JCPSLP Vol 22 No 2 2020

Table 1. Cranial nerve examination

Cranial nerve

Method used to examine function

Outcome

Trigeminal CN V

Jaw opening/closing, jaw lateralisation. Sensation to face. Close eyes, wrinkle brows, smile, pout, puff cheeks with air.

Reduced range of movement with adequate strength. Nil changes in sensation. Mild facial weakness (left lower quadrant), adequate lip seal.

Facial CN VII

Glossopharyngeal & vagus CN IX/X

Volitional and reflexive cough. Observation of palate.

Weak cough, aphonic, palate mobile.

Hypoglossal CN XII

Lingual movement.

Reduced strength and range of lingual movement.

Table 2. MBSImp analysis of VFSS procedure

MBSImp component

Physiological dysfunction (clinical framework)

Functional impact

4. Bolus transport/lingual motion

Mildly reduced tongue control and strength

Mildly increased anterior-posterior transfer. Tongue pumping. Mild premature spillage into the pharynx.

6. Initiation of pharyngeal swallow 8. Laryngeal elevation 9. Anterior hyoid excursion

Delayed initiation of swallow (more delayed with thin fluids)

Thin fluids filling the pyriform fossae prior to swallow initiation. Coating of residue on the aryepiglottic folds during and post swallow on all consistencies trialled. Aspiration on one occasion with thin fluids as the pyriform fossae residue over spilled into the airway. This in conjunction with poor airway protection secondary to reduced epiglottic deflection elicited a weak, spontaneous cough. This cough was ineffective in clearing the airway. Coating of residue on the aryepiglottic folds during and post swallow on all consistencies trialled. Aspiration on one occasion with thin fluids as the pyriform fossae residue over spilled into the airway. This in conjunction with poor airway protection secondary to reduced epiglottic deflection elicited a weak, spontaneous cough. This cough was ineffective in clearing the airway.

Effortful and reduced anterior hyoid movement

10. Epiglottic movement

Reduced epiglottic deflection

13. Pharyngeal contraction

Reduced strength of pharyngeal contraction

Valleculae residue on all consistencies trialled. Pyriform fossae residue with thin fluids.

15. Tongue base retraction

Mild base of tongue residue with puree

Mildly reduced base of tongue to posterior pharyngeal wall contact (especially with increased fatigue)

Jack not only was impacted at the body function and structure level, but also experienced impacts to his activities and participation, relating to his changed communication interactions with his wife, and friends, and requiring pen and paper to communicate his needs. Dysphagia To initially assess dysphagia, Jack underwent a clinical bedside examination (CBE). CBE involves a detailed case history about the course and nature of the swallowing dysfunction, an examination of cranial nerve function, and trials of various food and fluid textures (Wertz, Rosenvek, McCullough & Dinneen, 1999). Results of his cranial nerve examination are reported in Table 1 and revealed generalised reduction of range and strength. To further examine the cause and nature of his dysphagia, Jack underwent a videofluoroscopic swallow

study (VFSS) on 7 May 2015. The VFSS was conducted at the metropolitan hospital with two VFSS trained speech-language pathologists and a radiographer. Both lateral and anterior-posterior views were obtained. Jack sat independently in a chair throughout the assessment. He was independent with self-feeding throughout. Thin, mildly thick, moderately thick, extremely thick fluids and puree food were prepared with radiopaque barium as per standard practice and trialled. The VFSS was analysed in three ways: (a) subjectively as per local process detailing the oral and pharyngeal phases of the swallow; (b) objectively using the modified barium swallow impairment profile (MBSImP) by a registered MBSImp clinician (Martin- Harris et al., 2008); and (c) penetration/aspiration events were rated using the penetration aspiration scale (PAS; Rosenbek, Robbins, Roecker, Coyle, & Wood, 1996).

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JCPSLP Volume 22, Number 2 2020

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