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Bulbar and pseudobulbar palsies (Epidemiology (Rare, Usually UMN or LMN,…
Bulbar and
pseudobulbar palsies
Epidemiology
Rare
Usually UMN or LMN
If both UMN and LMN, its MND
Aetiology
Pseudobulbar
Vascular: extensive stroke/haemorrhage
Degenerative: MND
Bulbar
Neoplastic: branstem/skull base tumour
Degenerative: MND, syringobulbia
Clinical
presentation
Pseudobulbar
Slurred speech
Dysphagia
Emotional lability
Bulbar
Nasal speech
Dysphagia
Diagnosis
Examination
CN exam
Tongue: spastic/slow (UMN, wasted/fasiculating (LMN)
Palate movement/swallowing: absent (both)
Gag reflex: absent (LMN), brisk (UMN)
Limb exam
Normal (unless MND, extensive stroke)
Investigations
Bloods
FBC, CRP, U+E, LFT,
TFT, glucose, lipids, clotting
Imaging
CT head (SOL, bleeds)
MRI spine (syringobulbia, tumours)
Bedside
Obs
ECG (AF etc)
Special tests
NCT (normal)
EMG (MND)
Muscle biopsy (MND)
History
DH
Meds, allergies
FH
Strokes, cancers, MND
PMH
Known medical conditions
SH
Living arrangements, occupation,
smoking, alcohol
PC/HPC
Swallowing difficulty,
slurred/nasal voice, emotion changes,
other symptoms
Management
Initial ABCDE
Definitive
Per cause
Definition
Bulbar palsy
Bilateral LMN lesion of CN IX and X
Pseudobulbar palsy
Bilateral UMN lesion of CN IX and X