Question

Case Study 5 - Swallowing

Sarah Miller is a 48 yo female who admitted to the ED with right hemiparesis, dysarthria and a reflexive cough while taking small sips of water. MRI of the brain confirmed an MCA distribution stroke. A bedside swallow evaluation was ordered which revealed the following: R facial droop with moderately dysarthric speech. Tongue deviates to the right on protrusion. Lips strength is moderately impaired. Palpation of larynx/hyoid during a dry swallow revealed mildly reduced laryngeal elevation/excursion. Vocal quality is soft and breathy. Unable to complete diakochokinetic rate due to poor approximation and coordination of movements.

1. Name 3 cranial nerves you think could be damaged and explain why? (6)

2. What indications (ie symptoms) do you subjectively consider based on the patient’s presentation (prior to initiating the exam) just based off of what you see, hear and have read about the medical history? (2)

3. What does the inability to complete the diadochokinetic rate tell you about the patient’s speech/swallow deficits? (2)

Answer 1

One — the sixth cranial nerve — affects eye movement to the side, and the other — the seventh cranial nerve — affects facial movement. A stroke on one side of the pons will affect these nerves causing the eye and facial muscle weakness on the same side of the body as the injury.... Also the 9th cranial nerve is damaged...

Signs and SymptomsEdit

• Hemiparesis or hemiplegia of the lower half of the contralateral face
• Hemiparesis or hemiplegia of the contralateral upper and lower extremities*
• Sensory loss of the contralateral face, arm and leg*
• Ataxia of contralateral extremities*
• Speech impairments/aphasia: Broca's area, Wernicke's or Global aphasia as a result of a dominant hemisphere lesion (usually the left brain)
• Perceptual deficits: hemispatial neglect, anosognosia, apraxia, and spatial disorganization as a result of a non-dominant hemisphere lesion (usually the right brain)^[
• Visual disorders: déviation conjuguée, a gaze preference towards the side of the lesion; contralateral homonymous hemianopsia

Note: *faciobrachial deficits greater than that of the lower limb

The diadochokinetic (DDK) rate is a measurement that speech-language pathologists (SLPs) can make. These professionals help people with communication problems. They can use the DDK rate to assess, diagnose, and treat speech and language problems. The DDK rate is also known as the “Fletcher time-by-count test of diadochokinetic syllable rate.”

The DDK rate measures how quickly you can accurately repeat a series of rapid, alternating sounds called “tokens.” They’re designed to test how well you can make sounds with different parts of your mouth, tongue, and soft palate. The tokens contain one, two, or three syllables, such as:

• “puh”
• “puh-tuh”
• “puh-tuh-kuh”

The DDK rate is a measure of the repetitions of sounds within a designated amount of time. For example, your test results will show how many seconds it takes you to repeat a token 10 times.....

Multiple parts of your body control or affect your ability to speak, including the:

• cerebellum, or the bottom back portion of your brain
• central nervous system
• muscle and bone structures in your face, mouth, and throat

Your SLP can use the DDK rate to detect specific speech variations associated with different underlying conditions. Common variations and associated disorders include the following:-

Dysarthria is a motor speech disorder that causes slow or limited movement of your mouth, face, and respiratory system. It’s often a result of stroke or other brain injury...

Aphasia is a disorder marked by speaking in short phrases that make sense but are produced with great effort. It occurs due to damage to the left hemisphere of your brain.