GUIDED BY : MS.S.

DIVYA

PRESENTED BY : E.AKASH
: N.SANTHOSH
 Myasthenia gravis is a
chronic autoimmune
neuromuscular disease
 Causes weakness in the
skeletal muscles, which are
responsible for breathing
and moving parts of the
body, including the arms
and legs.
 The ratio of 150-200 / one million
people gets affected
 Age group :
24-46 years more common in
female than in male 32-61 years
more common in male than in
female
 MG

Anticholinergic
Anti musk
receptors
antibodies
antibodies
 Muscular weakness
 Increase fatigue with
sustained effort
 Cranial muscular gets
affected
 Diplopia
 Chewing
 Hyper nasality
 Dysarthria
 CT,MRI
 EMG
 Pulmonary Function Test
 Tensolan Edrophoniam
 Anticholenestrate Drugs
 Immuno Supresive Drugs
 Plasmapherasis
 Thymectomy
 Name :xxx
 Age/gender :50 years/Female
 Occupation :Teacher

BRIEF HISTORY:
Complaint of UNCLEAR & HYPERNASAL
SPEECH. Currently the client communicates her
needs through sentences
• ELECTRODIAGNOSTIC TEST were done at DHAKA on 10/7/19-NCS and EMG of right
upper , left lower and tongue muscles were done and it reveals Active disorder of motor
neuron with axons or both involving cranial muscles

• ACETYLCHOLINE RECEPTORS BINDING ANTIBODY TEST was done on 3.11.2018

reveals NEGATIVE RESULTS OF MYASTHENIA GRAVIS

• CHEST CT SCAN was done on GREEN LIFE HOSPITAL DHAKA ON 18.1.2019 reveals
that Bilateral Hilae and Mediastinal, Lymphademopathy with Multifocal inflammatoy
lesion, Tiny nodule and fibrosis at both the lungs suggestive tuberculosis and scarcodisis
• VOICE EVALUTION done at KKR HOSPITAL on 9.4.2019 reveals HYPERNASALITY
 PRE-MORBID STATUS
The client cognition ,speech
and swalloing were reported to
be normal
POST –MORBID STATUS
The client has no difficulty in
auditory comprehension,
logical thinking, reasoning
where has the client reported
to have hypernasal speech for
past 2 years and occasionally
nasal regurgitation during
swallowing the liquids for past
1 year
JAW TEETH

 Range of motion : slow  Occlusion :Appropriate(no

 Symmetry :Normal malocclusion)
 Arrangement :normal
 Movement : slow
LABIAL
 Range of motion :Restricted at
right side
 Lip spread /i/ : Adequate
 Lip rounding/u/ : Inadequate
 Symmetry : Slightly drooping
towards right side
 Lip closure at rest :Present
 Lip closure during sentence
repetition : Fair
 Strength during puckering :
Weak
 Puffing of cheeks : Adequate
LINGUAL
 Surface color : Normal
 Size : Normal
 Range of motion : Reduced
 Protrusion : Present
 Elevation of tip : Present
 Point to right side : Present
 Point to left side : Present
 Retraction : Present
 Strength : Reduced
 Asymmetry : Slight Deviation
 Rapid repetitive rapid
movements : Reduced Speed
 Rapid repetitive vertical
movements : Reduced Speed
 HARD AND SOFT PALATE

 Color : Normal
 Arch height : Normal
 Symmetry at rest and movement : Normal
 Gag reflex : reduced
Cranial nerve Findings
V Trigeminal Sensory functions are
adequate .
Motor functions are
adequate except the jaw
muscles .(jaw muscles
get fatigued after 15
seconds during the task
of opening of the mouth
against resistance)
VII Facial Drooping of eye lid
Drooping of right lip
IX Glossopharyngeal Adequate
X Vagus nerve Gag reflex was present.
Motor functions are
adequate.
XI Spinal accessory Adequate
XII Hypoglossal Weakness , fasciculation
 Chewing : Normal
 Sucking : Present
 Blowing : Present
 Swalloing : Adequate for solid consistency foods
 Biting : Adequate
 Co-ordination of respiration and swallowing : Adequate
 Co-ordination of respiration and speech : Adequate
 Maximum Phonation duration
 /a/-30 seconds
 /i/-27 seconds
 /u/-31 seconds
 Impression: Adequate Maximum phonation duration
PARAMETERS RESULT
Pitch Adequate
Pitch variability Present
Pitch break Absent
Diplophonia Absent
Pitch range Restricted
Loudness Present
Loudness variability Present
Loudness range Present
Quality Normal
Tremor Absent
Voice break Absent
Endurance Fair
GRBAS -I scale: (Conversation)
 0-Normal, 1-Mild, 2-Moderate, 3-Severe
 Grade - 0 (Normal)
 Roughness - 0 (Normal)
 Breathiness - 0 (Normal)
 Asthenia - 1 (Mild)
 Strain - 1(Mild)
 Instability - 1(Mild)
 Impression: Mild asthenia, strain and instability were
observed
 YES

Is there a tremor? 

Is there blurring between syllables? 

Is there hypernasality? 

Is there nasal emission? 

Is there restriction in amplitude of motion of lips and jaw? 

Are there imprecise or distorted consonants? 

 Frenchay Dysarthria Assessment (Enderby, 1983)
 Cough : There were no difficulty was found in both tasks.

 Swallow : There were no abnormality were present in task.

 Dribble / Drool : There were no difficulty was present

 Respiration
◦ During rest: There was Inhalation or exhalation no smooth or is shallow in task
performance
.
◦ During speech: There were no difficulty was present

 Lips
◦ At rest: Lips slightly drooping apart or asymmetrical

 Retraction: Slight asymmetry-notice

 ◦ Seal : Occasional air leakage, break in lip seal, lip seal not
consistent for plosion on each sound.
◦ Alternate movements: - Patient able to articulate both
movements in 15 seconds. May have faltering rhythm or
variability in rounding or, spreading of lips.
During speech:- Some weakness or briskness. Variable with
occasional omissions

 Jaw
◦ At rest: Jaw relaxed in normal position
◦ During speech: Jaw was fairly fixed during speech

◦ Soft Palate : Movement: Present ( Excessive Nasalization is
noted) Indicative of (?) Velopharyngeal Incompetency
 Laryngeal : Changes in volume but noticeably uneven progression
was observed.

 Tongue:
◦ At rest : the tongue show occasionally involuntary movement
or minimal diviation
◦ Protrusion: the client performs the task very slow but was
normal
◦ Elevation: the client moves the tongue well but slow
◦ Lateration: the client moves well but takes 5 to 6 seconds

 Intelligibity:
◦ Word repetition : Ten words correctly interpreted by the speech
therapist, but therapist had to use particular care in listening and
interpreting what was heard Sentence: Speech abnormal but
intelligible patient occasionally has to repeat.
 Speech intelligibility rating scale
 AYJNIHH intelligibility rating the client has score of
3 which reveals intelligible although noticeably
difference.

 Hindi Articulation test

 Distortion of /k/ to kh, / g/ to gh,/s/ to /s:/, /j/ to jh , /d/
to /n/, /p/ to /n/ , /h/to/n/
 Mild Dysarthria Consequent to (?) Myasthenia
Gravis
 Reduced Speech Intelligibility with Hypernasal
Speech
 Normal Voice Quality with Reduced Loudness and
Pitch variability