Bulbar and pseudobulbar palsy

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.

    Causes

    Bulbar palsy

    • Motor neurone disease
    • Syringobulbia
    • Guillain-Barre syndrome
    • Poliomyelitis
    • Subacute menignitis (carcinoma, lymphoma)
    • Neurosyphilis
    • Brainstem CVA

    Pseudobulbar palsy

    The commonest cause is bilateral CVAs affecting the internal capsule.

    Other causes include:

    • Multiple sclerosis
    • Motor neurone disease
    • High brainstem tumours
    • Head injury

    Features

    Bulbar palsy

    The clinical features include:

    • Gag reflex – absent
    • Tongue – wasted, fasciculations
      “wasted, wrinkled, thrown into folds and increasingly motionless”.
    • Palatal movement – absent.
    • Jaw jerk – absent or normal
    • Speech – nasal
      “indistinct (flaccid dysarthria), lacks modulation and has a nasal twang”
    • Emotions – normal
    • Other – signs of the underlying cause, e.g. limb fasciculations.

    Pseudobulbar palsy

    The clinical features include:

    • Gag reflex – increased or normal
    • Tongue – spastic
      “it cannot be protruded, lies on the floor of the mouth and is small and tight”.
    • Palatal movement – absent.
    • 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”.
    • Emotions – labile
    • Other – bilateral upper motor neuron (long tract) limb signs.

    LITFL

    CCC Differential Diagnosis Series

    NEURO

    Anosmia, Ataxia, Blepharospasm, Bulbar and Pseudobulbar palsy, Central Pontine Myelinosis, Cerebellar Disease, Chorea, Cranial nerve lesions, Dementia, Dystonia, Exophthalmos, Eye trauma, Facial twitches, Fixed dilated pupil, Horner syndrome, Loss of vision, Meningism, Movement disorders, Optic disc abnormality, Parkinsonism, Peripheral neuropathy, Radiculopathy, Red eye, Retinal Haemorrhage, Seizures, Sudden severe headache, Tremor, Tunnel vision

    RESP

    Bronchial breath sounds, Bronchiectasis, High airway pressures, Massive haemoptysis, Sore throat, Tracheal displacement

    CVS

    Atrial Fibrillation, Bradycardia, Cardiac Failure, Chest Pain, Murmurs, Post-resuscitation syndrome, Pulseless Electrical Activity (PEA), Pulsus Paradoxus, Shock, Supraventricular tachycardia (SVT), Tachycardia, VT and VF, SVC Obstruction

    GIT

    Abdominal distension, Abdominal mass, Abdominal pain, Asterixis, Dysphagia, Hepatomegaly, Hepatosplenomegaly, Large bowel obstruction, Liver palpation abnormalities, Lower GI haemorrhage, Malabsorption, Medical causes of abdominal pain, Rectal mass, Small bowel obstruction, Upper GI Haemorrhage

    GUT

    Genital ulcers, Groin lump, Scrotal mass, Urine colour, Urine Odour, Urine transparency

    MSK

    Arthritis, Shoulder pain, Wasting of the small muscles of the hand

    DERM

    Palmar erythema, Serious skin signs in sick patients, Thickened Tethered Skin, Leg ulcers, Skin Tumour, Acanthosis Nigricans

    ENDO

    Diabetes Insipidus, Diffuse Goitre, Gynaecomastia, Hirsutism, Hypoglycaemia, SIADH, Weight Loss

    HAEM

    Splenomegaly

    PAEDS

    Floppy infant 

    MISC

    Anaphylaxis, Autoimmune associated diseases, Clubbing, Parotid Swelling, Splinter haemorrhages, Toxic agents and abnormal vitals, Toxicological causes of cardiac arrest

    IMAGING

    CHEST: Atelectasis, Hilar adenopathy, Hilar enlargement on CXR, Honeycomb lung, Increased interstitial markings, Mediastinal widening on mobile CXR, Pulmonary fibrosis, Pseudoinfiltrates on CXR, Pulmonary opacities on CXR,
    ABDO: 
    Gas on abdominal X-ray, Kidney mass,
    BRAIN: 
    Intracranial calcification, Intracranial structures with contrastVentriculomegaly,
    OTHER: Pseudofracture on X-Ray

    LABS

    LOW: Anaemia, Hypocalcaemia, hypochloraemia, Hypomagnesaemia

    HIGH: Bilirubin and Jaundice, HyperammonaemiaHypercalcaemia, Hyperchloraemia, Hyperkalaemia, Hypermagnesaemia

    ACID BASE: Acid base disorders, Resp. acidosis, Resp. alkalosis,

    Creatinine, CRP, Dipstick Urinalysis, Laboratory Urinalysis, Liver function tests (LFTs), Pleural fluid analysis, Urea, Urea Creatinine Ratio, Uric acid, Urinalysis, Urine Electrolytes


    CCC 700 6

    Critical Care

    Compendium

    Chris is an Intensivist and ECMO specialist at The Alfred ICU, where he is Deputy Director (Education). He is a Clinical Adjunct Associate Professor at Monash University, the Lead for the  Clinician Educator Incubator programme, and a CICM First Part Examiner.

    He is an internationally recognised Clinician Educator with a passion for helping clinicians learn and for improving the clinical performance of individuals and collectives. He was one of the founders of the FOAM movement (Free Open-Access Medical education) has been recognised for his contributions to education with awards from ANZICS, ANZAHPE, and ACEM.

    His one great achievement is being the father of three amazing children.

    On Bluesky, he is @precordialthump.bsky.social and on the site that Elon has screwed up, he is @precordialthump.

    | INTENSIVE | RAGE | Resuscitology | SMACC

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