Speech and Language Exam

This is perhaps more of an adjunct to the management of stroke. However,  I’ve found that it can be easily deployed at the bedside and helps the examining doctor focus on the more likely differentials – leading to more pertinent investigations – resulting in faster, more focused treatment.

And it’s not half bad if final meds get it in their long/short case!

Dysphasia – Impairment of language

Dysarthria – Impairment of muscular control of speech

Great diagram for visualizing the locations when they are affected

 

At the bedside:

  1. Establish dominant lobe – opposite to dominant hand (Broca’s and Wernicke’s area)
  2. Ensure examination is fair:
    1. Is English your first language?
    2. Do you have any hearing difficulties?
    3. Do you wear dentures? – is there anything impeding the speech
    4. Does the patient understand
  3. Inspection
    1. Unequal pupils or ptosis
    2. Facial asymmetry or weakness, etc.
    3. Any obvious neurological deficit(s) in the face
  4. Screening question for fluency and gross abnormality
    1. How did you get here today?
    2. How are you feeling today?

Assessment of Dysphasia:

  1. Expressive – an expressive dysphasia presents as an inability to find the right words – both spoken and written.
    1. Get them to write a sentence on a piece of paper
  2. Conductive
    1. Get them to repeat – ‘no ifs ands or buts’
  3. Receptive
    1. 3 stage command
      1. Do not give away any visual cues when assessing 3 stage commands.
  4. Nominal
    1. Get them to identify an object and parts on that object (e.g. a watch, a watch strap, a watch face)

Assessment of dysarthria:

  1. [M] Lips – CN VII (Facial) – MaMaMa
  2. [L] Tongue – CN XII (Hypoglossal) – LaLaLa
  3. [K] Soft palate – CN IX and X (Glossopharyngeal and Vagus) – Kakaka
  1. Screen for ‘cerebellar speech’ (slurred words or staccato speech)
    1. Baby hippopotamus
    2. West register street
    3. British constitution
  2. Turn head and cough
    1. Check for a low-pitch prolonged ‘bovine’ sound suggestive of a vagal nerve palsy
  3. Count from 20 to 1 – assessing for use dependent changes
    1. Fatiguing – Myasthenia Gravis
    2. Improvement – Lambert Eaton

 

Further tests

  1. Assess swallow (Dry swallow test, water swallow test)
  2. Full CN exam
  3. Higher cognition test (MMSE, MoCA, Addenbrooke’s cognitive examination)
  4. Mood and affect (Mental status exam, GERRI exam)

Interpreting results

Speech production

  1. Central nervous processes
    1. Understands sounds as words
    2. Interpret meaning of words
    3. Express thoughts and feelings into words
    4. Manipulate muscles to generate sounds to produce speech
  2. Peripheral nervous stimulation of motor speech
  3. Motor production of speech
    1. Vocal cord vibration to generate volume and pitch
    2. Manipulate the oropharynx, tongue, and lips to produce sounds that form speech
Where the magic happens

Speech failure

  1. Dysphasia (from CNS problems)
    1. Expressive (issue with Broca’s area)
    2. Receptive (issue in Wernicke’s area – the sound the patient hears is not understood as words, unable to carry out 3 step commands)
    3. Conductive (issue with arctuate fasciculus)
    4. Nominal (issue with auditory association cortices, the post. Aspect of the temoral lobe – inability to name objects)
  2. Dysphonia
    1. Nerves (e.g. lesions to CN IX or X)
    2. Muscles (local damage e.g lung infiltration, goitre, post-thyroidectomy, Lymph node hyperplasia)
  3. Dysarthria (inability to annunciate key sounds)
    1. Lips – facial nerve
    2. Tongue – hypoglossal
    3. Palate – glossopharyngeal and vagus
Pretty cool

 

 

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