archneur.jamanetwork.com/article.aspx?articleid=592082

http://link.springer.com/article/10.1007%2Fs00455-007-9127-y

I continue to evaluate ALL stroke patients, per our protocol.

I assess them at bedside with trial consistencies.  Cranial nerves are examined through an oral mech exam.

http://en.wikipedia.org/wiki/Cranial_nerve

http://www.wisc-online.com/Objects/ViewObject.aspx?ID=ap11504

If you have access to ASHA SIG 13 Perspectives, there is an excellent Food for Thought regarding Cranial Nerves by Dr. Giselle Carnaby.

The most important part of a cranial nerve exam is to understand the nerve functions so that you can assess dysfunction during your oral mech examination.

By understanding normal you will be able identify abnormal.

My nursing staff, so far, has responded well to the 3 ounce swallow assessment and we will continue it in our facility.

So, people may wonder what other screening tools are available for dysphagia.

Remember, when looking at these screenings, you want to examine validity and reliability.  Some research terms:

Accuracy:   The amount the test result reflects the true clinical state. If disease is present, a truly accurate test will always give a positive result, whilst if disease is not present, the test will always give a negative result. This is not the case for all tests.

Sensitivity:   Sensitivity is the measure used to report how effective a test is in identifying individuals with a disease. The higher the sensitivity/the proportion of positive results the better.

Specificity:   The measure used to report how effective a test is in identifying individuals without the disease. The higher the specificity/proportion of negative test results the better.

Reliability: Reliability is the degree of consistency of what a test measures i.e. the extent to which a test or any measuring procedure provides the same result on repeated trials. Within the study, reliability is concerned with the consistency of the measurement tool when employed by nurses compared against its use by the SLTR for determining the presence or absence of dysphagia and the appropriateness of referring acute stroke patients to the SLT.

Validity: The extent to which a test accurately measures what it is supposed to measure. Within the research programme, validity is concerned with the measurement tool’s success at detecting the presence or absence of signs of dysphagia and the appropriateness of decisions to refer patients for full clinical dysphagia assessment when used by nurses in a given context with the acute stroke population as measured against the ‘Gold standard (the SLTR’s bedside assessment of swallowing) measure outcomes.

(Information from the Thesis The Design and Evaluation of a Valid Dysphagia Screening Tool for Acute Stroke Patients)

Screening Information

TOR BSST

http://www.ncbi.nlm.nih.gov/pubmed/19074483

http://stroke.ahajournals.org/content/40/2/555.full.pdf?keytype=ref&ijkey=n0zDwfiMa6KDe1P

Massey Bedside Swallowing Screen

http://www.ncbi.nlm.nih.gov/pubmed/12391741

Clinical Assessment of Swallowing and Prediction of Dysphagia Severity

http://ajslp.asha.org/cgi/content/short/6/4/17

Clinical and cognitive predictors of swallowing recovery in stroke

(Information taken from the above link)

Using the following:

Clinical predictors of aspiration risk. Predictor Operational Definition

Dysphonia Voice disturbance in parameters of vocal quality, pitch, or intensity.

Dysphoria Speech disorder resulting from disturbances in muscular control that affect respiration, articulation, phonation, resonance, or prosody.

Abnormal Gag Reflex Absent or weakened velar or pharyngeal wall contraction, unilaterally or bilaterally, in response to tactile stimulation of posterior pharyngeal wall.

Abnormal Volitional Cough Weak, verbalized, or absent response upon command to cough.

Cough After Swallow Cough immediately after or within 1 min of ingestion of calibrated volumes of water (5, 10, and 20 mL in duplicate).

Voice Change After Swallow Alteration in vocal quality after ingestion of calibrated volumes of water.

Score         Classification                                   Description

1                Normal                                                   No airway invasion.

2                Mild                                                      Bolus enters airway                                                                                        with clearing.

3                Moderate                                              Bolus enters airway                                                                                         without clearing.

4    Moderate                                              Bolus contacts vocal                                                                                      cords with airway                                                                                            clearing.

5   Moderate                                              Bolus contacts vocal cords                                                                             without airway clearing.

6  Severe                                                    Bolus enters trachea and is                                                                            cleared into larynx or out                                                                                of airway.

7 Severe                                                   Bolus enters trachea and is not                                                                      cleared despite patient attempts.

8 Severe                                                   Bolus enters trachea and patient                                                                    does not attempt to clear.

Classification                    Description

Normal-Mild                       Range from no laryngeal penetration to                                                        evidence of laryngeal penetration.

Moderate                           Two or less aspiration episodes of one                                                            consistency.

Severe                               More than two aspiration episodes of one                                                     consistency or aspiration of more than one                                                     consistency

50 ml water swallow test and/or pulse oximetry

http://www.ncbi.nlm.nih.gov/pubmed/11213241

Pharyngeal Sensation Assessment, Oromotor Assessment, and 50-ml Water Test

http://www.problemsinanes.com/pt/re/merck/fulltext.00007670-200305000-00035.htm;jsessionid=RGnQDnhy6rW2cTdSQnsdKZj9Fp8TznvgBRhb5ph07wVW9HXrP6LT!1786591821!181195628!8091!-1?nav=reference

Gag Reflex

http://www.ncbi.nlm.nih.gov/pubmed/16172818

30-ml water swallowing test 

http://www.ncbi.nlm.nih.gov/pubmed/16024482

Swallowing Provocation Test

http://www.ncbi.nlm.nih.gov/pubmed/11083358

http://www.thelancet.com/journals/lancet/article/PIIS0140-6736(05)74258-6/fulltext

Standardized Swallowing Assessment (SSA)

http://www.ncbi.nlm.nih.gov/pubmed/11822494

http://www.medscape.com/viewarticle/726565

Timed Test of Swallowing and Questionnaire

http://www.ncbi.nlm.nih.gov/pubmed/10024948

Oxygen Saturation Monitoring

http://ageing.oxfordjournals.org/content/29/6/495.full.pdf

http://www.ncbi.nlm.nih.gov/pubmed/11191240

50ml Drinking Test 

http://www.ncbi.nlm.nih.gov/pubmed/8902426

Resources for screening of swallowing ability and stroke.

The following is a link to a review of different dysphagia screening tools.  Screening Tools

The following is an interesting article for dysphagia s/p stroke.  Dysphagia and Aspiration Post Stroke

History Taking and Physical Exam

Slides regarding dysphagia screenings

Swallow Screening for Stroke Patient Resource Guide

SIG 13 Frequently Asked Questions (FAQ) on Swallowing Screening: Special Emphasis on Patients With Acute Stroke 

Swallow Screen Assessments in Literature

Screening Tests in Evaluating Swallowing Function

The importance of looking at screenings and deciding which is best for you is the responsibility of individual SLPs.  Understanding what to look for in a screen is important.

Do I recommend a diet based on a screening?

Nope.