Differential Diagnosis

Question 1

Differential diagnosis –

Answer 1

the process of narrowing possibilities and reaching conclusions about the nature of a deficit.

Question 2

When doing a speech evaluation, should you always try to make a diagnosis?

Answer 2

Yes

Question 3

Reasons for not being able to make a diagnosis include (2):

Answer 3

o Noncooperative patient

o Equivocal/uncertain findings

Question 4

Why is it helpful to state what it is not in a diagnosis?

Answer 4

– i.e. if it is not ataxic – implies that there isn’t cerebellar involvement
- if it is not hypokinetic or hyperkinetic – there is no basal ganglia involvement

*can state these things

Question 5

Is it helpful to establish that a dysarthria is present but that can’t specify the type?

Answer 5

Yes, if you cannot give a definitive diagnosis

Question 6

If you can’t make a definitive diagnosis what should you do?

Answer 6

You must describe what you find, and state why a definitive diagnosis can’t be made

Question 7

If a diagnosis is not determined should you offer a diagnosis?

Answer 7

No

You can state that the diagnosis is undetermined. Also using words such as “equivocal, probably, possible” give indications of how confident you are in your diagnosis

Question 8

Make the speech diagnosis relate to:

Answer 8

• the suspected neurological diagnosis
• or suspected site of lesion

*It is helpful to the neurologist if the speech signs are not consistent with suspected diagnosis or site of lesion as well as when they are consistent with suspected diagnosis

Question 9

Is it possible for more than one speech disorder to exist at the same time?

Answer 9

Yes,
*so just identifying a single disorder isn’t always sufficient.

• You must be able to account for all of the deviant characteristics – if the disorder you identified does not do this, then another disorder may be present

Question 10

Does an evaluation always have to find deviant speech?

Answer 10

No.

it may indicate normal speech or speech within normal range

Question 11

By providing a label for the diagnosis, you are providing:

Answer 11

a composite of information associated with that label

It is a kind of shorthand for communicating information about disorders

Question 12

Is there is overlap among dysarthrias in terms of certain characteristics?

Answer 12

Yes

For example, many have imprecise articulation as a characteristic, so the presence of imprecise articulation DOESN’T HELP you in distinguishing between dysarthrias.

Question 13

Are there also some characteristics that are unique to certain dysarthrias?

Answer 13

Yes

and these CAN be used to distinguish between dysarthrias.

Question 14

Why might an evaluation come up with speech WNL but the patient still has a disorder (2)?

Answer 14

In the initial stages of some diseases, speech may have changed but not significantly enough to be judged deviant

It is also possible that the person may be incorrectly identifying a developmental problem of articulation as related to a neurological disease.

Question 15

Etiologies (10):

Answer 15

1 Vascular
2 Degenerative disease
3 TBI
4 Surgical trauma
5 Toxic and metabolic conditions
6 Infectious and inflammatory conditions rarely cause dysarthrias
7 Demyelinating diseases
8 Anatomic malformations such as Arnold-Chiari (malformations of the brain)
9 Neuromotor junction disorders, muscle disease and neuropathies
10 OR in the absence of a neurologic diagnosis

Question 16

Vascular –

Answer 16

can cause any type of dysarthria

Most often it causes spastic, UUMN, and ataxic dysarthia.

Hemorrhagic stroke is the most common cause of dysarthrias

Question 17

Degenerative disease -

Answer 17

• also can cause any type of dysarthria
• Most often it causes spastic, ataxic, hypokinetic and flaccid dysarthrias
• ALS is a frequent cause of flaccid & spastic but other types of dysarthrias are not usually seen in ALS, so if there is another type of dysarthia existing, there may be another disease or the diagnosis of ALS may be in error.
• Also Parkinson’s is only associated with hypokinetic dysarthria

Question 18

TBI –

Answer 18

• can cause any type of dysarthria
• but in closed head injury the most common type is spastic
• OHI do not usually cause flaccid dysarthria but can cause the other CNS dysarthrias (spastic, ataxic, UUMN).
• Skull fracture and neck traumas can cause flaccid dysarthrias, but not other types

Question 19

Surgical trauma –

Answer 19

• can cause any type of dysarthia except hypokinetic.
• Surgeries involved with ear, nose throat, chest/cardiac areas are only associated with flaccid dysarthria.
• Neurosurgery can cause CNS dysarthrias as well as flaccid dyarthria

Question 20

Toxic and metabolic conditions –

Answer 20

• do not typically cause flaccid or UUMN dysarthria but can cause the other types
• Toxic conditions associated with drugs/medications cause hyperkinetic and ataxic dysarthias most often

Question 21

Infectious and inflammatory conditions -

Answer 21

• rarely cause dysarthrias although they sometimes do occur

- The type of dysarthria depends on the condition

Question 22

Demyelinating diseases –

Answer 22

• can cause any type of dysarthria but hypokinetic is rare.
• The type of dysarthria depends on the disorder, Guillain Barre disease is usually associated with flaccid whereas
• MS is usually associated with ataxic dysarthria

Question 23

Anatomic malformations -

Answer 23

-e.g. Arnold-Chiari (malformations of the brain)

– most often associated with flaccid dysarthria

Question 24

Neuromotor junction disorders, muscle disease and neuropathies –

Answer 24

• only cause flaccid dysarthria because they are PNS diseases

Question 25

Dysarthria present in the absence of a neurologic diagnosis -

Answer 25

- sometimes the etiology is undetermined particularly for hyperkinetic, spastic and ataxic dysarthrias

Question 26

Oral Mechanism Findings are used for:

Answer 26

– certain findings in the oral mechanism are not required for MSD but are used as confirmatory signs:

Question 27

Oral Mechanism Findings for Flaccid Dysarthria:

Answer 27

– atrophy and fasiculations often occur in FD and do not occur in other dysarthias or apraxia - Hypotonia and a hypoactive gag reflex occur more often in FD than other dysarthrias - Rapid loss of intelligibility is indicative of Myasthenia Gravis but not other MSDs - Nasal regurgitation may be seen FD

Question 28

Oral Mechanism Findings for Spastic Dysarthria:

Answer 28

- pathological oral reflexes - hyperactive gag reflex - and pseudobulbar effect are found most often in this dysarthria - Also more problems exist with dysphagia and drooling than other MSDs but may occur with others

Question 29

Oral Mechanism Findings for Ataxic Dysarthria:

Answer 29

– may have dysmetria in nonspeech jaw, face and tongue movements (This isn’t seen in other dysarthrias typically) - Other oral mech findings may be normal

Question 30

Oral Mechanism Findings for Hypokinetic Dysarthria:

Answer 30

– orofacial tremors - masked face is common and not seen with other MSDs

Question 31

Oral Mechanism Findings for Hyperkinetic Dysarthria:

Answer 31

- abnormal movements may be seen both at rest and in speech that are not seen in other dysarthrias

Question 32

Oral Mechanism Findings for UUMN Dysarthria:

Answer 32

- unilateral facial and lingual weakness without atrophy or fasiculations is common but not typically seen in other dysarthrias

Question 33

Speech Characteristics of Flaccid Dysarthria:

Answer 33

– phonatory and resonatory abnormalities are most common distinguishing characteristics. - If the Xth nerve is affected you may see breathiness, diplophonia, audible inspiration & short phrases – these are not as common in other dysarthrias - Breathiness does occur in hypokinetic dysarthria but listen for greater hoarseness and the presence of diplophonia in FD which would differentiate the two. - Hypernasality occurs in other dysarthrias, most often spastic and hypokinetic, but still is most pronounced in FD. - Rapid deterioration of speech occurs only in connection with FD in Myasthenia Gravis

Question 34

Speech Characteristics of Spastic Dysarthria:

Answer 34

– slow rate combined with slow but regular AMRs, strained voice quality are most common features and aren’t typically seen in other dysarthrias - It is the presence of all three that is not typical in other dysarthrias. - You may have a strained voice quality in hyperkinetic dysarthria but it usually isn’t accompanied by the slow rate

Question 35

Speech Characteristics of Ataxic Dysarthria:

Answer 35

- irregular articulatory breakdowns, irregular AMRs and dysprosody are primary distinguishing characteristics. - You may also hear these in UUMN and hyperkinetic dysarthria but to distinguish look for abnormal movements in hyperkinetic dysarthria and unilateral lower facial and tongue weakness in UUMN

Question 36

Speech Characteristics of Hypokinetic Dysarthria:

Answer 36

- the only dysarthria in which rapid and blurred speech and AMRs occur but it doesn’t have to occur in hypokinetic dysarthria - If palilalia occurs – it only occurs with hypokinetic dysarthria

Question 37

Speech Characteristics of Hyperkinetic Dysarthria:

Answer 37

- abnormal movements are particular to this dysarthria

Question 38

Speech Characteristics of UUMN Dysarthria:

Answer 38

- its mildness and transient duration helps to differentiate UUMN - It may be confused with ataxic due to irregular breakdowns - AMRs are usually normal but can be mildly irregular. - The voice may sound somewhat spastic because of strained voice, but is usually milder in degree than Spastic Dysarthria - It rarely has hypernasality

Question 39

Dysarthria versus Apraxia: | • Apraxia occurs with what kind of damage? (2 things)

Answer 39

- left hemisphere lesions except when there is right hemisphere language dominance or mixed dominance - supratentorial damage

Question 40

Dysarthria versus Apraxia: | • Dysarthria occurs with damage to:

Answer 40

supratentorial, posterior fossa, spinal or peripheral lesions

Question 41

Dysarthria vs. Apraxia: | • Apraxia occurs primarily with lesions to what system(s)?

Answer 41

the carotid system

Question 42

Dysarthria vs. Apraxia: | • Dysarthria occurs with damage to what system(s):

Answer 42

not only with carotid lesions but with other vascular systems lesions

Question 43

Which dysarthria is most difficult to differentiate from AOS?

Answer 43

UUMN

Question 44

Speech Characteristics that differentiate AOS and dysarthria: Oral mech exams indicate the neuromuscular problem associated with...

Answer 44

dysarthria

Question 45

Speech Characteristics that differentiate AOS and dysarthria: Which subsystems are affected with dysarthria?

Answer 45

– all subsystems affected

Question 46

Speech Characteristics that differentiate AOS and dysarthria: Which subsystems are affected with Apraxia of Speech?

Answer 46

– mainly articulation and prosody are affected

Question 47

Speech Characteristics that differentiate AOS and dysarthria: Which is more often associated with aphasia?

Answer 47

- AOS is more often associated with aphasia than dysarthria

Question 48

Speech Characteristics that differentiate AOS and dysarthria: What kinds of articulation errors do we see with AOS and dysarthria?

Answer 48

o Artic errors are usually distortions in dysarthria & in apraxia (Recent research indicates errors are mostly distortions in apraxia and are predictable – not substitutions as once thought.)

Question 49

Speech Characteristics that differentiate AOS and dysarthria: Which do you see groping behaviors?

Answer 49

o Apraxic speakers grope, dysarthria speakers do not. | Patients with phonemic paraphasias may also present with groping behaviors.

Question 50

Dysarthria vs Aphasia: Oral Mech Exam

Answer 50

o Aphasia patients can have normal oral mech exam, dysarthria usually do not

Question 51

Dysarthria vs Aphasia: Language problems

Answer 51

• Dysarthria patients do not have language problems, aphasia patients do

Question 52

Forms of Neurogenic Mutism(5): | table 15-6, page 368

Answer 52

``` 1 Conditions that have diffuse or multifocal damage 2 Anarthria – (lack of speech) 3 Mutism related to apraxia 4 Mutism due to aphasia 5 Cognitive-affective disturbances ```

Question 53

Neurogenic Mutism: | 1 Conditions that have diffuse or multifocal damage:

Answer 53

are more likely to be associated with mutism due to cognitive-affective disturbances than with anarthria, AOS,aphasia

Question 54

Neurogenic Mutism: | 2 Anarthria – (lack of speech)

Answer 54

– usually have significant neuromotor deficits in bulbar muscles that cause mutism - It’s sometimes present without limb motor deficits. - Usually has significant dysphagia and other oromotor abnormalities and this helps in dx - Rarely does anarthric mutism occur in absence of nonspeech oromotor abnormalities - When attempting to speak, their restricted articulatory ROM, reduced loudness and strained, groaning quality is diagnostic

Question 55

Neurogenic Mutism: | 3 Mutism related to apraxia

Answer 55

- can be associated with normal findings in oral mech exam | - Mute apraxic pts usually try to speak and show frustration when they can’t

Question 56

Neurogenic Mutism: | 4 Mutism due to aphasia

Answer 56

- similar to mute apraxic pts except they may have problems following instructions - If mutism is present, aphasia is usually severe so they do poorly on language tests

Question 57

Neurogenic Mutism: | 5 Cognitive-affective disturbances

Answer 57

– May be due to reduced arousal and alertness - If speech does eventually occur, there are delays with brief unelaborated speech