Face and Jaw muscles:
    Facial Vii and Trigeminal V (jaw)
Is the mouth symmetric?
 Lower face paralysis or weakness
Can the examiner force the lips open?
 Muscle strength, will droop to the weaker side.
Does the face have an expressionless, mask-like appearance?
 Parkinson
When the patient looks up, is there wrinkling on both halves of the forehead?
 Yes, unilateral innervation if just lower face is affected
 No, damage to Vii nerve (facial) where it branches from the brainstem.
Is the patient’s smile symmetric?
 Evidence of weakness or reduced range of motion
Is the patient able to pucker lips
 Muscular strength and ROM of lips
Is the patient able to puff out cheeks and impound air?
 Seal of velum/lips
Does the jaw hang loosely?
 Bilateral damage to trigeminal (V)
Does the jaw deviate to one side when open?
 Unilateral damage to trigeminal (V); deviates to the weaker side
Is he able to move jaw from right to left?
 Bilateral weakness of jaw
Is the patient able to keep the jaw closed while the examiner attempts to open it?
 Examining strength of masseter and temporalis
Is able to keep the jaw open while the examiner attempts to close it?
 Bilateral weakness  of these muscles of the jaw: digastric, mylohyoid and  geniohyoid
Apraxia: groping during any of the above

Tongue:
Hypoglossal (Xii) innervates the intrinsic and extrinsic muscles of the tongue

Does the size of the tongue appear normal at rest?
 Bilateral atrophe- entire tongue affected
 Unilateral damage – atrophy on the same side
Is the tongue symmetrical at rest?
 Same as above
Are fasciculations present when the tongue is at rest?
 Damage to lower motor neurons (hypoglossus Xii)
Does the tongue remain still while at rest?
 Hyperkinetic movements disorders (chorea and dystonia) may cause the tongue to  involuntarily protrude, contract, rotate, and move side to side.
Is the patient able to protrude the tongue completely
 Checking posterior fibers of genioglossus (protrudes the tongue)
 And the vertical and transverse intrinsic muscles (pointing the tongue)
 If bilateral weakness, only protrude a little if any.
 If unilateral tongue will deviate to the affected side because of unequal  contractions of the genioglossus) the unaffected side will cause the tongue to  point to the affected side.
Can the P. keep the tongue tip at midline while the C. pushes the tongue to the left or right?
 Tongue strength (genioglossus, superior longitudinal and inferior longitudinal
Is the patient able to touch the upper lip with the tongue tip?
 ROM of tongue protrusion muscles (genioglossus, vertical and transverse  intrinsic) and the superior longitudinal (lifts the tongue tip)
Can the P. keep the tongue tip pressed against the inside of the cheek as the C. pushes the cheek inward?
 Tongue strength (longitudinal)
Move the tongue side to side?
 ROM for the superior and inferior longitudinal muscles

Velum and pharynx
 Vagus X
Does the velum rise symmetrically for “ah”
 Look at velum and pharynx (moving medially)
 Bilateral – Reduced ROM and speed
 Unilateral- reduced movement on the affected side; uvula will be pulled toward   stronger side.
Is there a pharyngeal gag reflex when the back wall of the pharynx is touched?
 Examining sensory impulse through the glossapharyngeal (IX) to brainstem;
 From the brainstem

Laryngeal Functions:
 Tests strength and ROM of laryngeal adductor and abductor muscles.

Can produce a sharp cough?
 Vocal fold adduction; good subglottic air pressure; Those with weak cough will  have a soft, breathy quality; tests adequacy of respiratory system (forced  exhalation)
Can produce a sharp glottal stop?
 Tests vocal fold adduction. If no to cough but yes to glottal stop—respiratory  rather than weak vf adduction.
Is inhalatory stridor present? Take a quick deep breath.
 If adductor muscle paralysis prevents VF abducted completely—inhalatory stridor; may be bilateral or unilateral damage to vagus.

Phonatory Respiratory System

Take a deep breath and say /a/ as long, steadily, and clearly as you can
 Adequacy of breath support; vf adduction for phonation;
Is there a latency period between the signal to say /a/ and the initiation of phonation?
 Delay-weakness in the phonatory-respiratory system; sequencing difficulties  (apraxia)
Quality pitch and loudness of phonation
 Want steady, even, smooth, and clear
 Hypernasality- inadequate velopharyngeal closure
 Breathiness- incomplete vocal fold adduction
 Harshness- too much adduction
 Diplophonia-usually bec. Of unilateral vf paralysis
 Pitch-
  Low spastic dysarthria and several of hyperkinetic dysarthria
 Tremor-hyperkinetic
 Pitch breaks – flaccid
 Loudness
  Excessive loudness variations- kyperkinetic
  Poor respiratory- reduced loudness/phonation: flaccid and hypokinetic

Resonation
 Problems mostly seen in flaccid, spastic, and hypokinetic
Take a deep breath and say /u/ for as long as you can, use nasal mirror for emissions
 Maximizes velopharyngeal closure.
Alternatingly squeezing nares and not squeezing. Presence of nasality.  You should not  hear a difference in the sound with the alternating squeezing.

Combined system (phonation, respiration, resonation and articulation)
 AMR
 Flaccid and spastic: slow and regular AMR
 Ataxic and hyperkinetic: slow and irregular AMR;
   excessive variations in loudness
 Hypokinetic AMRs rapid, blurring the sounds

 SMR:
 delays in beginning the task, phoneme substitutions, incorrect sequencing of  syllables (APRAXIA)
Stress testing:
 Count 1-100; tests for myasthenia gravis: rapid deterioration of articulation  resonance and phonation; tire

Testing for nonverbal oral apraxia:
 Request the subject to smile, pucker lips, protrude the tongue bite lower lip:  demonstrate groping

Testing for Apraxia of speech:
 Demonstrate numerous sequencing errors; islands of normal speech (automatic  and emotional speech)
 See pg 49 See DuBaul test of Apraxia for adults.

Connected Speech
 Read a standard passage: Grandfather or Rainbow; rate according to pg 51