Pseudobulbar Palsy

What is pseudobulbar palsy?

Pseudobulbar palsy happens when damage to a specific part of your brain (corticobulbar tract) causes a collection of neurological symptoms. These include:

• Difficulty speaking (dysarthria).
• Difficulty swallowing (dysphagia).
• Rapid and exaggerated changes in mood (pseudobulbar affect).

Pseudobulbar palsy isn’t a condition itself but rather a complication of other neurological and cerebrovascular conditions. Healthcare providers may also call it supranuclear bulbar paralysis.

What are the symptoms of pseudobulbar palsy?

The main features of pseudobulbar palsy are difficulty speaking, difficulty swallowing and rapid, dramatic changes in mood.

This can involve symptoms like:

• Drooling or excessive drooling.
• Differences in the rhythm and sound of your speech. You may have an overly nasal tone.
• Tongue weakness or paralysis (glossoplegia).
• Facial muscle weakness.
• Difficulty chewing.
• Outbursts of uncontrolled or inappropriate laughing or crying.
• Muscle spasms in your jaw (trismus).
• Exaggerated facial reflexes, like jaw jerking.

About 85% of children with pseudobulbar palsy experience cognitive impairment and seizures.

Depending on the underlying cause of pseudobulbar palsy, you may have other symptoms.

What causes pseudobulbar palsy?

Bilateral damage (affecting both sides) to a specific part of your brain called the corticobulbar tract causes pseudobulbar palsy. The function of the corticobulbar tract is to control muscles in your head and face. It supplies input to the cranial nerves that support these muscles.

Many conditions can damage this tract and lead to pseudobulbar palsy, like:

• Traumatic brain injuries.
• Brainstem tumors.
• Inflammation and infections that affect your brain.
• Chronic (long-term) neurological conditions.
• Cerebrovascular conditions, like strokes and vascular malformations.

Common causes of pseudobulbar palsy include the following chronic neurological conditions:

• Amyotrophic lateral sclerosis (ALS).
• Parkinson's disease.
• Progressive supranuclear palsy.
• Multiple sclerosis (MS).

How is pseudobulbar palsy diagnosed?

Healthcare providers mainly diagnose pseudobulbar palsy based on your symptoms. The primary concern is identifying the underlying cause if it’s not already known.

A provider will ask about your symptoms and when they started. They’ll also want to know your medical history, like if you’ve ever had a stroke. They’ll do a physical exam and a neurological exam.

Because so many conditions can cause pseudobulbar palsy, your provider may recommend a variety of tests to rule out or confirm possible causes. These may include:

• Blood tests.
• Spinal tap for cerebrospinal fluid (CSF) analysis.
• Imaging tests, like a brain MRI.
• EEG (electroencephalogram).
• Evoked potential tests.
• Speech and cognitive assessments.

How is pseudobulbar palsy treated?

There’s no direct treatment for pseudobulbar palsy. Instead, your healthcare team will recommend therapies for managing its features. You’ll also need treatment for the underlying cause.

You’ll likely have a team of healthcare providers, which may include:

• Primary care physician.
• Neurologists.
• Speech-language pathologists.
• Respiratory therapists.
• Psychologists or psychiatrists.
• Social workers.
• Pharmacists.

Therapies for difficulty swallowing

Various therapies can help with difficulty swallowing (dysphagia) depending on its severity. Some options include:

• Adjusting eating postures, eating tools and the consistency of your food.
• Swallowing muscle training.
• Physiotherapy, like electrical, magnetic or thermal stimulation.
• Medications, like nifedipine and metoclopramide.

Your provider may recommend a feeding tube if you aren’t getting enough to eat or drink or if you’re at risk of choking.

Therapies for difficulty speaking

You may benefit from speech therapy to improve communication. A speech-language pathologist can also work with your loved ones to teach them how to communicate with you better.

During speech therapy sessions, you may learn:

• Exercises to strengthen your tongue, lips and jaw muscles (if possible).
• Strategies for speaking more clearly, like slowing speech and intentionally using specific muscles to form sounds and words.
• Nonverbal communication techniques, such as sign language or writing.

Treatment for pseudobulbar affect

Medications can help manage pseudobulbar affect (PBA). Your provider may prescribe:

• Dextromethorphan/quinidine sulfate (Nuedexta®): The U.S. Food and Drug Administration (FDA) has approved a combination of dextromethorphan (a cough suppressant) and a very low dose of quinidine sulfate (a drug used in the past to treat cardiac arrhythmias) as the first drug specifically developed to treat PBA.
• Antidepressants: Tricyclic antidepressants, selective serotonin reuptake inhibitors (SSRIs) and serotonin and norepinephrine reuptake inhibitors (SNRIs) may help manage the symptoms of PBA.

Can I prevent pseudobulbar palsy?

As there are multiple possible causes of pseudobulbar palsy, there’s nothing you can directly do to prevent it.

What is the prognosis for people with pseudobulbar palsy?

The prognosis (outlook) for people with pseudobulbar palsy depends greatly on the underlying cause.

If you’ve had a stroke or traumatic brain injury, it’s possible to slowly recover the neurological functions that are affected by pseudobulbar palsy.

On the other hand, pseudobulbar palsy typically doesn’t improve in cases of chronic degenerative conditions, like MS, Parkinson's disease and ALS.

Your healthcare team will be able to give you a better idea of what to expect given your unique circumstances.

What are the complications of pseudobulbar palsy?

Pseudobulbar palsy can lead to the following complications:

• Aspiration pneumonia: Difficulty controlling your tongue and mouth muscles may lead to inhaling bits of food or liquids, which can cause aspiration pneumonia.
• Malnutrition and dehydration: Severe dysphagia can make it nearly impossible to swallow foods and liquids. This can lead to malnutrition and dehydration. You may need a feeding tube if you have severe dysphagia.
• Mental health conditions: Pseudobulbar palsy can significantly impact your life. And some of its effects, like difficulty speaking and uncontrollable emotional outbursts, may cause you to withdraw from social interactions. This can affect your mental health and may cause depression and/or anxiety.

Is pseudobulbar palsy fatal?

Pseudobulbar palsy isn’t directly fatal. But many of the underlying conditions that cause it (like stroke and ALS) can be. Pseudobulbar palsy can also lead to certain complications, like aspiration pneumonia, which can be fatal if they’re not treated.

When should I see my healthcare provider?

If you have pseudobulbar palsy, you’ll need to see your healthcare team regularly to make sure your treatment plan is working well.