SPEECH ABNORMALITIES

Dr Ramarao.ch

Terminology Neuroanatomy Cerebral dominance Evaluation Aphasia syndromes Dysarthria

CONTENTS

Dysarthria- a specific disorder of articulation in which basic language intact.

Anarthria-total loss of articulation Aphasia- is true language disturbance in which patient

demonstrates an impaired production or comprehension of spoken language.

Dysphasia-difficulty in speech Alexia – is loss of reading ability Agraphia- loss of writing ability. Apraxia-A failure of ability to carry out well organized

voluntary movement correctly despite the fact that motor,sensory&coordinative functions are not significantly impaired.

TERMINOLOGY

Phonemes-smallest meaning carrying sounds

Morphology-use of appropriate word endings and connector words for tenses, possessives and singular Vs plural

Semantics- meaning of a word or phrase

Syntax- arrangement of words & phrases to create sentences.

Discourse-use of these elements to create organized and logical expression of thoughts

LINGUISTIC COMPONENTS

NEUROANATOMY

Auditory cortex-reception of spoken language.

Wernicke’s area-decoding of sounds into linguistic information.

Brocas area- spontaneous speech and repetition

SMG- phoneme processing in comprehension and phoneme production for repetition and speech

AG- processing of visual language into auditory language information

NEUROANATOMY

Arcuate fasciculus- connects sensory and motor language areas.

Role of subcortical structures

Thalamus- a relay station for RAS, appears to alert the language system

Basal ganglia-involved in expressive speech

Left hemisphere dominance-seen in >99% of right handed individuals and 70% of non right handlers

Right hemisphere dominance-seen in 13% of left handed individuals and <1% of right handed individuals

Mixed dominance- seen in those with a strong family history of left handedness

CEREBRAL DOMINANCE FOR LANGUAGE AND HANDEDNESS

Spontaneous speech Comprehension Repetition NAMING READING Writing

EVALUATION

The first step in language testing is to listen carefully to the patient's spontaneous speech.

If the patient offers none, open-ended questions should be asked in order to elicit speech production

It is wise to ask the patient to discuss relatively uncomplicated issues, such as "Tell me why you are in the hospital" or 'Tell me about your work."

SPONTANEOUS SPEECH

Several clinical observations must be made and noted while listening to the patient's spontaneous speech

• Is speech output present?

• Is the speech dysarthric or dysprosodic?

• Is there evidence of specific aphasic errors (e.g., errors of syntax, word-finding pauses, abnormal words, or paraphasias)

Non fluent speech- Non fluent output is sparse and effortful, contains primarily nouns (substantive words), is agrammatic and contains frequent wordfinding pauses.

For instance, the non fluent patient describing winter weather might say "ah, ah, cold . .. snow ... freezing ... ah, ah ... cold.“

Patients with non fluent aphasia are likely to have an anterior left hemisphere lesion.

TYPES OF APHASIC SPEECH

Fluent aphasia- The output is fluent and is characterized by normal or excessive rate of word production

Content words (nouns and verbs) are lacking, and, in contradistinction to non fluent output, small grammatic words such as articles, conjunctions, and interjections prevail.

For example,a patient attempts to describe how his wife accidentally threw away something important,perhaps his dentures: ‘we don’t need it anymore she says.And with it when that was downstairs was my teeth-tick….a…den…dentith…my dentist.”

The nouns and verbs are often paraphasic.

Verbal or semantic paraphasia- The complete word substitution ("pen" for "car")

Phonemic or literal paraphasia- The syllable substitution ("lar" for "car"')

Neologistic paraphasia- The substitution of a non-English or nonsense word is the neologistic (new word) paraphasia

Fluent aphasia usually associated with posterior lesions.

PARAPHASIAS :

Two methods of testing comprehension: pointing commands and questions that can be answered with a "yes" or "no" response.

Testing the patient's ability to point to single objects in the room, body parts, or articles collected from the examiner's pockets is an excellent way to quantify single-word comprehension.

Next, a series of simple and complex questions that require only "yes" or "no" answers should be asked. For example, "Is this a hotel?" "Is it raining today?" "Do you eat breakfast before dinner?"

COMPREHENSION

Repetition is a complex process that can be affected by impaired auditory processing, disturbed speech production, or disconnection between receptive and expressive language functions.

Testing should present material in ascending order of difficulty, beginning with single monosyllabic words and proceeding to complex sentences.

REPETITION

Ball. Airplane,hippopotamus Mississippi River. The little boy went home.

TEST ITEMS

A deficit in naming(anomia) is the single MC finding in aphasic patients.

Anomia may also be objectively tested with a confrontation naming test.

The examiner should select from 10 to 20 items. Several categories of objects should be used (colors, body parts, room objects, articles of clothing, and parts of objects)

NAMING

Colors

RedBlueYellowPinkpurple

Body parts

EyeLegTeethThumbknuckles

Room objects

DoorWatchShoeShirtceiling

Parts of objects

Watch stemCoat lapelWatch crystalSole of shoeBuckle of belt

Testing objects

Reading ability is one of the few aspects of mental status testing that is directly related to educational experience.

Both reading comprehension and reading aloud ability should be tested.

If the patient is not aphasic, screen for alexia by having the patient read a paragraph from a newspaper or magazine. To test reading in patients with aphasia, begin with having them read aloud first short single words, then phrases, sentences, and finally paragraphs

READING

Agraphia is diagnosed when a patient demonstrates basic language errors, gross spelling errors, or use of paragraphias (word or syllable substitutions).

To test writing, first have the patient write letters and numbers to dictation. Second, ask the patient to write the names of common objects or body parts.

Third, if patients can successfully write single words, ask them to write a short sentence describing the weather, their job, or a picture from a magazine

WRITING

APHASIA SYNDROMES

Global aphasia, the most common and severe form of aphasia, is character ized by spontaneous speech that is either absent or reduced to a few stereo typed words or sounds (e.g., "ba, ba, ba" or "dis, a dis, a dis").

Comprehension is absent or reduced to only recognition of the patient's name or a few selected words.

Performance on repetition is at the same level as spontaneous speech. Reading and writing are likewise severely impaired

GLOBAL APHASIA

Global aphasia is caused by a large lesion that damages most or all of the combined language areas motor and sensory (anterior and posterior shaded areas).

The most common lesion causing global aphasia is an occlusion of the internal carotid artery or the middle cerebral artery at its origin, caused by an embolus from the heart or carotid artery

GLOBAL APHASIA

Feature characteristic

Spontaneous speech Non-fluent,mute

Naming Impaired

Auditory comprehension Impaired

Repitition Impaired

Reading Impaired

writing Impaired

Associated signs Right hemianopia,right hemiparesis,right hemisensory loss

behavior Often depressed

Features of Global aphasia

Patients with Broca's aphasia have nonfluent, dysarthric, dysprosodic, effortful speech.

The characteristic speech has been called agrammatic or telegraphic.

For example, one patient with Broca's aphasia described a picture of a boy on a stool stealing cookies while his mother is washing dishes and letting the sink run over in the following manner: "Boy .. .ah girl cookie ... stool falling ... water spilling . .. dishes."

BROCAS APHASIA

Repetition and reading aloud are as severely impaired as spontaneous speech.

Auditory and reading comprehension are surprisingly intact, although the comprehension of complex grammatic phrases (e.g., "Do you eat lunch before breakfast?") is often impaired.

The lesion causing Broca's aphasia includes more than Brodmann's area 44 alone.

Auditory and visual (reading) comprehension are intact because parietal and temporal lobes are not damaged.

These patients often undergo an interesting and significant emotional change, characterized by frustration, agitation, and depression

The prognosis for language recovery in patients with Broca's aphasia is generally more favorable than in those with global aphasia.

Spontaneous speech Non fluent, hesitant, mute to agrammatic, often dysarthric

Naming impaired

Auditory comprehension Intact for simple material; impaired for complex syntactic constructions

Repitition Impaired, hesitant

Reading Difficulty reading aloud, often poor reading comprehension

writing Difficulty writing

Associated signs Right hemiparesis, right hemisensory loss.

behavior Frustrated, depressed

Features of Brocas aphasia

Wernicke's aphasia can be considered the linguistic opposite of Broca's aphasia.

The patient with Wernicke's aphasia has fluent, effortless, well-articulated speech.

The output, however, contains many paraphasias and is often devoid of substantive words.

The essential feature of Wemicke's aphasia is a severe disturbance of auditory comprehension

WERNICKE’S APHASIA

Repetition is severely impaired because of a severe auditory processing defect. Naming is grossly paraphasic.

Because the damage is restricted to parietal and temporal lobes in most patients, the person with classic Wemicke's aphasia does not have hemiplegia.

They are frequently totally unaware of their problem and may talk endlessly without the slightest appreciation of their language deficit.

Feature Characteristics

Spontaneous speech Fluent, but paraphasic errors

Naming Impaired, often paraphasic

Auditory comprehension Impaired, often for even simple questions

Repetition Impaired

Reading Usually impaired

writing Well formed but paragraphic

Associated signs Right hemianopia

behavior Inappropriately happy, sometimes angry, suspicious

FEATURES OF WERNICKE’S APHASIA

The hallmark of conduction aphasia is a disproportionate deficit in repetition.

Two lesions are known to cause conduction aphasia.

The first is usually reported to involve the supramarginal gyrus and arcuate fasciculus.

The second lesion damages the insula, contiguous auditory cortex, and underlying white matter.

CONDUCTION APHASIA

Feature Characteristic

Spontaneous speech Fluent, with literal paraphasic errors

Naming Variably intact

Auditory comprehension Intact

Repetition poor

Reading Variable aloud, comprehension intact

writing Variably intact

Associated signs Right hemiparesis, right hemisensory loss, visual field defects

behavior No characteristic behavior

FEATURES OF CONDUCTION APHASIA

The linguistic opposite of conduction aphasia is transcortical aphasia

The transcortical aphasias are characterized by intact repetition of spoken language but disruption of other language functions.

Three types- Transcortical sensory aphasia Transcortical motor aphasia Transcortical mixed aphasia

TRANSCORTICAL APHASIAS

Feature TMA TSA MTCA

Speech Non fluent Fluent Non fluent

Naming Impaired Impaired Impaired

Repetition Preserved Echolalic Echolalic

comprehension Preserved Impaired Impaired

Reading Preserved Impaired Impaired

Writing Reduced Paragraphic Poor

Associated signs

Right leg >arm weakness, abulia

variable Right or bilateral hemiparesis

FEATURES OF TRANSCORTICAL APHASIAS

The lesions that cause transcortical aphasia are either extensive, crescent-shaped infarcts within the border zones between major cerebral vessels.

Transcortical motor aphasia is seen with an anterior border zone lesion, whereas transcortical sensory aphasia indicates a lesion that re sembles a reversed C.

These lesions spare perisylvian cortex.

The most common causes of transcortical aphasia are:

1. Anoxia secondary to decreased cerebral circulation, as seen in cardiac arrest

2. Occlusion or significant stenosis of the carotid artery 3. Anoxia due to CO poisoning 4. Dementia

In some patients with aphasia, the only language defects are word-finding difficulty and an inability to name objects on confrontation.

Lesions in many parts of the dominant hemisphere can cause anomic aphasia; thus, the localizing significance of this type of aphasia is limited.

The most severe anomic aphasia, however, is noted in patients with temporal lobe lesions involving the second and third temporal gyri

ANOMIC APHASIA

Feature Characteristic

Spontaneous speech Fluent aphasia with word finding pauses and circumlocutions

Naming Impaired

Auditory comprehension Intact

Repetition Intact

Reading Intact

writing Intact except for word finding difficulty

Associated signs Variable, often absent

FEATURES OF ANOMIC APHASIA

Aphasia

BrocaGlobalTCMA

Mixed TCA

WernickeConduction

AnomicTCSA,pure word deafness

Approach to Aphasia

Non fluent

Fluent

BrocasGlobalTCMA

Mixed TCA

BrocaGlobal

Global

Broca

TCMAMixed TCA

Mixed TCA

TCMA

Nonfluent aphasia

Impairedrepetition

Intactrepetition

comprehension

comprehension

WernickeConduction

AnomicTCSA

WernickeConduction

Wernicke

Conduction

AnomicTCSA

TCSA

Anomic

Fluent aphasias

Impairedrepetition

Intactrepetition

comprehension

comprehension

Some patients with vascular lesions (either hemorrhage or infarct) of the thalamus, putamen, caudate nucleus, or internal capsule will demonstrate aphasic symptoms.

They have mild anomia and comprehension deficits but excellent repetition.

Anterior lesions tend to produce speech-production problems, whereas posterior lesions result in comprehension difficulty

SUBCORTICAL APHASIA

Owing to their mixed cerebral dominance, left-handed individuals may become aphasic secondary to a lesion in either hemisphere.

The resultant aphasia is usually milder and is associated with greater recovery than an aphasia caused by a similar lesion in a right-handed patient.

Aphasia in Left-Handed Individuals (Non-Right-Handers)

Patients do not have aphasic speech, agraphia, or alexia, yet are lacking in verbal language comprehension.

The lesion that produces this condition is located in the posterior language area and is often bilateral.

The lesion is deep in the temporal lobe and effectively disconnects auditory input from the auditory cortex.

PURE WORD DEAFNESS

Inability to understand written speech,The classic syndrome of pure alexia without agraphia is caused by a left posterior cerebral artery occlusion(lesion in left occipital cortex) in a right-handed individual.

All visual information enters only the right hemisphere.

The right visual cortex perceives the written material but cannot transmit it to the left hemisphere because of the lesion in splenium of corpus callosum.

ALEXIA

The inferior parietal lobe in the dominant hemisphere (primarily area 39, the angular gyrus) is the association cortex that combines the visual and auditory information necessary for reading and writing

A second distinct type of alexia, classically called alexia with agraphia, results from damage to the inferior parietal lobe itself (angular gyrus ).

This lesion renders the patient unable to read or write.

The linguistic message to be written originates in the posterior language area, is then translated into visual symbols in the inferior parietal area, and is finally transferred to the frontal language area for motor processing.

Two syndromes are seen in patients with damage to the dominant parietal lobe

1. Agraphia with alexia, 2. A syndrome of agraphia in association with other parietal

lobe signs (dys-calculia, right-left disorientation, and finger agnosia), called Gerstmann's syndrome

AGRAPHIA

One rare pure agraphia occurs only in the left hand.

This syndrome is seen in patients with lesions of the anterior corpus callosum.

These patients are agraphic with the left hand only, because the right motor cortex is disconnected from the language areas of the left hemisphere.

Neurotic patients- produces a halting,effortful,telegraphic speeech pattern.They

have normal comprehension,repetition,and naming.

Acute aphonia-total inability to adduct the vocal cords and make audible sounds.It is a conversion reaction or more commonly,secondary to insult to the speech apparatus.

Elective mutism is another functional speech disorder characterised by willful reluctance to speak

Non organic speech disorders

Articulation requires correct bilateral co-ordination of the tongue, lips, palate, larynx and muscles of respiration.

Examination- 1. Listen to the patient’s enunciation during history taking 2. Ask the patient to repeat certain phrases. These include British constitution, methodist episcopal, west

register street etc. Facial paralysis causes difficulty with labials like b, p, m, w. Tongue paralysis affects letters like l, d, n, s, t, x, z. Palatal paralysis produces nasal speech.eg:’b & d become

m&n.

DYSARTHRIA

Type Localization Auditory signs Diagnosis

Flaccid LMN Breathy, nasal voice Stroke, MG

Spastic Bilateral UMN Strain strangle, harsh voice, slow rate

B/L strokes, tumors.

Ataxic cerebellum Irregular articulatory breakdowns, excessive and equal stress

Stroke,multiple sclerosis,hereditary ataxia,choreas, anticonvalsant toxicity

Hypokinetic or rigid Extra pyramidal Rapid rate, reduced loudness, monopitched

PD

Hyperkinetic Extra pyramidal Prolonged phonemes, variable rate

Dystonia, HD

Spastic-flaccid UMN+LMN Hypernasality, harsh voice, slow rate

ALS,multiple strokes

Classification of dysarthrias