Cranial Nerve/Oral Mech
Exam: What Every SLP Needs
to Know
Kelly Dailey Hall, Ph.D. CCC/SLP
Pediatric Speech & Language Services, Inc.
University of North Carolina Greensboro
kdhall2@uncg.edu
What’s in a name?
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Oral Mechanism Exam
Oral Motor Exam
Oral Peripheral Exam
Speech Mechanism exam
Why We Do The Things We Do
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SLPs should ALWAYS look inside the mouth
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Stroke
Language Delay
Articulation Disorder
Feeding/swallow
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We’ve studied the head/neck indepth (not the whole
body)
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Longer look
Look for more things
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Myasthenia Gravis
Undiagnosed cleft
Tumor
Shortened frenulum
VPI
Medical conditions
Thyroid disease
Purpose of the Oral Mechanism
Examination
• Determine the structural and functional
adequacy of the oral mechanism for speech.
• Should be routine part of every speech/language
evaluation, regardless of client’s particular
communication disorder
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findings may help shape theory of etiology,
diagnosis and prognosis for change, direction for
treatment.
May save someone’s life
Tools
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gloves
Tongue depressor
Pen light
Small hand held mirror
Stop watch
Other tools: Cotton gauze, Sucker
Make a game (where’s the mouse)
What stuctures do we look at?
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Teeth
Tongue
Jaw (mandible)
Tonsils
Hard/soft palate
cheeks
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Face (symmetry)
Neck
Ears
Nose
Skin
Any facial deviancies
that my contribute to
speech/hearing/swallow
ing disorders
What CNs do we screen?
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CN V (trigeminal)
CN VII (facial)
CN VIII (acoustic)
CN IX (glossopharyngeal)
CN X (vagus
CN XI (spinal accessory)
CN XII (hypoglossal)
You can have disorders of structure/function
or both
Or have none
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When structure or function is impaired, we
refer the pt back to the physician
Speech therapy continues or is put on hold
Team approach
SLP often forgo them because they don’t
think it’s necessary
It is!
Fast, easy to do
NO eval is complete without one
You are the ONLY one that really takes time
to look inside/outside the mouth and the CNS
system
Cranial Nerve Review
CN V
Trigeminal
Sensory/Motor
– sensory to
the face and
motor to the
muscles of
mastication
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Sensory nerve branches
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Ophthalmic: forehead, eyes, nose
Maxillary: upper lip, maxilla, maxillary sinus,
upper teeth, cheeks, palate
Mandibular: mandible, lower lip, a portion of the
external ear, the first 2/3 of the tongue, the bottom
set of teeth
CN VII Facial (Finn)
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Sensory/motor –
face
Muscles of facial
expression
Taste sensation
from anterior 2/3 of
tongue
Bell’s Palsy
http://www.webmd.com/hw/health_guide_atoz/zm2734.asp
Effects on Communication
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Facial muscle weakness
Facial expressions
Production of speech
-Bilabials
-Labiodental
-Vowels
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Stapedius Muscle
-Hyperacusis
CN VIII Acoustic
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Sensory –
hearing/balance
CN IX Glossopharyngeal
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Sensory: taste and general sensation to the
posterior 1/3 of tongue
Motor: laryngeal elevation, pharyngeal
constriction
Communication/swallowing
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Elevates and dilates pharynx
Regulation of saliva
Saliva:
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Underproduction
Overproduction
Saliva necessary
CN X Vagus
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Sensory/Motor –
larynx
3 branches
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Pharyngeal
Superior
recurrent
CN XI Spinal Accessory
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Motor –
larynx/pharynx,
Sternocleidomastoid
shrugging
CN XII Hypoglossal
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Motor and Sensory
Innervates all
intrinsic and
extrinsic muscles
Receives taste and
tactile info
Facilitates speech
Allows for precise
articulation
CN Screening
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CN V Trigeminal
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Sensory: swipe quadrants
Motor: clench teeth-palpate masseter, temporalis
Open-close mouth: symmetry, ROM
Mandible side-side
Open mouth-don’t let me shut (strength)
CN VII Facial
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Sensory: taste
Motor:
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Observe face at rest (symmetry)
look at ceiling-symmetry of wrinkles; don’t let me
open your eyes
Smile-symmetry
Puff cheeks-don’t let me push in
Frogs neck
CN VIII Acoustic
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Observe balance during walking
Brush fingers
IX/X glossopharyngeal/vagus
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Motor
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Dry swallow
/a/ prolonged-look for symmetry of pharyngeal mvt
Deviated uvula?
Voice quality
Gag—no way!
XI spinal accessory
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Motor
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Shrug shoulders against resistance
Look left/right-palpate SCM
XII hypoglossal
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Motor
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Tongue protruded (no lip assistance)
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Side-to-side
Lateral resistance to tongue depressor
Don’t let me push it in
Tip elevation without jaw assistance
Back elevation (ka ka or ga ga)
Look for fasciculations, tremors
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Look for migration
Apraxia
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"apraxia of speech is an articulation disorder
that results from impairment due to brain
damage, of the capacity to order the
positioning of speech musculature and the
sequencing of muscle movements for
volitional production of phonemes and
sequences of phonemes; but it is not
accompanied by significant weakness,
slowness, or incoordination of these same
muscles in reflex and automatic acts
(Chapey, 1986, p.422)
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1. Inconsistent Errors: Repetitions,
Substitutions, Simplifications, Distortions
Additions, Deletions
2. Articulatory Breakdowns Increase With:
Word Complexity, Word Length
3. Well rehearsed utterances better than
spontaneous utterances
4. Struggling behaviors to self correct
articulatory errors
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Dysarthria
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Term for a collection of motor speech
disorders due to impairment originating in the
central or peripheral nervous
system. Respiration, articulation, phonation,
resonation, and/or prosody may be affected
Ataxic Dysarthria
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Damage of bilateral or unilateral cerebellar
hemispheric lesions or damage to the
cerebellar outflow tracts produce
discoordination and dysmetria in the oral
speech musculature as well as the muscles
of the axial and appendicular skeleton.
Speech Characteristics: Consonant
imprecision, omissions, and distortions
particularly at word, phrase, and sentence
endings. Speech has an intoxicated quality.
Unilateral Upper Motor Neuron
(UUMN) Dysarthria
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Damage resulting from a focal, unilateral
corticobulbar tract lesion.
Speech Characteristics: Imprecise
consonants, decreased loudness, limited
pitch range, low pitch, short phrases and slow
rate.
Spastic Dysarthria
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Damage resulting from bilateral corticibulbar
tract lesion, bihemispheric disease along with
involvement of periventricular white matter
and
internal capsules.
Speech Characteristics: Imprecise
articulation, slow diadochokinesis, variable
hypernasality, nasal emissions, strainstrangled phonation, frequent lapses of
laughing or crying, decreased rate, and
reduced breath support
Hypokinetic Dysarthria
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Damage caused by unilateral or bilateral
lesions of the substantia nigra or its
projections. Characteristic of Parkinson's
Disease
Speech Characteristics: Decreased
loudness, reduced pitch inflections, and
breathy-harsh voice. Variable articulatory
precision and rapid diadochokinesis,
decreased loudness, silent intervals or
inappropriate pausing followed by short
rushes of rapid speech.
Hyperkinetic Dysarathria
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Results from a lesion in the basal ganglia or
biochemical imbalance.
Speech Characteristics: Imprecise
articulation, irregular diadochokinesis,
inappropriate
prolongations of sounds, inappropriate
silences between and among words, variable
or
fast rate, vocal harshness, reduced pitch and
loudness variations, phonatory arrest, and
tremor. When there is velopharyngeal and
Flaccid Dysarthria
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Damage caused by neuropathy (e.g.,
progressive bulbar palsy, infarct, trauma),
myoneuropathy (e.g., myastenia gravis,
Eaton-Lambert syndrome), or myopathy (e.g.,
myotonis dystrophy, polymyositis).
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Speech Characteristics: Severity and extent
of speech involvement depends on the
number of and degree to which the cranial
nerves/ muscles and spinal nerves/muscles
are involved.
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Bilateral IX and X nerve lesions - continuous
hypernasality and nasal emission due to velopharyngeal
involvement; hoarse, gurgly voice, weak or absent
cough, dysphonia, decreased loudness and unstable
pitch, short phrases, reduced stress, decreased
respiratory support for speech, inspiratory and/or
expiratory stridor.
V, VII, and XII nerve lesions - imprecise,
slow-labored articulation, reduced
diadochokinesis.
Mixed
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Amyotrophic Lateral Schlerosis
flaccid-spastic
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Multiple Sclerosis
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Wilson's Disease ataxic-spastic and hypokinetic
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Progressive Supranuclear Palsy spastichypokinetic-ataxic and flaccid
spastic-ataxic