Bulbar palsy

Bulbar palsy
Bulbar palsy
Specialty	Neurology
Symptoms	Dysphagia, dysarthria, flaccid paralysis, muscle atrophy, drooling of saliva, reduced or absent gag reflex

Bulbar palsy refers to a range of different signs and symptoms linked to impairment of function of the glossopharyngeal nerve (CN IX), the vagus nerve (CN X), the accessory nerve (CN XI), and the hypoglossal nerve (CN XII). It is caused by a lower motor neuron lesion in the medulla oblongata, or from lesions to these nerves outside the brainstem, and also botulism. This may be caused by any of a number of genetic, vascular, degenerative, inflammatory, and other underlying conditions. It can be differentiated from pseudobulbar palsy. When there is airway obstruction, intubation is used.

Signs and symptoms

Symptoms

dysphagia (difficulty in swallowing).^[1]
difficulty in chewing.
nasal regurgitation.
difficulty in handling secretions, including aspiration of liquids.^[2]
difficulty breathing (airway obstruction).^[2]
dysphonia (defective use of the voice, inability to produce sound due to laryngeal weakness).
dysarthria (difficulty in articulating words due to a CNS problem), such as slurred speech.^[1]

Signs

flaccid paralysis,^[1] such as soft palate weakness (examined by asking the patient to say aah).^[1]
muscle atrophy,^[1] such as tongue atrophy with fasciculations.
nasal speech lacking in modulation and difficulty with all consonants.
drooling of saliva.^[1]
normal or absent jaw jerk.
reduced or absent gag reflex.^[1]

In addition, there may be lower motor neuron lesions of the limbs.

The ocular muscles are spared and this differentiates it from myasthenia gravis.

Causes

Genetic: Kennedy's disease,^[1] acute intermittent porphyria.
Vascular causes: medullary infarction, such as lateral or medial medullary infarction.^[1]
Degenerative diseases: amyotrophic lateral sclerosis,^[1]^[3] syringobulbia,^[1] Wolfram syndrome.
Inflammatory/infective: Guillain–Barré syndrome,^[1] poliomyelitis,^[1] Lyme disease.
Cancer:^[1] brainstem glioma, malignant meningitis.
Toxic: botulism, venom of bark scorpion (species Centruroides), some neurotoxic snake venoms.^[4]
Autoimmune: myasthenia gravis.

Mechanism

Bulbar palsy involves problems with function of the glossopharyngeal nerve (CN IX), the vagus nerve (CN X), the accessory nerve (CN XI), and the hypoglossal nerve (CN XII).^[1] These all emerge from pathways in the medulla oblongata.^[1] A lower motor neuron lesion can impair their function.^[5]^[1]

Diagnosis

Differential diagnosis

In contrast, pseudobulbar palsy is a clinical syndrome similar to bulbar palsy but in which the damage is located in upper motor neurons of the corticobulbar tracts in the mid-pons (i.e., in the cranial nerves IX-XII), that is the nerve cells coming down from the cerebral cortex innervating the motor nuclei in the medulla. This is usually caused by stroke.

Treatment

In patients with airway obstruction due to bulbar palsy, intubation may be used.^[2] This can be tracheal intubation or supraglottal intubation.^[2]

References

^ ^a ^b ^c ^d ^e ^f ^g ^h ⁱ ^j ^k ^l ^m ⁿ ^o ^p ^q Rea, Paul (2015). "5 - Hindbrain (Rhombencephalon)". Essential Clinical Anatomy of the Nervous System. Academic Press. pp. 91–98. doi:10.1016/B978-0-12-802030-2.00005-4. ISBN 978-0-12-802030-2. Archived from the original on 2021-11-20. Retrieved 2021-11-20.
^ ^a ^b ^c ^d Warrell, David A. (2020). "137 - Animals Hazardous to Humans: Venomous Bites and Stings and Envenoming". Hunter's Tropical Medicine and Emerging Infectious Diseases (10th ed.). Elsevier. pp. 966–987. doi:10.1016/B978-0-323-55512-8.00137-X. ISBN 978-0-323-55512-8. Archived from the original on 2021-11-20. Retrieved 2021-11-20.
^ Jones, Bronwyn (2008). "19 - Abnormalities of Pharyngeal Function". Textbook of Gastrointestinal Radiology (3rd ed.). Saunders. pp. 253–269. doi:10.1016/B978-1-4160-2332-6.50024-5. ISBN 978-1-4160-2332-6. Archived from the original on 2021-11-20. Retrieved 2021-11-20.
^ http://www.us.elsevierhealth.com/wilderness-medicine-9781437716788.html ^{[permanent dead link]}
^ "Bulbar Palsy". Palsy. Archived from the original on 2011-04-27.

External links

[:0-1] ^ ^a ^b ^c ^d ^e ^f ^g ^h ⁱ ^j ^k ^l ^m ⁿ ^o ^p ^q Rea, Paul (2015). "5 - Hindbrain (Rhombencephalon)". Essential Clinical Anatomy of the Nervous System. Academic Press. pp. 91–98. doi:10.1016/B978-0-12-802030-2.00005-4. ISBN 978-0-12-802030-2. Archived from the original on 2021-11-20. Retrieved 2021-11-20.

[:1-2] Warrell, David A. (2020). "137 - Animals Hazardous to Humans: Venomous Bites and Stings and Envenoming". Hunter's Tropical Medicine and Emerging Infectious Diseases (10th ed.). Elsevier. pp. 966–987. doi:10.1016/B978-0-323-55512-8.00137-X. ISBN 978-0-323-55512-8. Archived from the original on 2021-11-20. Retrieved 2021-11-20.

[3] Jones, Bronwyn (2008). "19 - Abnormalities of Pharyngeal Function". Textbook of Gastrointestinal Radiology (3rd ed.). Saunders. pp. 253–269. doi:10.1016/B978-1-4160-2332-6.50024-5. ISBN 978-1-4160-2332-6. Archived from the original on 2021-11-20. Retrieved 2021-11-20.

[4] ttp://www.us.elsevierhealth.com/wilderness-medicine-9781437716788.html ^{[permanent dead link]}

[5] "Bulbar Palsy". Palsy. Archived from the original on 2011-04-27.

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