Speech

Question 1

Where in the brainstem do you find the bulbar nerves?

Answer 1

Medulla (used to be called ‘the bulb of the spine’, hence the name of the nerves)

Question 2

What do you look for when inspecting for the hypoglossal nerve (CN XI)?

Answer 2

Palatial asymmetry and uvula deviation- if present are away from lesion

Question 3

What are you listening for when you assess a patient’s speech in a CN exam?

Answer 3

• Quality
• Volume (hoarseness, quietness)

Question 4

What cranial nerves are responsible for controlling speech and swallow?

Answer 4

The bulbar nerves- CN IX, X, XI and XII (Glossopharyngeal, vagus, accessory and hypoglossal)

Question 5

What is dysphonia?

Answer 5

Impaired production of voice sounds due to impaired ability to produce voice sounds using the vocal organs (mouth, tongue, throat or vocal cords) E.g. hoarse, breathy, harsh, rough

Question 6

What is dysarthria?

Answer 6

• Disorder of speech.
• Impaired articulation due to dysfunction of the muscles needed to produce speech in the tongue, lips, mouth or NM pathway disruption.
• There is no problem in understanding cognitive language.

Question 7

What is dysphasia?

Answer 7

Disorder of language

Question 8

How do you test for dysarthria?

Answer 8

• Repetition of phrases:
  
  • “Yellow lorry”- tests lingual sounds
  • “Baby hippopotamus”- tests labial sounds
  • “The Leith police dismisseth us” - multiple processes
• Count to 30- muscles fatigue in MG

Question 9

How do you test for dysphonia?

Answer 9

Aspects of CNX examination

• Voice: Quiet or bovine
• Cough: “Bovine” (when a patient can’t close their glottis)
• “Say ahhh”: vocal cord tension

Question 10

How do you test for dysphasia?

Answer 10

• “Name 3 objects”: Nominal dysphasia
• 3 stage command: Receptive dysphasia. Avoid visual clues by instructing from behind
• Repeat sentence: “Today is Thursday”- tests for conductive dysphasia

Question 11

What are some causes of dysarthria?

Answer 11

• Pseudo-bulbar palsy
• Bulbar palsy
• Cerebellar lesions

Question 12

What is a pseudo-bulbar palsy?

Answer 12

Impairment of the bulbar nerves due to bilateral UMN lesion in the mid pons

Question 13

Where is the lesion in a pseudo-bulbar palsy?

Answer 13

Bilateral lesions most commonly in the corticobulbar tract in the brainstem.

Question 14

What are the signs of a pseudo-bulbar palsy?

Answer 14

• Difficulty with lingual sounds –> “hot potato speech”
• Brisk jaw jerk (as UMN)
• May have difficulty chewing and swallowing
• May show emotional lability

Question 15

What are the causes of a pseudo-bulbar palsy?

Answer 15

• Vascular: bihemispheric vascular disease e.g. bilateral internal capsule infarcts
• Neurological: MS, MND
• Neoplasia: Brainstem tumour
• Trauma

Question 16

Why are psuedo-bulbar palsies only seen with bilateral lesions?

Answer 16

Most CN nuclei (except VII and XII) recieve bilateral innervation from the corticobulbar tract i.e. recieve UMN fibres from both hemispheres. This ensures they receive cortical innervation even in the presence of a unilateral pyramidal tract lesion.

Question 17

What is a bulbar palsy?

Answer 17

Impairment of the bulbar cranial nerves due to a lower motor neuron lesion

Question 18

What are the signs of a bulbar palsy?

Answer 18

• Unilateral LMN weakness
• Palatal weakness –> nasal “Donald Duck” speech
• May also occur with dysphagia and problems chewing

Question 19

What are the causes of a bulbar palsy?

Answer 19

• Neurological: MND, GBS
• NMJ disorder: Myasthenia gravis, botulinism
• Vascular: Brainstem vascular disease e.g. basilar ischaemia
• Infection: Poliomyelitis, subacute meningitis, neurosyphilis
• Trauma: Syringobulbia

Question 20

Where would a lesion causing a bulbar palsy be?

Answer 20

In the medulla, or from lesions of the bulbar nerves outside the brainstem

Question 21

How would you describe cerebellar speech?

Answer 21

Slurred, drunken speech

Question 22

What are the causes of dysphonia?

Answer 22

• Medical: Local cord pathology
  
  • Infection: Laryngitis
  • Neoplasm: Tumour
  • Nodule
• Surgical:
  
  • Recurrent laryngeal nerve palsy

Question 23

What symptoms would you expect with an expressive aphasia?

Answer 23

• Non-fluent speech
• Intact comprehension

Question 24

Where is the lesion in expressive dysphasia?

Answer 24

Broca’s area- frontal lobe

Question 25

What symptoms would you expect in receptive dysphasia?

Answer 25

Fluent but meaningless speech Impaired comprehension

Question 26

Where is the lesion in receptive aphasia?

Answer 26

Wernicke's area- temporal lobe

Question 27

What symptoms would you expect in a conductive dysphasia?

Answer 27

Intact comprehension Unable to repeat words or phrases

Question 28

Where is the lesion in a conductive dysphasia?

Answer 28

Damage to the arcuate fasciculus- connects Broca's and Wernicke's area