Speech Examinations Component What do to/rational Distinguish between dysphagia, dysarthria and dysphonia. Dysphagia: Dominant higher centre disorder in the use of language for communication. Speech Dysarthria: Difficulty with articulation. Dysphonia: Altered quality of sound with reduction in volume as a result of vocal cord disease. Expressive or receptive dysphasia. Expressive: Anterior dysphagia Patient understands but cannot answer appropriately. Speech is non-fluent. When lesion is in the posterior part of the dominant third frontal gyrus -> Broca’s area. Receptive Posterior dysphagia Patient cannot understand the spoken word -> auditory aphasia or written word alexia. Suggests that the patient is unable to understand any commands or questions or to recognise written words in the absence of deafness or blindness. Occurs when there is a lesion such as infarction, haemorrhage or space occupying tumour in the dominant hemisphere in the posterior part of the first temporal gyrus -> Wernicke’s area. Other types of dysphagia: Nominal Difficulty in naming objects. Dysphasia The patient may use long sentences to overcome failure to find the correct words e.g. circumlocution. Causes: lesion in the dominant posterior temporoparietal area, encephalopathy or intracranial pressure effects of a distinct space occupying lesions. May also happen in the in the recovery phase rom any dysphagia. Conductive When the patient repeats statements and naming objects poorly but can follow commands. Causes: lesions in the articulate fasciculus and/or other fibres linking Wernick’s and Broca’s areas. Fluent or non-fluent. Fluent: Flowing with frequent errors and content is poor. Often mistaken with to with confusion. Non-fluent: Slow Effortful significant patient frustration Words are often nouns or verbs though there may be paraphasia errors. Otherwise, further assessment is impossible. Do not give patient any hints and ensure that no one else in the room does. Simple commands: Close your eyes. Show me your tongue. Assessment of comprehension Increase difficulty: Tough your right ear with your left hand. Touch your chin then your forehead. Point to the ceiling after you point to the floor. Out of all types of fluent speech only receptive patients cannot comprehend. In non-fluent speech comprehension is often mildly impaired, but written or verbal commands are followed. Ask the patient to name a few objects. Fluent speech (receptive, conductive or nominal) -> poor performance. Non fluent speech (expressive) -> poor but may be better than spontaneous speech. If the patient is fluent but conveys information with paraphrase errors such as treen or train such as using a word of similar sound or spelling to the one untended -> receptive or conductive aphasia. If speech is slow, hesitant or non-fluent -> expressive aphasia is more likely. Repetition Start simple and increase complexity. Good to start with: Blue sky Green grass. Hippocampus Early screen for dysphagia Longer sentences We went to the circus and had a good time. No ifs, ands or buts. In conductive and receptive aphasia this cannot be done. Assessment of Speech for Dysphagia In expressive aphasia this is poor. Simple repetition can be done in expressive aphasia but with great efforts. Free Speech Could ask the patient to describe their hobbies. Could ask the patient about daily tasks such as: Asking them about the steps of getting dressed. Could show the patient a picture and ask them to describe it. Allows for assessment of fluency of speech and gives initial insights into visual functions. Reading Conductive and receptive aphasia have difficulty -> dyslexia In non-fluent speech patients may have dyslexia in reading. Writing Conductive aphasic patients have impaired writing -> dysgraphia. Receptive aphasic patients have abnormal content of writing. Patients with dominant frontal lobe lesions may have dysgraphia. In non-fluent/expressive aphasia -> dysgraphia may be present. No disorder of speech but disorder or articulation. Can occur because of disorder at: Upper motor neuron lesions of CN. Extra-pyramidal conditions e.g. PD. Cerebral lesions -> disturb rhythm of speech. Assess by asking the patient to say: British constitution or Peter Piper picked a peck of pickled peppers. Pseudobulbar palsy. Infarction in both internal capsules -> interruption of descending pyramidal tracts to the brainstem motor nuclei -> fascial muscles paralysis -> spastic dysarthria. Assessment of Dysarthria Jaw jerk is usually increased. Bulbar palsy Causes nasal speech whereases fascial muscle weakness causes slurred speech. Extrapyramidal disease can case monotonous speech -> bradykinesia and muscle rigidity. Other causes -> alcohol intoxication and cerebellar disease. Loss of coordination. Slow slurred and often explosive speech Speech broken into syllables -> scanning speech. Mouth ulcerations or disease May mimic dysarthria. Alteration in sound of voice Assessment of Dysphonia E.g. voice huskiness with decreased volume due laryngeal diseases E.g. following a viral infection or a tumor of the vocal cords or a recurrent laryngeal nerve palsy.