Bulbar vs pseudobulbar palsy

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Describe a bulbar voice
Blocked nose, nasal escape
Daffy Duck
Soft voice
Bovine cough (no sharp start)
Moist voice, gargles
What's the party trick to demonstrate bulbar voice with nasal escape?
Hold mirror / cold metal under the nose, get pt to say 'pop pop pop pop' --> fogs up
How do consonants sound with a bulbar voice?
Consonants not clean, crisp. 'La la la', fast but not clean. Demonstrate: baby hippopotamus
Where's the lesion in a bulbar palsy? (UMN vs LMN? What area)?
Where's the lesion in a pseudobulbar palsy? (UMN vs LMN? What area)?
A bulbar palsy is a lower motor neuron lesion of cranial nerves IX, X and XII.
A pseudobulbar palsy is an upper motor neuron lesion of cranial nerves IX, X and XII.
Bulbar palsy - comment on:
gag reflex
tongue
jaw jerk
speech
emotions
Gag reflex - absent
Tongue - wasted, fasciculations, lateral furrows
Jaw jerk - absent or normal
Speech - nasal, soft, Daffy Duck, moist voice
Emotions - normal
Other - signs of the underlying cause, e.g. limb fasciculations.
Pseudobulbar palsy - comment on:
gag reflex
tongue
jaw jerk
speech
emotions
Gag reflex - increased or normal
Tongue - spastic. No fasciculations
"it cannot be protruded, lies on the floor of the mouth and is small and tight".
Jaw jerk - increased
Speech - spastic: "a monotonous, slurred, high-pitched, 'Donald Duck' dysarthria" that "sounds as if the patient is trying to squeeze out words from tight lips".
Strangled, effortful voice. la la la is forced, slow, clumsy
Emotions - labile
Other - bilateral upper motor neuron (long tract) limb signs.
What are the causes of bulbar palsy?
Motor neurone disease
Syringobulbia
Guillain-Barre syndrome
Poliomyelitis
Subacute menignitis (carcinoma, lymphoma)
Neurosyphilis
Brainstem stroke
What are the causes of pseudobulbar palsy?
The commonest cause is bilateral strokes affecting the internal capsule.

Other causes include:
Multiple sclerosis
Motor neurone disease
High brainstem tumours
Head injury