Pseudobulbar palsy and Balbar palsy

• Symptoms linked to impaired function of CN 
  • 9 Golossopharngeal
  • 10 – Vagus
  • 11 – Accessory
  • 12 – Hypoglossal

Aspect	Pseudobulbar Palsy	Bulbar Palsy
Definition	A condition due to bilateral upper motor neuron lesions affecting the corticobulbar tracts.	A condition due to lower motor neuron lesions affecting the cranial nerves IX, X, XI, and XII.
Causes	Stroke, multiple sclerosis, motor neuron disease, head trauma, brain tumors, and cerebral palsy.	Motor neuron disease (ALS), stroke, brainstem tumors, Guillain-Barre syndrome, and myasthenia gravis.
Clinical Presentations	Dysarthria, dysphagia, emotional lability (involuntary laughing or crying), and spastic tongue.	Dysarthria, dysphagia, nasal regurgitation, weak cough, and atrophy and fasciculations of the tongue.
Signs	– Hyperreflexia of the jaw jerk – Spastic tongue – Emotional lability	– Absent or diminished gag reflex – Atrophy and fasciculations of the tongue – Nasal speech and regurgitation
Management	– Address underlying cause (e.g., antiplatelet therapy for stroke, immunomodulation for MS) – Speech and language therapy – Nutritional support (e.g., PEG tube if severe dysphagia) – Medications for emotional lability (e.g., SSRIs)	– Address underlying cause (e.g., anticholinesterase for myasthenia gravis) – Speech and language therapy<br>- Nutritional support (e.g., PEG tube if severe dysphagia) – Respiratory support if necessary

Pseudobulbar Palsy

• upper motor neuron lesion to the corticobulbar pathways in the pyramidal tract.
• bilateral impairment of the function of the lower cranial nerves IX, X, XI and XII involving eating swallowing and talking m.

Causes:

1. Stroke: Particularly bilateral strokes affecting the corticobulbar tracts.
2. Multiple Sclerosis (MS): Demyelination affecting the brainstem pathways.
3. Motor Neuron Disease (MND): Especially amyotrophic lateral sclerosis (ALS).
4. Head Trauma: Severe injuries leading to brainstem damage.
5. Brain Tumors: Tumors compressing or infiltrating the brainstem.
6. Cerebral Palsy: Particularly when involving the corticobulbar tracts.

Clinical Presentations:

1. Dysarthria: Difficulty in articulation due to spasticity of the speech muscles.
2. Dysphagia: Difficulty in swallowing, which can lead to aspiration.
3. Emotional Lability: Inappropriate or uncontrollable laughing or crying.
4. Spastic Tongue: Increased muscle tone in the tongue.

Signs:

1. Hyperreflexia of the Jaw Jerk: Exaggerated jaw jerk reflex +++
2. Spastic Tongue: Stiff and spastic tongue movement.
3. Emotional Lability: Observable involuntary emotional expressions.
4. Gag Reflex: Typically preserved or exaggerated.

Management:

1. Address Underlying Cause:
   • Stroke: Antiplatelet therapy, anticoagulation, and rehabilitation.
   • MS: Immunomodulatory therapies like interferons, glatiramer acetate, or monoclonal antibodies.
2. Speech and Language Therapy: To improve communication and swallowing.
3. Nutritional Support:
   • PEG Tube: Percutaneous endoscopic gastrostomy if severe dysphagia is present.
4. Medications for Emotional Lability:
   • SSRIs: Selective serotonin reuptake inhibitors.
   • Dextromethorphan/Quinidine: Specifically approved for pseudobulbar affect.

Bulbar Palsy

• It is a Bilateral – lower motor neuron lesion – either at nuclear or fascicular level in the medulla or from bilateral lesions of the lower cranial nerves outside the brain-stem
• classified – progressive or non progressive

Causes:

1. Motor Neuron Disease (ALS): Progressive degeneration of lower motor neurons.
2. Stroke: Particularly affecting the medulla oblongata.
3. Brainstem Tumors: Tumors affecting cranial nerve nuclei.
4. Guillain-Barre Syndrome: Acute inflammatory demyelinating polyneuropathy.
5. Myasthenia Gravis: Autoimmune disorder affecting neuromuscular junction.

Clinical Presentations:

1. Dysarthria: Slurred speech due to muscle weakness.
2. Dysphagia: Difficulty in swallowing, leading to choking or aspiration.
3. Nasal Regurgitation: Due to palatal weakness.
4. Weak Cough: Inability to clear secretions effectively.
5. Atrophy and Fasciculations of the Tongue: Visible muscle twitching and wasting.

Signs:

1. Absent or Diminished Gag Reflex: Due to cranial nerve IX and X involvement.
2. Atrophy and Fasciculations of the Tongue: Indicative of lower motor neuron involvement.
3. Nasal Speech and Regurgitation: Hypernasal speech and fluid regurgitation through the nose.
4. Palatal Weakness: Soft palate fails to elevate properly.

Management:

1. Address Underlying Cause:
   • ALS: Riluzole and supportive care.
   • Myasthenia Gravis: Anticholinesterase medications (e.g., pyridostigmine), immunosuppressants, thymectomy.
2. Speech and Language Therapy: To assist with communication and swallowing.
3. Nutritional Support:
   • PEG Tube: If severe dysphagia is present.
4. Respiratory Support:
   • Non-Invasive Ventilation: BiPAP or CPAP in case of respiratory muscle weakness.
   • Tracheostomy: In severe cases requiring long-term ventilation support.