• Inspection for nasal deformity
• Nostrils: discharge, polyps

• Place a metal tongue depressor underneath the nostrils (lengthways)
• The condensation of expired air on the metal tongue depressor can been seen
• The areas of condensation of the two sides can be compared

More detailed Ix: endoscope, sinus puncture

Nasal endoscope

• To see further inside nasal cavity
• See uncinate process - outlining middle meatus
• Bulla ethmoidalis
• If remove uncinate process surgically, can see maxillary sinus with perforation
• If previous maxillary sinusitis with perforation, may have accessory maxillary sinus opening (at posterior part of middle meatus)

• If go further in with nasal endoscope
• Eustachian tube opening on lateral wall
• Fossa of Rosenmuller behind Eustachian tube
• Difficult to see with post-nasal mirror - therefore nasal endoscope more accurate

Non-infective allergic rhinitis: no airspace, paler mucosa

Polyps: pale oedematous bags

Inverted papilloma: fleshy, less transparent, benign tumour (with malignant potential)

Inspection of oral cavity

• Headlight is better than a torch, both hands are free with the headlight
• 2 tongue depressors are better than 1
• Each part of the oral cavity is inspected systematically (discoloration, mass - features)
• Look at the submandibular duct opening at the floor of mouth (either side of frenulum, can see course on floor of mouth) and parotid duct opening at the buccal mucosa opposite the upper molar teeth (slightly raised area)
• Mobility of the tongue is evaluated by asking the patient to protrude the tongue
• The throat is inspected by asking the patient to say "ah"
• Also check facial nerve + LN (branches (1) Temporal - Frontalis (2) Zygomatic - orbicularis oculi (3) Buccal - zygomaticus (4) Mandibular - orbicularis oris (5) Cervical - platysmus

• Palpate the oral cavity to evaluate the consistence, depth, mobility and extent of involvement of a lesion
• Palpate parotid duct: clench teeth (tense masseter), below and lateral to cheekbone

1. Oral cavity: mastication, bolus formation and propulsion
2. Pharynx: bolus transit
3. Larynx: airway protection
4. Oesophagus: bolus propulsion to stomach

1. Oral Preparatory Phase:

• Prior to the voluntary phase of swallow
• Bolus pulled together to form a cohesive mass; bolus held between anterior tongue and hard palate
• Probs: don't know food approaching, cannot open mouth to receive food

• Stripping action of the tongue, squeezing the bolus posteriorly against hard palate
• Voluntary stage of the swallow; takes < 1 second to complete

• Triggering of swallowing reflex when bolus passes the anterior faucial arch
• Elevation and retraction of the velum (soft palate) - stops food from entering nasal cavity
• Initiation of pharyngeal peristalsis
• Elevation of the larynx (epiglottis everts downwards) and closure of the vocal fold - closure of airway
• Relaxation of the cricopharyngeal sphincter
• Takes < 1 second to complete

• Transit of bolus from CP sphincter to stomach
• Takes 8 - 20 seconds to complete (depends on type of food - eg. Liquid faster, solid slower)

• Difficulty in swallowing and drinking as a result of anatomical abnormalities or changes, or neurological impairment
• Life threatening as a result of malnutrition, dehydration and aspiration pneumonia (esp. elderly)
• Dysphasia vs. feeding disorder: dysphagia = swallowing disorder, may have no difficulty feeding himself; feeding disorder = poor hand-eye co-ordination

• Dribbling/ accumulation of saliva
• Needs for frequent suctioning
• Respiratory distress/ SOB
• Poor appetite/ wt loss
• Wet/ gurgly voice
• Significant facial droop with drink/ food coming out from mouth (esp. CVA Pt)
• Liquid coming out from nares (eg. NPC - problem elevating soft palate, food/ liquid moves up above level of soft palate)
• Choking or persistent coughing
• Painful swallow/ food lodged in the throat (problem with oesophageal phase)
• Hold food in mouth/ spit food out (eg. Demented Pt cannot tell you what is wrong, but hold food in mouth)

• Stroke
• Neuro diseases: PD, MG, dementia
• Head injury/ brain tumour (esp. those requiring surgery)
• Congenital oromaxillofacial abnormalities (eg. Cleft palate - cannot form airtight seal between teat and mouth)
• Oral cancer (eg. Ca maxilla - resect maxilla - food enters nasal cavity; ca tongue resection - food remains in mouth because no bulk, cannot move from front to back of mouth)
• NPC (1) Poor function of soft palate, also may have vocal cord palsy - cannot protect aw properly (2) After radiotherapy, severe fibrosis of neck muscles, may not be able to elevate larynx on swallowing (3) Cricopharyngeal sphincter may not be able to relax, therefore food cannot enter oeso)
• Premature babies: prematurity of oral musculature
• Cerebral palsy: inappropriate m movt (XS spasticity/ flaccid)
• Babies born with different syndromes - eg. Pierre Robin syndrome (micrognathia with cleft palate, glossoptosis and absent gag reflex)

• Aka modified barium swallow
• Done with X-ray (some radiation)
• Assess both structural and functional aspects of swallowing (any diverticulum, growth - eg. Tumour larynx so big that is presses against oesophagus)
• Examine movement patterns of different organs of swallow, from oral to upper oesophageal areas
• Examine bolus transit
• Examine presence of aspiration (silent/ non-silent) and amount/ severity of bolus aspirated [silent aspiration: cannot be detected at bedside (1) Penetration: above level of vocal cord (2) Aspiration: beyond level of vocal cord]

• Examine part of the pharyngeal phase of swallow
• The acute swallow cannot be examined - soft palate elevates and blocks view of endoscope
• Testing on sensation
• Invasive
• No irradiation

• Examine the oral stage of swallow (paeds usually have problems with oral phase)
• Mainly used with paediatrics
• Non-invasive
• No irradiation

• Examine the pattern of peristaltic pressure waves during deglutition
• Examine mainly the pharyngeal and oesophageal phases of swallow

• Examine the activity of oral musculature during deglutition
• Used as biofeedback (surface EMG) for training swallow manoeuvre

MEDICAL HISTORY

1. Case history - medical Dx, medical Hx, Hx of aspiration pneumonia (eg. Ca tongue different from CVA)

MEDICAL STATUS

2. Medical condition & respiratory status (additional oxygen?)
3. Nutritional status (severely dehydrated/ malnourished mean difficulty taking in food)
4. Alertness/ consciousness (cannot feed Pt when not conscious)

OROMOTOR EXAMINATION

5. Oromotor examination
6. Labial, lingual and palatal control and function

LARYNGEAL FUNCTION EXAMINATION

7. Laryngeal function examination - voice quality, breathing-phonation co-ordination, voluntary + reflexive cough (adequate strength, delayed/ immediate, protective mechanism)
8. Oral feeding trial (if suitable): different amount, consistency/ texture, posture, utensil, temperature, taste, etc

• Texture: eg. Ca tongue: cannot form bolus, therefore liquids better cf. CVA will have less control therefore more likely to choke with liquids
• Posture: eg. Ca tongue benefit from tilting head back (use gravity to move bolus from front to back of mouth); some pt's need their heads flexed forward
• Utensils: eg. Spoon, cup, glossectomy spoon, syringe, babies (teats, bottles)
• Temperature: may have sensory loss, therefore respond better to some temperatures

1. Phonation: use vocal cords to produce sound
2. Resonation: nasal and oral cavity as resonating cavities (nasal: soft palate relaxed - "mmm"; oral "aah" soft palate raised)
3. Articulation: tongue, lips, teeth movt

1. Voice disorders
2. Resonance disorders - eg. Cannot make nasal sound, NPC cannot produce oral sound because soft palate not functioning properly (speech hypernasal)
3. Articulation disorders - eg. "Jo/ sun_" as "do/ dun_" due to faulty learning (NOT tongue-tied/ short frenulum, very rare)
4. Fluency disorders - eg. Stuttering (some secondary behaviour - body movt, fluttering eyes)

• Computerised Speech Lab
• Visipitch:
• Aerophone: aerodynamics during speech - eg. supraglottic pressure, maximal airflow rate
• Larngography: graphic display of vocal cord movt by introducing 2 electrodes across vocal cords (when adducts, current passes through)
• Spectography: energy during voice production

• Use ears to listen to voice quality
• Voice assessment profiles: eg. Hoarseness, huskiness, whispering (vocal cord nodules), vocal cord palsy (breathiness)
• Functional assessment: "aah" in one breath should be male > 20 seconds (female > 15 seconds), max number of syllables per breath (vocal cord palsy: cannot use expiratory air successfully, so may only have 1 syllable per breath), normal 20-30 per breath

• Nasometer (1) Nasal to oral resonance ratio (2) Waveform display with statistical analysis (3) Used as Tx tool as well (visual feedback for Pt)

• See-scape
• Foggy mirror

• Electropalatography (EPG) for assessing tongue placement

• Articulation
• Cantonese Segmental Phonology test

• Professional voice user - eg. Teacher, singer, actress
• Vocal abusers - eg. Housewives, children
• Laryngectomee (if total, tracheoesophageal speech, pneumatic device, etc)
• Pt's following thyroidectomy - during operation, recurrent laryngeal n damaged
• Pt's following stroke - weakness in one side of body, vocal cords on that side affected
• Tracheostomised Pt's - when tube there, voice cannot be produced (1) Cuffed: mechanical ventilation, air-tight seal, balloon around tube, cannot produce voice (no air passes through vocal cords) (2) Uncuffed: space between tube and trachea, when Pt occludes tracheotomy tube, can still produce voice

• Pt with cleft palate (repair before age 1 - start to speak at age 1 yo; may have VPI - velopalateal incompetence, resulting in hypernasality)
• Patients with NPC: soft palate not moving therefore no oral sounds (hypernasality)
• Glossectomised Pt's (large space in oral cavity, oral sounds are very hollow)
• Pt's with large adenoid (usu. children, blocks way to nasal cavity, has hyponasality, usu. temporal problem (pharynx enlarges as child ages) or resolved by surgical means

• Children with developmental delay/ speech delay
• Pt with MR
• Pt with cleft lip/ palate - may have developed inappropriate tongue movements, which remain after remain of cleft palate
• NPC
• Stroke/ Neuro deficit