Question

Swallowing- Case Study

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?

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?

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

Answer 1

1. Facial nerve : The patient shows right facial droop and decreased strength of lip muscles. This is a result of weakness of facial muscles. The facial muscles are supplied by facial nerve and damage to this nerve will result in facial droop.
Glossopharyngeal nerve : Decreased elevation of the larynx suggests weakness of the larynx. The larynx is supplied by glossopharyngeal nerve and damage to this nerve results in laryngeal weakness.
Hypoglossal nerve : The tongue is supplied by hypoglossal nerve. Damage to this nerve causes tongue to deviate on the affected side.
So the three cranial nerves that seem to be damaged are facial nerve, glossopharyngeal nerve and hypoglossal nerve.
2. The subjective symptoms in the patient are :

- right side hemiparesis

- slurred speech

- difficulty in speaking

- difficulty in swallowing

- right side facial droop

- soft and breathy vocal quality

3. Diadochokinetic rate is the rate at which a client can repeat alternating syllables in a predecided time limit. Diadochokinetic rate assesses the alternating speech movements. Generation of speech and pronounciation of alternating syllables require the parts of brain associated with speech, swallowing and language to work together in coordination with each other.
If the patient is unable to complete Diadochokinetic rate it indicates impairment of structures associated with speech, swallowing and the associated muscles.