- For all examinations: wash your hands (perhaps less relevant here!), introduce yourself, and ask for permission (consent) to examine.
- Assessment of speech can be a tricky examination. The key is to be systematic yet quick, and to assess as many 'types' or 'qualities' of the speech as rapidly as possible in order to get a rough idea of what kind of pathology you are dealing with.
- Remember that you are testing several features: the quality of the speech (dysarthria, dysphonia), the content of the speech (expression - Broca's area), and the patient's understanding of your commands (receptive function - Wernicke's area).
- Fluency & volume: assess during history taking
- Ask patient to cough sharply
- Comprehension: execute a 3 step non-verbal task, eg. 'touch your chin, then your nose, then your ear'
- Repetition: 'no ifs, ands or buts' and 'British constitution'
- Naming: point to 2 objects
Assessment of Speech
- To begin, say to the patient: 'tell me where you are? or 'describe x for me'. This will get them talking and enable you to screen for any abnormalities. Remember that even in exams, it is perfectly possible to get someone who is completely normal and has absolutely no pathology, so be prepared to find nothing!
- Listen out for the features mentioned above. Is the patient confabulating? (making up the content to compensate for anterograde amnesia - seen in alcoholics with Wernicke-Korsakoff's phenomenon).
- Ask the patient to repeat the words: 'unversity' or 'british constitution' - listen for dysarthria / bulbar (LMN = nasal speech + tongue fasciculating + wasting) / pseudobulbar (UMN = hot potato speech + increased jaw jerk + spastic)
- Get the patient to perform 3-step commands (any receptive dysphasia?)
- Name and describe objects and what they do (nominal aphasia/expressive dysphasia)
- Cough + say ?eee? (dysphonia)
- If appropriate, perform a Mental State Examination (it may be wise to open with this if you are uncertain if the patient has an expressive/receptive problem vs a dementia).
To complete: Thank the patient.
- DYSPHONIA: altered quality of voice (reduced volume) due to vocal cord disease.
- Assessment : Look for quiet voice and bovine (hollow sounding) cough.
- DYSARTHRIA: inability to shape noise into words.
- Assessment : Slurred and slowed pronunciation on saying ?university? or ?British constitution?
- DYSPHASIA (receptive): difficulty in understanding speech.
- Assessment : Execute a 3-step command. Often have fluent speech.
- DYSPHASIA (expressive): can understand, but cannot answer appropriately
- Assessment : Non-fluent speech, word finding difficulties
Types of Dysphasias
- Difficulty in expression of speech. Caused by a lesion in at the inferior frontal gyrus (on language dominant hemisphere).
- Speech is slow and 'forced', and features short phrases. Comprehension is usually intact. Repetition of both auditory and visual stimuli is usually impaired.
- Difficulty in comprehension. Caused by a lesion in at the posterior part of superior temporal gyrus (on language dominant hemisphere).
- Speech may appear quite fluent, although may not necessarily make sense. Repetition of both auditory and visual stimuli is usually impaired.
- Difficulty in repetition. Caused by a lesion in the arcuate fasciculus (inferior parietal lobe of language dominant hemisphere - connects Wernicke's to Broca's areas).
Arcuate fasciculus intact, so repetition spared. 3 types:
- Mixed: Both Broca's and Wernicke's areas are damaged, leaving little comprehension/expression of language, however repetition is possible.
- Sensory: Like Wernicke's, but with a lesion either posterior or superior to Wernicke's area, leaving repetition spared.
- Motor: Like Broca's, but with a lesion either anterior or superior to Broca's area, leaving repetition spared.
NB: Global aphasia is loss of all three - Broca's, the arcuate fasciculus and Wernicke's areas, resulting in a total language disturbance.