Cases for after mid-term Flashcards
A 44-year-old woman presented with an 8-month history of speech difficulty that she thought was caused by ongoing stress. Neurologic examination was normal, and her neurologist wondered whether her complaint was stress related. Speech pathology consultation was requested.
During speech evaluation the patient said her speech deteriorated when she was tired or under stress and that it frequently changed while she was coaching volleyball. She described it as “slurred, almost like my mouth freezes . . . almost sounds like it goes nasal.” She vaguely described alteration of chewing and swallowing at such times but denied choking or drooling. The speech problem would persist until she rested. Her primary sources of stress were a busy schedule caring for her three school-age children and coaching a high school volleyball team. She described her family life and work as stable and happy, but busy.
Speech was initially normal. After 6 minutes of continuous reading aloud, she developed mild sibilant distortions, equivocal hoarseness, and intermittent vocal flutter. Speech AMRs were normal. She did not become hypernasal, but inconsistent nasal airflow was detected on a mirror held at the nares during repetition of nonnasal sounds and phrases. After another 4.5 minutes of reading, she began to interdentalize /s/ and /z/, distort affricates, and mildly distort /r/. Oral mechanism examination immediately after stress testing demonstrated only equivocal lingual weakness. She became upset and cried when her speech changed, making it difficult to separate the effects of her emotional response from weakness. Speech returned to normal after 30 seconds of rest.
She was asked to return the following day at 5 PM, after volleyball practice. Although speech was initially normal, it deteriorated quickly and significantly, the same as it had the day before; pitch breaks and cheek fluttering during speech also were evident.
What kind of dysarthria?
Flaccid
A 71-year-old woman presented to the neurology clinic with a history of leg weakness, followed gradually during the next year by hand weakness, speech difficulty, and, finally, shortness of breath and chewing and swallowing difficulty. Initial neurologic examination revealed upper and lower extremity weakness and facial and tongue weakness, but no fasciculations. The neurologist thought that myasthenia gravis was the most likely diagnosis but not the only possibility. EMG and nerve conduction studies were arranged, as well as speech and swallowing evaluations.
Speech pathology examination confirmed that speech difficulty was initially manifest as some “shakiness” in her voice in the evening, followed by “slurring” of speech and hoarseness, all of which were worsening. Her speech was better in the morning and worse with fatigue. Food would pocket in her cheeks and she had to use a finger to remove it. Chin and bilateral lingual fasciculations were present. The tongue was mildly weak bilaterally. Voice quality was mildly hoarse. Vocal flutter was evident during conversation and vowel prolongation. Lingual fricative and affricate distortions were subtly evident. Speech rate was normal. There was no significant deterioration of speech during several minutes of continuous reading. Speech AMRs and sequential motion rates (SMRs) were normal in rate and rhythm. Intelligibility was normal.
What kind of dysarthria?
Flaccid
“My mind’s runnin’ at interstate speeds and my speech is in the school zone.”
What kind of dysarthria?
Spastic
A 41-year-old woman presented for speech evaluation before neurologic assessment. She had been aware of a change in her speech for about a year, and people frequently asked if she was taking drugs or drinking. Her speech worsened under conditions of stress or fatigue. She denied chewing or swallowing difficulty. She mentioned that her 49-year-old brother also had gait, balance, and speech difficulties.
Conversational speech was characterized by irregular articulatory breakdowns (1,2); reduced rate (1,2); dysprosody (1); occasional excess and equal stress (0,1); reduced pitch (0,1); and nonspecific, subtle hoarseness (0,1). Speech AMRs were slow and irregular (1,2). Prolonged “ah” was unsteady (1). Speech intelligibility was normal. Oral mechanism examination was normal in size, strength, and symmetry. There were no pathologic oral reflexes.
What type of dysarthria?
Ataxique
A 27-year-old woman presented with a history of progressive gait imbalance, hand incoordination, and “slurred speech.” Her symptoms worsened around her menstrual periods and when she was nervous or fatigued; they had worsened slightly during a pregnancy. During speech examination, she admitted to an approximately 10-year history of “slurred speech” that did not seem to be worsening. Conversational speech was characterized by occasional irregular articulatory breakdowns (0,1). Infrequently, rate was mildly slowed and multisyllabic words were produced with excess and equal stress. Prolonged “ah” was unsteady (1). Speech AMRs were slow (1) but not noticeably irregular.
What type of dysarthria?
Ataxique
“I sound like I’m drunk”. What type of dysarthria
Ataxique
Patient reports an inability to coordinate breathing with speaking and sometimes notes that she bites her cheek or tongue while talking or eating.
What kind of dysarthria
Ataxic
