Bulbar palsy

Published on 02/04/2015 by admin

Filed under Internal Medicine

Last modified 22/04/2025

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85 Bulbar palsy

Instruction

Examine this patient’s cranial nerves.

Ask the patient a few questions.

Test this patient’s speech.

Salient features

History

• Ask the patient about nasal regurgitation, dysphagia

• Slurring of speech (patient may sound as if they have been intoxicated)

• Difficulty in chewing and swallowing

• Choking on liquids.

Examination

• Nasal speech lacking in modulation and great difficulty with all consonants

• Wasting of the tongue with fasciculations (see Fig. 69.1)

• Weakness of the soft palate: ask the patient to say ‘aah’

• There may be accumulation of the saliva

• Fasciculation elsewhere (particularly trunk muscles).

Proceed as follows:

• Check the jaw jerk (normal or absent)

• Tell the examiner that you would like to do the following:

• Check gag reflex
• Examine the hands for fasciculations, dissociated sensory loss.

Diagnosis

This patient has bulbar palsy (lesion) caused by motor neuron disease (aetiology) and has difficulty in swallowing (functional status).

Questions

What may be the underlying cause?

• Motor neuron disease: after age 60 rapidly progressive bulbar palsy is the commonest presenting symptom (p. 270)

• Guillain–Barré syndrome

• Syringomyelia (p. 280)

• Poliomyelitis

• Nasopharyngeal tumour

• Neurosyphilis

• Neurosarcoid.

What are the stages of swallowing?

There are three phases to swallowing: oral, pharyngeal and oesophageal. Six events occur during the oropharyngeal phase of swallowing:

Elevation of the tongue: soft bolus preparation with saliva

Posterior movement of the tongue: movement of food bolus into the hypopharynx

Elevation of the soft palate: closes the passage into the nasopharynx as the food bolus reaches the hypopharynx

Elevation of the hyoid: helps to bring the epiglottis under the tongue

Elevation of the larynx: opens up the retrolaryngeal space, further facilitating the movement of the epiglottis under the tongue

Tilting back of the epiglottis: covers the opening of the larynx to prevent aspiration.

These rapid series of events last about 1.5 s and, once initiated, are completely reflexive.

Remember: ‘Amyotrophic’ refers to the muscle atrophy, weakness and fasciculation that signify disease of the lower motor neurons. ‘Lateral sclerosis’ refers to the hardness to palpation of the lateral columns of the spinal cord in postmortem specimens, where gliosis follows degeneration of the corticospinal tracts. The clinical results are upper motor neuron signs: overactive tendon reflexes, Hoffmann signs, clonus and Babinski signs.

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