Examine this patient's cranial nerves.Ask the patient a few questions.Test this patient's speech.



Ask the patient about nasal regurgitation, dysphagia.· Slurring of speech (patient may sound intoxicated).· Difficulty in chewing and swallowing.· Choking on liquids.


Nasal speech lacking in modulation, and great difficulty with all consonants.· Wasting of the tongue with fasciculations.· Weakness of the soft palate: ask the patient to say 'aah'.· There may be accumulation of saliva.· Fasciculation elsewhere (particularly trunk muscles).Proceed as follows:· Check the jaw jerk (normal or absent).· Tell the examiner that you would like to do the following:-Check the gag reflex.-Examine the hands for fasciculations, dissociated sensory loss.


This patient has bulbar palsy (lesion) due to motor neuron disease (aetiology) and has difficulty in swallowing (functional status).


What may be the underlying cause?·

Motor neuron disease - after the age of 60, rapidly progressive bulbar palsy is the commonest presenting symptom (see pp193-6).· Guillain-Barrd syndrome.· Syringomyelia (see pp 199-202).· Poliomyelitis.· Nasopharyngeal tumour.· Neurosyphilis.· Neurosarcoid.