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Motor Speech Disorders Exams 1 + 2 > Flaccid Dysarthria > Flashcards

Flaccid Dysarthria Flashcards

1
Q

A Lesion in ______ can cause flaccid dysarthria

A

LMN system

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2
Q

UMN involves all of pathway above or below the level of the synapse?

A

above

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3
Q

LMN involves the pathway above or below the synapse to the muscle fiber?

A

below

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4
Q

In the UMN system, do fibers leave the brain stem?

A

No, fibers never leave the brain stem

*except for the cortico-spinal tract

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5
Q

T or F

Deficits are the similar when they occur in the LMN or UMN systems

A

False.

Deficits are very different if they occur in the LMN or UMN system

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6
Q

What results in because it all comes together in the LMN system.severe damage in the UMN system?

A

need 2 lesions that take out both bilateral tracts to have severe damage

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7
Q

Is there severe damage if there is 1 lesion in the UMN system?

A

No.

If just one lesion, something can get through to the LMN system

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8
Q

With the LMN system, it takes ____ lesion(s) to wipe out the function?

A

1

* because it all comes together in the LMN system

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9
Q

Where do lesions that result in flaccidity occur?

A

Anywhere along the motor unit

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10
Q

Do symptoms vary according to where the lesion/damage is?

A

Yes.

Symptoms vary according to where damage occurs

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11
Q

Primary unique deficit in flaccidity is..

A

Weakness to muscles.

Can happen to any muscle.

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12
Q

Weakness refers to…

A

…reduced strength/force of muscle contraction

Most things can be explained on basis of weakness

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13
Q

If the palate too weak to close, the patient will have…

A

hypernasality

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14
Q

UMN system damage results in what kind of dysarthria?

A

Spastic dysarthria.
Primary unique deficit is spasticity.
Can also have some weakness but weakness is not defining character.

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15
Q

What is the primary unique deficit of spastic dysarthria?

A

Spasticity

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16
Q

What is the only dysarthria with PNS involvement?

A

Flaccid dysarthria

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17
Q

2 other names for PNS

A

LMN and FCP – refer to same as PNS

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18
Q

When motor units are damaged…

A

…muscle looses its ability to contract

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19
Q

If all of the LMN input (nerve impulse) is lost to a muscle what occurs?

A

paralysis

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20
Q

It there is only partial loss of LMN input what occurs?

A

paresis

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21
Q

What is paresis?

A

There’s still some input to muscle, but contraction is weakened, therefore weaker muscle movement

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22
Q

Other defining characteristics of Flaccid Dysarthria (4):

A
  1. Hypotonia & weak reflexes
  2. Atrophy
  3. Fasiculations & fibrillations. Fasiculations don’t occur immediately after insult – takes a while to see them (1-3 weeks after nerve supply is gone). They’re quick, jerky movements in resting muscles. Difference between fasiculations & fibrillations - fasiculations are visible, fibrillations aren’t.
  4. Progressive muscle weakness – in all flaccid dyarthria fatigue is a factor. But in some disorders, there is a quick weakening with use. The muscle fatigues quickly when used. This occurs in neuromuscular junction dz, such as Myasthenia Gravis.
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23
Q

Where the damage occurs on the motor unit determines…

A

the type of characteristics

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24
Q

ATROPY & FASICULATIONS ARE ONLY SEEN IN LMN or UMN INVOLVEMENT?

A

LMN INVOLVEMENT

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25
Q

Hypotonia & weak reflexes:

A

Weak muscles leads to hypotonia (reduced muscle tone).

This affects speed, range/accuracy of muscle movements.

Reflexes may be diminished or completely gone.

With flaccidity in muscles, muscle doesn’t contract so you get flabby muscle

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26
Q

Atrophy:

A

Muscle starts to waste away, loses mass/bulk when nerve fibers are damaged

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27
Q

Fasiculations & Fibrillations:

A

Quick, jerky movements in resting muscles

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28
Q

Do fasiculations occur immediately after insult?

A

No.

It takes a while to see them (1-3 weeks after nerve supply is gone)

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29
Q

What is the difference between fasiculations & fibrillations?

A

Fasiculations are visible, Fibrillations aren’t

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30
Q

What are some etiologies of Flaccid Dysarthria (8):

A
  1. Neuromuscular Junction Dz ( e.g. Myasthenia Gravis)
  2. Vascular disorders (e.g. Wallenberg’s lateral medullary syndrome)
  3. Infectious processes (e.g. polio)
  4. Demyelinating Dz - such as Guillian Barre dz –
  5. Muscle diseases – such as Muscular Dystrophy
  6. Degenerative dz – such as motor neuron dz (e.g. ALS)
  7. Anatomic anomalies such as Arnold Chiari malformation
  8. Radiation treatment
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31
Q

Neuromuscular Junction Dz (e.g. Myasthenia Gravis):

A

Chronic dz characterized by rapid weakness of voluntary movement of muscles & improvement with rest

AcH receptors are destroyed in MG so receptors aren’t receptive to AcH, which triggers muscle contraction

When you let the muscle rest, it functions more normally.

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32
Q

Myasthenia Gravis occurs in men _____ and in women _____.

A

Men: after age 50
Women: between 20-40 years of age

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33
Q

Main characteristics of Myasthenia Gravis (3):

A
  1. drooping eyelids
  2. weak facial muscles
  3. flaccid dysarthria
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34
Q

What is the “Tensilon” test given for Myasthenia Gravis?

A

Injections of tensilon give after pt shows signs of fatigue when talking

Pt should show rapid improvement.

To have pt do stress test for this – count to 100, etc.

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35
Q

Vascular disorders:

A

Brain stem stroke that affects cranial nerve nuclei can cause flaccid dysarthria

Other vascular syndromes, such as Wallenberg’s lateral medullary syndrome, may result in flaccid dysarthria

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36
Q

Infectious processes-polio:

A

polio is viral dz in which LMN cell bodies may be affected

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37
Q

Demyelinating Dz - such as Guillian Barre dz:

A

unknown cause, loss of myelin occurs in some nerves.

Facial & oropharyngeal muscles are affected 1st, often results in flaccid dysarthria & dysphagia

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38
Q

Muscle diseases – such as Muscular Dystrophy:

A

Genetic, inherited, and degenerative.

Muscle fibers degenerate.

Flaccid dysarthria is frequent symptom.

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39
Q

Degenerative dz- motor neuron dz

A

groups of disorders – motor neurons degenerate

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40
Q

Degenerative dz- ALS:

A

most common type of motor neuron dz

Affects both UMN and LMN system

Results in mixed dysarthria with flaccid component

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41
Q

Anatomic anomalies – Arnold Chiari malformation:

A

Congenital (occurs at birth)

Results in distortion of brain stem which may result in impairment of cranial nerves.

Often don’t see symptoms till adulthood.

Flaccid dysarthria is one symptom.

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42
Q

Radiation treatment:

A

Used for CA tx

Can have side effects leading to neuropathy (any dz of the nerve) with resulting flaccid dysarthria

43
Q

What is neuropathy?

A

any dz of the nerve

44
Q

All symptoms of damage in Flaccid Dysarthria are due to lesions in the LMN or UMN system?

A

LMN system

45
Q

Cranial Nerve V (Trigeminal Nerve):

A

Originates at pons

Provides sensory information about jaw, face, lip and tongue

Provides motor function to jaw

46
Q

3 branches of Cranial Nerve V (Trigeminal):

A
  1. Sensory opthalmic branch
  2. Sensory maxillary branch
  3. Motor & sensory mandibular branch
47
Q

The Sensory opthalmic branch of the Trigeminal Nerve (CN V) innervates…(1)

A

upper face

48
Q

The Sensory maxillary branch of the Trigeminal Nerve (CN V) innervates…(1)

A

midface

49
Q

The Motor & sensory mandibular branch of the Trgeminal Nerve (CN V) innervates…(3)

A
  • jaw muscles
  • tensor tympani
  • tensor veli palatini (tenses & flattens velum)
50
Q

T or F

If Cranial Nerve V (Trigeminal Nerve) is damaged, usually other cranial nerves are damaged

A

True.

Rarely is it damaged alone

51
Q

Unilateral damage (LMN) to Cranial Nerve V (Trigeminal) symptoms:

A

Jaw deviates to side of weakness or may be easily pushed to one side.

May not feel much muscle contraction of masseter when pt bites down

52
Q

Bilateral damage (LMN) to Cranial Nerve V (Trigeminal):

A

Jaw may hang open at rest

Pt may not be able to close jaw or may move it slowly or have reduced ROM

If examiner tries to open or close jaw & have pt resist this, pt may not be able to resist the movement

53
Q

Pt complaints with LMN damage to Cranial Nerve V (Trigeminal):

A

Complaints related to jaw weakness, i.e. difficulty chewing, drooling, etc

Sensory complaints of decreased sensation from face, cheek, tongue, teeth, palate
–>Asses by having pt close eyes & touch face

54
Q

How do you asses for effects on speech of Vth nerve (Trigeminal) damage:

A

Have pt read or converse – listen to speech

Do AMR’s (puh, etc.; tuh, etc.; kuh, etc.) – should be more imprecision/slowness for puh

If Myasthenia Gravis present, may be progressive weakness in jaw opening

55
Q

Unilateral damage to Vth (Trigeminal) does/does not affect speech significantly?

A

Does not

56
Q

Bilateral damage to Vth (Trigeminal) does/does not affect speech?

A

Does

57
Q

Symptoms of bilateral damage to Vth (trigeminal) Nerve:

A
  • Patient may try to hold jaw closed to compensate
  • Speech rate may be slow.
  • Sensory impairment may affect articulation due to reduced sensory information regarding movements of articulators.
    • ->Pt with sensory problem may exaggerate artic movements to compensate
58
Q

What does Cranial Nerve VII (Facial Nerve) do?

A

Only concerned with motor components for speech.

It innervates lip muscles to aid in producing bilabials and labiodentals

It helps to firm cheek muscles to allow build-up of intraoral air pressure.

Sensory portion carries info for taste from anterior 2/3 of tongue

59
Q

Bell’s palsy:

A

Common condition affecting VIIth nerve

Results from unilateral VIIth damage

Affects upper and lower facial muscles – difficulty opening eyes

Most have full recovery

Usually due to viral infection

60
Q

Symptoms of (LMN) unilateral lesion to Cranial Nerve VII (Facial Nerve) (7):

A
  1. At rest, affected side sags & is hypotonic
  2. Forehead may be unwrinkled
  3. Eyebrow drooped
  4. Eye open and unblinking
  5. Tip of nose & corner of mouth may be drawn toward affected side
  6. Drooling may occur
  7. If pt smiles, face will show more movement toward the good side
61
Q

Symptoms of Bilateral lesions (LMN) to Cranial Nerve VII (Facial Nerve):

A

*more rare than unilateral

Symptoms include:

  1. Damage isn’t so striking because there is facial symmetry.
  2. At rest, mouth is lax, space between lips more than normal.
  3. Pt may not be able to retract lips or puff out cheeks.
  4. Drooling may occur.
  5. Pt may complain of not being able to move lips well in speech & that food spills out of mouth.
62
Q

What is synkinesis?

A

An abnormal contraction of muscle next to the muscle that is normally moving

63
Q

What can cause synkinesis?

A

VIIth nerve damage can result in abnormal movements of face – synkinesis

64
Q

How do you asses for VIIth (Facial) nerve damage effects on speech (6):

A
  1. Use conversation, reading, AMRs & stress testing
  2. May see “flutter in cheek” - due to less resistance to intraoral pressure.
  3. May be poor bilabial closure with more imprecision on “puh” than “tuh”, etc.
  4. May be some slowness, but precision more affected than speed.
  5. Do stress testing for Myasthenia Gravis
  6. For both unilateral and bilateral, look for pt compensation
65
Q

Assessing for unilateral damage to VII (Facial) Nerve effects on speech (3):

A
  1. Damage may be mild distortion of some sound, especially bilabials & labiodentals
  2. Visible symptoms may be more apparent than speech symptoms
  3. Vowels not usually affected
66
Q

Assessing for bilateral damage to VII (Facial) Nerve effects on speech:

A
  1. Pt may not be able to make bilabials & labiodentals at all
  2. Vowels may be distorted if pt can’t round or spread lips
67
Q

Pt compensations with unilateral damage to VII (Facial) Nerve:

A
  1. Pt may prop up sagging side or assist in movement

2. May have exaggerated jaw closure to try to make bilabial sounds

68
Q

Pt compensations with bilateral damage to VII (Facial) Nerve:

A
  1. May substitute lingual alveolar sounds for bilabials i.e. t/p
69
Q

Glossopharyngeal Nerve (IXth):

A
  • Motor fibers originate in the reticular formation of medulla and pass through posterior fossa and into phayrnx to innervate the stylopharyngeus muscle (raises pharynx in speech & swallowing)
  • Sensory fibers bring info from pharynx & posterior 1/3 of tongue. It is this component that makes us gag. Damage here may result in decreased gag reflex
70
Q

Is the Glossopharyngeal Nerve (IX) usually damaged alone or with another nerve?

A

IXth nerve rarely damaged alone

Damage usually affects Vagus as well

71
Q

How do you assess for Glossopharyngeal Nerve (CN IX) damage?

A
  • By eliciting gag reflex
  • Check symmetry of reflex.
  • Reduced gag may implicate either sensory or motor part of nerve.
  • Sensory part affected if pt reports decreased sensation in the area.
  • Note – not always a reliable test of IXth nerve function as some pts experience normal gag reflex after IXth damage.
  • IXth nerve damage may cause reduced pharyngeal elevation during swallowing due to poor innervation for stylopharyngeus.
  • May also be pain in pt’s throat going down to back of lower jaw. Can be triggered by swallowing or sticking out tongue.
  • Speech signs – damage to IXth cannot be assessed directly through speech tasks.
72
Q

Vagus Nerve (CN X) (location):

A
  • Exits at lower level of medulla along with IXth and XIth nerves.
  • Has 3 branches
73
Q

The 3 branches of the Vagus Nerve (CN X):

A
  1. Pharyngeal
  2. Superior laryngeal branch
  3. Recurrent laryngeal branch
74
Q

Location of the Pharyngeal Branch of the Vagus Nerve (CN X):

A

-goes to pharynx & palate

75
Q

Location of the Superior Laryngeal Branch of the Vagus Nerve (CN X):

A

– goes to larynx & pharynx

76
Q

Location of the Recurrent Laryngeal Branch of the Vagus Nerve (CN X):

A

– goes to upper chest & loops around blood vessels, then travels back up to larynx

77
Q

Pharyngeal branch of Vagus innervates (3 areas):

A
  1. Muscles of Pharynx (except stylopharyngeus which is innervated by IXth)
  2. Muscles of Soft Palate (including the levator palatini) (except tensor veli palatini which is innervated by Vth) - results in palatal constriction and elevation in speech & swallowing. (Hypernasality may result if damage occurs here.)
  3. Palatoglossus Muscle – contraction can either depress soft palate or pull sides of tongue up and back
78
Q

Superior laryngeal branch of the Vagus Nerve innervates (internal & external branches):

A
  • Internal part brings sensation from larynx & base of tongue.
  • External part innervates inferior pharyngeal constrictor muscles & cricothyroid muscle. (Damage can result in pitch problems.)
79
Q

Recurrent laryngeal branch of the Vagus Nerve innervates:

A
  • all intrinsic laryngeal muscles except cricothyroid

- Sensory fibers bring sensory info from vocal folds & larynx

80
Q

Lesion to the Vagus Nerve that are above separation of the 3 branches will affect:

A

All muscles supplied by the specific nerve below the level of lesion

i.e.
the pharyngeal & palatal muscles innervated by the pharyngeal branch

cricothyroid muscle innervated by superior laryngeal
branch
AND
all other intrinsic laryngeal muscles innervated by recurrent laryngeal branch

81
Q

Lesions of the Vagus Nerve below the pharyngeal branch but still high enough to affect other 2 branches will….

A

Not affect pharyngeal & palatal muscles, but will cause paralysis or weakness to cricothyroid & other intrinsic laryngeal muscles

82
Q

Lesions of superior laryngeal branch of the Vagus Nerve but not recurrent branch will affect:

A

Cricothyroid muscles but not other intrinsic laryngeal muscles

83
Q

Lesions of the Vagus Nerve affecting only recurrent laryngeal nerve will cause:

A

Weakness or paralysis of the other intrinsic laryngeal muscles (except cricothyroid) on the side of the lesion

84
Q

Unilateral pharyngeal lesions above the origin of the 3 branches of the Xth nerve will cause (3 things):

A
  1. Soft palate hangs lower on side of lesion
  2. Soft palate pulls toward nonparalyzed side in phonation
  3. Gag reflex may be diminished.
85
Q

Bilateral pharyngeal lesions above the origin of the 3 branches of the Xth nerve will cause (3 things):

A
  1. Soft palate hangs low in pharynx at rest & moves little during phonation.
  2. Gag reflex may be diminished or absent
  3. May be nasal regurgitation in swallowing
86
Q

Speech signs of damage to the Xth Nerve (Vagus):

A

Can affect:

  • phonation
  • resonance
  • articulation
  • prosody
  • But phonation & resonance are the most affected*

-When pharyngeal branch is affected unilaterally there is only mild or no hypernasality, may be nasal emission during pressure consonants

87
Q

When pharyngeal branch of the Vagus Nerve (CN X) is affected bilaterally (4):

A
  1. Can be severe hypernasality & marked nasal emission
  2. Imprecise pressure consonants due to inability to build up intraoral pressure
  3. May be reduced intensity
  4. May be facial grimacing as they try to hold back air from nares
88
Q 
CN X (Vagus):
How do you tell if articulation problem is due to general weakness or to inability to impound oral pressure?
A

Pinch off nostrils and have pt speak. This allows the pressure to be maintained & can listen for weakness in articulators

89
Q 
CN X (Vagus):
Unilateral lesions below pharyngeal branchbut above superior laryngeal & recurrent laryngeal nerve can cause (6):
A
  1. Breathiness
  2. Aphonia
  3. Reduced loudness
  4. Diplophonia
  5. Reduced pitch
  6. Pitch breaks
90
Q 
CN X (Vagus):
Lesions of superior laryngeal nerve cause (unilateral and bilateral damage):
A
  • only slight, subtle changes in voice
  • If unilateral: may cause mild breathiness or hoarseness & some problems with pitch changing
  • Bilateral lesions can cause marked ability to change pitch
91
Q 
CN X (Vagus):
Unilateral recurrent laryngeal nerve lesions only causes:
A

breathy-hoarse voice & decreased loudness

92
Q 
CN X (Vagus):
Bilateral recurrent laryngeal nerve lesions cause (2):
A
  1. Inhalatory stridor but voice may be OK because folds are adducted closed enough to midline
  2. Airway may be compromised – this is serious
93
Q

Accessory Nerve (CN XI) (location and function):

A
  • Exits along with IXth and Xth nerves.
  • Is sensory and motor.
  • Aids in innervation to uvula, levator palatini (elevates soft palate) and intrinsic laryngeal muscles.
  • Important in head & neck movement.
  • Damage can be caused by neck surgery as well as those things mentioned affecting Xth nerve.
  • Effect on speech is negligible
94
Q

Nonspeech signs of Accessory Nerve (CN XI) damage:

A

Reduced shoulder elevation on side of lesion, weakened head turn on side opposite of lesion

95
Q

Bilateral lesions to Accessory Nerve (CN XI) can cause:

A

Head drooping with some mild effects on phonation & respiration

96
Q

Hypoglossal Nerve (CN XII) (Location and Function):

A
  • Originates in medulla.
  • Innervates all intrinsic & extrinsic tongue muscles except palatoglossus (innervated by Xth).
  • Is essential for tongue movement, chewing & swallowing.
  • Often seen with damage to IX, X, XI
  • Can be damaged by anything that causes damage to these other nerves, as well as neck surgery or trauma
97
Q

Nonspeech signs of unilateral (LMN) damage to the Hypoglossal Nerve (CN XII) (2):

A
  1. Tongue may deviate to weak side & to side of lesion upon tongue protrusion.
  2. Will have problems curling tongue tip on weak side and with pushing tongue into cheek with resistance (on weak side)
98
Q

Nonspeech signs of bilateral (LMN) damage to the Hypoglossal Nerve (CN XII) (5):

A
  1. Tongue may atrophy & have bilateral fasiculations.
  2. Tongue may not be able to protrude at all or with limited ROM but will be symmetrical in its excursion.
  3. Food may be squirreled in cheek & pt may not be able to move food around well in mouth.
  4. Pt may complain of tongue feeling heavy
  5. May be drooling due to tongue weakness.
99
Q

Speech signs of damage to the Hypoglossal Nerve (CN XII) (3):

A
  1. Main characteristic is imprecise articulation & first problems may be with lingual phonemes, i.e. t, d, s, sh, ch, r, l.
  2. May be resonance problems due to tongue falling back into pharynx. May sound like hypo or hypernasality but it isn’t. It is due to tongue position.
  3. May be exaggerated jaw movement to compensate for tongue weakness.
100
Q

How do you assess Hypoglossal Nerve (CN XII) damage?

A

By looking at lingual consonants in connected speech & AMRs

In AMRs “puh” should be OK but the others won’t. “Kuh” may be more affected than “tuh” because it is harder to get the back of the tongue up. In normal speakers, rate of producing “kuh” is slower than “tuh”.

101
Q

What is Bulbar Palsy?

A
  • A condition that occurs when there are several cranial nerves damaged
  • Can be caused by any of the etiologies we have discussed as well as disorders that typically affect multiple nerves, such as ALS, Myasthenia Gravis and brain stem tumors
102
Q

Multiple Cranial Nerve Lesions:

A
  • Can cause Bulbar Palsy
  • Nonspeech signs are similar to ones mentioned for single nerve damage but with a more severe effect
  • Damage to more than one cranial nerve frequently occurs because they are close together
103
Q

Distinguishing features (related to speech & respiration) of Flaccid Dysarthria (Duffy) (8):

A
  1. Hypernasality
  2. Nasal Emission
  3. Continuous breathiness
  4. Audible inspiration (stridor)
  5. Isolated articulatory imprecision
  6. Atrophy
  7. Fasiculations
  8. Diplphonia

Motor Speech Disorders Exams 1 + 2 (10 decks)

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