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16/11/17 04:05 AM Dr. Chintan Parmar
SPEECH
Speech is one of the ways we
communicate with our environment, to
express our thoughts, memories and
feelings.
It is also an effective way to monitor
normal growth and development
1
16/11/17 04:05 AM Dr. Chintan Parmar
LANGUAGE
 To understand spoken and
printed words and to express
ideas in speech and writing is
called language.
 It is an example of skilled
voluntary movements.
2
Anatomical components of the
Anatomical components of the
speech system for human
speech system for human
language.
language.
• Sound in human language is
produced by the regulation of
airflow from the lungs through the
throat (vocal cord), nose and mouth.
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04:05 AM 3
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Dr. Chintan Parmar
Dr. Chintan Parmar
 The larynx contains folds of muscle
called the vocal folds (sometimes
called vocal cords).
 The opening between the vocal
folds is known as the glottis.
 These folds can be relaxed, letting air
flow freely through the glottis,
 or tensed, so that the air vibrates as it
passes through the glottis.
 If the folds are only partially closed,
a whispered sound is produced.
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Dr. Chintan Parmar
16/11/17 04:05 AM Dr. Chintan Parmar
Resting Adduction Abduction
.
5
16/11/17 04:05 AM Dr. Chintan Parmar
The process of producing speech
The process of producing speech
sounds:
sounds:
 The process of producing speech sounds:
lungs: fill with air
contraction of rib cage forces air from the lungs into
the trachea - the volume of air determines the amplitude
of the sound
trachea (windpipe): conveys air to the vocal tract.
The vocal cords, at the top of the trachea, separate the
trachea from the base of the vocal tract
 vocal tract consists of:
 pharynx (throat)
 mouth
 nose
 the tongue, teeth and lips
 the shape of the vocal tract determines the type of
speech sound - e.g., the /a/ in "hat" vs the /i/ in "hit
6
 Speech differs from breathing in that at some
point in the path you set the air in rapid
motion or vibration
Two principal components of speech
production
 Excitation - create a sound by setting the air
in rapid motion
 Vocal tract - "shape" the sound
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Dr. Chintan Parmar
16/11/17 04:05 AM Dr. Chintan Parmar
A. Excitation: three principal forms
1. Phonation: vibration of vocal
cords
2. Frication: Turbulent air flow
3. Plosive: Closure at some
point in the vocal tract,
followed by a release of air
8
16/11/17 04:05 AM Dr. Chintan Parmar
Phonation: vibration of vocal
Phonation: vibration of vocal
cords
cords
 The vocal cords consist of ligament and
muscle, and are adjustable under muscle
control.
 The cartilage surrounding the vocal cords
provides support.
 Vibration
 cords tense, pressed together - no air
flows
 air pressure from the lungs forces them
open
 local pressure is reduced --> cords close
 the cycle repeats
9
 The result is a periodic release of air into the
pharynx.
 The fundamental frequency of the vocal cord
opening/closing cycle becomes the fundamental
frequency (informally, the "pitch") of the resulting sound.
 The tenser the vocal cords
- the higher the pitch
- the shorter the period
 Typical frequency of vocal cord open/close cycle:
 male: 128 Hz
 female: 256 Hz
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Dr. Chintan Parmar
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Neurophysiology of Speech and
Neurophysiology of Speech and
Language
Language
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04:05 AM 12
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Dr. Chintan Parmar
Dr. Chintan Parmar
Speech Structures in the Brain
 Wernicke's Area: Auditory association area.
Language comprehension and formulation (both
spoken and written)
 Dejerine Area : Visual speech center
 Broca's Area: Speech production and
comprehension. Pre-motor speech planning.
 Exner’s Area : Motor writing center
 Arcuate fasciculus: Pathway interconnecting
Broca's Area and Wernicke's area.
 Supplementary Motor Cortex: Seems to be related
to word finding, rhythm, phonation, articulation.
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Dr. Chintan Parmar
16/11/17 04:05 AM Dr. Chintan Parmar
Brain Asymmetries in Speech and
Brain Asymmetries in Speech and
Language
Language
 Dominant Left Hemisphere
 The left hemisphere is generally considered
to be the language dominant
(categorical) hemisphere.
 The non-dominant (Representational) or
right hemisphere is believed to be
responsible for the expression of feelings
such as joy, sorrow, anger, depression,
delight.
 It is also important in the production of
speech prosody which is a component of
how we signal emotion in speech.
 Spatio-temporal Relations such as recognition
of face, identification of object
14
16/11/17 04:05 AM Dr. Chintan Parmar
Categorical Hemi.
 For categorization
and symbolization.
 Lesion produce
 Language
disorder
 Patient is disturbed
 Loss of recent
verbal memory
Representational
Hemi.
 Recognition of face,
identification of
object, musical
themes.
 Lesion produce
 Astereognosis
 Agnosia
 Patient not disturbed
 Loss of Recent visual
memory
15
16/11/17 04:05 AM Dr. Chintan Parmar
Cerebral Dominance for
Cerebral Dominance for
Language and Left and Right-Handedness
Language and Left and Right-Handedness
 Right-handed individuals have a
98% probability of left hemisphere
dominance for language
 Left-handed individuals show a
much more complex pattern.
 For these people, both hemispheres
are involved in language processing
16
16/11/17 04:05 AM Dr. Chintan Parmar
Cerebral Dominance for
Cerebral Dominance for
Language and Anatomical Asymmetry
Language and Anatomical Asymmetry
 There is some evidence for
anatomical asymmetry of some
language areas.
 The left hemisphere Wernicke's
Area is said to be larger than the same
structure on the right side.
 This is true for a majority of right
handers but not so for majority of left
handers.
17
16/11/17 04:05 AM Dr. Chintan Parmar
What about language comprehension?
What about language comprehension?
Where is the most logical place to put the
Where is the most logical place to put the
comprehension area? (sensory speech)
comprehension area? (sensory speech)
 First you must decide if language is primarily
visual or auditory? When you read (written
speech), do you "hear" the words in your head?
 When you listen (spoken speech), do you "see"
the words as written?
 Which came first, written or spoken
language?
 You probably agree that language is more of an
auditory phenomenon than visual.
 As expected, the language comprehension
area is just adjacent to auditory cortex,
where the parietal lobe meets the temporal
lobe.
 This area was discovered by Wernicke in 1874
18
16/11/17 04:05 AM Dr. Chintan Parmar 19
16/11/17 04:05 AM Dr. Chintan Parmar
Spoken speech
Spoken speech
Ear (sound)
Primary auditory
area(41)
Auditory – psychic
area (21)
Auditory speech area
(22)
20
16/11/17 04:05 AM Dr. Chintan Parmar
Written speech
Written speech
Primary visual
area
Visuo-psychic area
Dejerine area
(for internal
speech)
21
16/11/17 04:05 AM Dr. Chintan Parmar
MOTOR SPEECH
MOTOR SPEECH
 First and foremost, you need fine control
over the tongue and mouth.
 It would make sense to put your cortical
area near the mouth section of motor
cortex.
 Sure enough, just rostral to the motor-
mouth area of the precentral gyrus is a
small area that controls speech.
22
 It is called Broca's area, after the physician who
discovered it in 1861. It is located in the inferior frontal
gyrus. It process the information received from sensory
speech area into detailed and co-ordinate pattern for
vocalization.
 This pattern is than projected to motor cortex which
initiates the appropriate movement of lips, tongue and
larynx to produce speech
 Exner’s area: It is located in the middle frontal gyrus in
dominant hemisphere .
 It process the information from Broca's area into detailed
and coordinated pattern, which then along with motor
cortex initiates the appropriate movements of the hands
and fingers to produce written speech
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Dr. Chintan Parmar
16/11/17 04:05 AM Dr. Chintan Parmar 24
16/11/17 04:05 AM Dr. Chintan Parmar
EXPRESSION OF SPOKEN SPEECH
EXPRESSION OF SPOKEN SPEECH
word
Highest area of hearing
(area 41)
Wernicke's area.
Arcuate fasciculus
Broca’s area
Motor area(4)
25
16/11/17 04:05 AM Dr. Chintan Parmar
EXPRESSION OF Spoken & written
EXPRESSION OF Spoken & written
SPEECH
SPEECH
Primary visual area
Visual association area
Dejerine area
Wernicke's area.
Arcuate fasciculus
Broca’s area
Motor & Exner’s area
26
16/11/17 04:05 AM Dr. Chintan Parmar
Lastly,
 Language is far too complex to be broken down into two
discrete cortical areas. Obviously there are visual and
manual components to language, for reading and writing.
Where does sign language fit in?
 How do you explain a patient whose only deficit is an
inability to name tools? He can describe the use of a
hammer but not its name.
 How does a person's name - trigger the face, personality,
birth date, or voice of that person in your memory?
 Language is probably located all over the brain, with
extensive crosstalk between areas.
 The discrete areas of Broca and Wernicke may be
necessary for language, but they are certainly not
sufficient.
27
16/11/17 04:05 AM Dr. Chintan Parmar
Language impairment
Language impairment
 Speech impairment may be any of several speech
problems, particularly the following:
 Dysarthria is difficult, poorly articulated speech, such as
slurring.
 Aphasia is impaired expression or comprehension of
written or spoken language.
 Dysarthria is occasionally confused with aphasia.
 It is important to distinguish between a difficulty in
articulation of words versus a problem with the
production of language, as these have different
causes.
28
16/11/17 04:05 AM Dr. Chintan Parmar
APHASIA
APHASIA
 Aphasia is loss of communication skills previously
learned and commonly occurs following strokes or in
people with brain tumors or degenerative diseases that
affect the language areas of the brain.
 Aphasia represents a broad class of speech and
language disorders resulting from neurological
damage. Aphasias can be divided into two main types:-
 Expressive (Broca's) aphasia: Affects speech
production and is associated with left hemisphere
frontal lesions
 Receptive (Wernicke's) aphasia: Affects
comprehension and is mainly associated with lesions
in Wernicke's area of the left hemisphere
29
16/11/17 04:05 AM Dr. Chintan Parmar
Some additional types of
Some additional types of
aphasia
aphasia
 Conduction aphasia:- resulting from a
disconnection of the language perception and
disconnection of the language perception and
production centres
production centres usually resulting from a lesion in
the arcuate fasciculus which connects Broca's and
Wernicke's areas
 Such patients are unable to repeat aloud what they
unable to repeat aloud what they
hear.
hear.
 Transcortical aphasia:- Don't affect the speech
centres or the connections between them but affect
the connection of the speech centres to the rest of
the brain.
 Word deafness: Disconnecting Wernicke's area
from the auditory cortex
30
 Anomic aphasia:- difficulty naming objects. Pure forms of
this aphasia involve lesions in the angular gyrus.
 It is assumed that this results from a disconnection between
the sensory modalities and the rest of the brain.
 Global aphasia:- Widespread damage resulting in severe
impairment of all language and speech functions.
 Subcortical aphasia:- lesions of the thalamus. Damage
here results in verbal fluency and word repetition problems.
 The thalamus appear to be involved in
 directing attention to verbal input,
 in retrieving information from verbal memory and
 to play some role in the regulation of the activity of speech
producing muscles
16/11/17 04:05 AM 31
Dr. Chintan Parmar
16/11/17 04:05 AM Dr. Chintan Parmar
 In some cases of aphasia, the
problem eventually resolves
itself, but in others the condition
is irreversible.
 Head trauma
 Alzheimer's disease
 Stroke
 Transient ischemic attack (TIA)
 Brain tumor
Brain tumor
32
16/11/17 04:05 AM Dr. Chintan Parmar 33
16/11/17 04:05 AM Dr. Chintan Parmar
DYSARTHRIA
DYSARTHRIA
 Dysarthria is generally apparent in daily conversation
where there is difficulty expressing certain sounds or
words.
 This condition may be caused by taking excess
medications such as narcotics, phenytoin or
carbamazepine.
 Degenerative neurological disorders affecting the
cerebellum or brainstem can also cause dysarthria.
 Stroke that affects brainstem or cerebellar regions
can also cause dysarthria.
 Any facial weakness, such as Bell's palsy or tongue
weakness, can cause dysarthria.
 Poorly fitting dentures
Poorly fitting dentures
 Alcohol intoxication
34
Kluver Bucy syndrome
Kluver Bucy syndrome
 Anterior portion of the temporal lobe is
destroyed in monkeys  amygdala 
changes in the behavior
 Excessive tendency to examine objects
orally
 Loss of fear
 Decreased aggressiveness
 peacefulness
 Changes in the dietary habits
 Psychic blindness
 Excessive sex drive
16/11/17 04:05 AM Dr. Chintan Parmar 36

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physiologyofspeech-171116040546 (2).pdf

  • 1. 16/11/17 04:05 AM Dr. Chintan Parmar SPEECH Speech is one of the ways we communicate with our environment, to express our thoughts, memories and feelings. It is also an effective way to monitor normal growth and development 1
  • 2. 16/11/17 04:05 AM Dr. Chintan Parmar LANGUAGE  To understand spoken and printed words and to express ideas in speech and writing is called language.  It is an example of skilled voluntary movements. 2
  • 3. Anatomical components of the Anatomical components of the speech system for human speech system for human language. language. • Sound in human language is produced by the regulation of airflow from the lungs through the throat (vocal cord), nose and mouth. 16/11/17 16/11/17 04:05 AM 04:05 AM 3 3 Dr. Chintan Parmar Dr. Chintan Parmar
  • 4.  The larynx contains folds of muscle called the vocal folds (sometimes called vocal cords).  The opening between the vocal folds is known as the glottis.  These folds can be relaxed, letting air flow freely through the glottis,  or tensed, so that the air vibrates as it passes through the glottis.  If the folds are only partially closed, a whispered sound is produced. 16/11/17 04:05 AM 4 Dr. Chintan Parmar
  • 5. 16/11/17 04:05 AM Dr. Chintan Parmar Resting Adduction Abduction . 5
  • 6. 16/11/17 04:05 AM Dr. Chintan Parmar The process of producing speech The process of producing speech sounds: sounds:  The process of producing speech sounds: lungs: fill with air contraction of rib cage forces air from the lungs into the trachea - the volume of air determines the amplitude of the sound trachea (windpipe): conveys air to the vocal tract. The vocal cords, at the top of the trachea, separate the trachea from the base of the vocal tract  vocal tract consists of:  pharynx (throat)  mouth  nose  the tongue, teeth and lips  the shape of the vocal tract determines the type of speech sound - e.g., the /a/ in "hat" vs the /i/ in "hit 6
  • 7.  Speech differs from breathing in that at some point in the path you set the air in rapid motion or vibration Two principal components of speech production  Excitation - create a sound by setting the air in rapid motion  Vocal tract - "shape" the sound 16/11/17 04:05 AM 7 Dr. Chintan Parmar
  • 8. 16/11/17 04:05 AM Dr. Chintan Parmar A. Excitation: three principal forms 1. Phonation: vibration of vocal cords 2. Frication: Turbulent air flow 3. Plosive: Closure at some point in the vocal tract, followed by a release of air 8
  • 9. 16/11/17 04:05 AM Dr. Chintan Parmar Phonation: vibration of vocal Phonation: vibration of vocal cords cords  The vocal cords consist of ligament and muscle, and are adjustable under muscle control.  The cartilage surrounding the vocal cords provides support.  Vibration  cords tense, pressed together - no air flows  air pressure from the lungs forces them open  local pressure is reduced --> cords close  the cycle repeats 9
  • 10.  The result is a periodic release of air into the pharynx.  The fundamental frequency of the vocal cord opening/closing cycle becomes the fundamental frequency (informally, the "pitch") of the resulting sound.  The tenser the vocal cords - the higher the pitch - the shorter the period  Typical frequency of vocal cord open/close cycle:  male: 128 Hz  female: 256 Hz 16/11/17 04:05 AM 10 Dr. Chintan Parmar
  • 11. 16/11/17 04:05 AM Dr. Chintan Parmar 11
  • 12. Neurophysiology of Speech and Neurophysiology of Speech and Language Language 16/11/17 16/11/17 04:05 AM 04:05 AM 12 12 Dr. Chintan Parmar Dr. Chintan Parmar
  • 13. Speech Structures in the Brain  Wernicke's Area: Auditory association area. Language comprehension and formulation (both spoken and written)  Dejerine Area : Visual speech center  Broca's Area: Speech production and comprehension. Pre-motor speech planning.  Exner’s Area : Motor writing center  Arcuate fasciculus: Pathway interconnecting Broca's Area and Wernicke's area.  Supplementary Motor Cortex: Seems to be related to word finding, rhythm, phonation, articulation. 16/11/17 04:05 AM 13 Dr. Chintan Parmar
  • 14. 16/11/17 04:05 AM Dr. Chintan Parmar Brain Asymmetries in Speech and Brain Asymmetries in Speech and Language Language  Dominant Left Hemisphere  The left hemisphere is generally considered to be the language dominant (categorical) hemisphere.  The non-dominant (Representational) or right hemisphere is believed to be responsible for the expression of feelings such as joy, sorrow, anger, depression, delight.  It is also important in the production of speech prosody which is a component of how we signal emotion in speech.  Spatio-temporal Relations such as recognition of face, identification of object 14
  • 15. 16/11/17 04:05 AM Dr. Chintan Parmar Categorical Hemi.  For categorization and symbolization.  Lesion produce  Language disorder  Patient is disturbed  Loss of recent verbal memory Representational Hemi.  Recognition of face, identification of object, musical themes.  Lesion produce  Astereognosis  Agnosia  Patient not disturbed  Loss of Recent visual memory 15
  • 16. 16/11/17 04:05 AM Dr. Chintan Parmar Cerebral Dominance for Cerebral Dominance for Language and Left and Right-Handedness Language and Left and Right-Handedness  Right-handed individuals have a 98% probability of left hemisphere dominance for language  Left-handed individuals show a much more complex pattern.  For these people, both hemispheres are involved in language processing 16
  • 17. 16/11/17 04:05 AM Dr. Chintan Parmar Cerebral Dominance for Cerebral Dominance for Language and Anatomical Asymmetry Language and Anatomical Asymmetry  There is some evidence for anatomical asymmetry of some language areas.  The left hemisphere Wernicke's Area is said to be larger than the same structure on the right side.  This is true for a majority of right handers but not so for majority of left handers. 17
  • 18. 16/11/17 04:05 AM Dr. Chintan Parmar What about language comprehension? What about language comprehension? Where is the most logical place to put the Where is the most logical place to put the comprehension area? (sensory speech) comprehension area? (sensory speech)  First you must decide if language is primarily visual or auditory? When you read (written speech), do you "hear" the words in your head?  When you listen (spoken speech), do you "see" the words as written?  Which came first, written or spoken language?  You probably agree that language is more of an auditory phenomenon than visual.  As expected, the language comprehension area is just adjacent to auditory cortex, where the parietal lobe meets the temporal lobe.  This area was discovered by Wernicke in 1874 18
  • 19. 16/11/17 04:05 AM Dr. Chintan Parmar 19
  • 20. 16/11/17 04:05 AM Dr. Chintan Parmar Spoken speech Spoken speech Ear (sound) Primary auditory area(41) Auditory – psychic area (21) Auditory speech area (22) 20
  • 21. 16/11/17 04:05 AM Dr. Chintan Parmar Written speech Written speech Primary visual area Visuo-psychic area Dejerine area (for internal speech) 21
  • 22. 16/11/17 04:05 AM Dr. Chintan Parmar MOTOR SPEECH MOTOR SPEECH  First and foremost, you need fine control over the tongue and mouth.  It would make sense to put your cortical area near the mouth section of motor cortex.  Sure enough, just rostral to the motor- mouth area of the precentral gyrus is a small area that controls speech. 22
  • 23.  It is called Broca's area, after the physician who discovered it in 1861. It is located in the inferior frontal gyrus. It process the information received from sensory speech area into detailed and co-ordinate pattern for vocalization.  This pattern is than projected to motor cortex which initiates the appropriate movement of lips, tongue and larynx to produce speech  Exner’s area: It is located in the middle frontal gyrus in dominant hemisphere .  It process the information from Broca's area into detailed and coordinated pattern, which then along with motor cortex initiates the appropriate movements of the hands and fingers to produce written speech 16/11/17 04:05 AM 23 Dr. Chintan Parmar
  • 24. 16/11/17 04:05 AM Dr. Chintan Parmar 24
  • 25. 16/11/17 04:05 AM Dr. Chintan Parmar EXPRESSION OF SPOKEN SPEECH EXPRESSION OF SPOKEN SPEECH word Highest area of hearing (area 41) Wernicke's area. Arcuate fasciculus Broca’s area Motor area(4) 25
  • 26. 16/11/17 04:05 AM Dr. Chintan Parmar EXPRESSION OF Spoken & written EXPRESSION OF Spoken & written SPEECH SPEECH Primary visual area Visual association area Dejerine area Wernicke's area. Arcuate fasciculus Broca’s area Motor & Exner’s area 26
  • 27. 16/11/17 04:05 AM Dr. Chintan Parmar Lastly,  Language is far too complex to be broken down into two discrete cortical areas. Obviously there are visual and manual components to language, for reading and writing. Where does sign language fit in?  How do you explain a patient whose only deficit is an inability to name tools? He can describe the use of a hammer but not its name.  How does a person's name - trigger the face, personality, birth date, or voice of that person in your memory?  Language is probably located all over the brain, with extensive crosstalk between areas.  The discrete areas of Broca and Wernicke may be necessary for language, but they are certainly not sufficient. 27
  • 28. 16/11/17 04:05 AM Dr. Chintan Parmar Language impairment Language impairment  Speech impairment may be any of several speech problems, particularly the following:  Dysarthria is difficult, poorly articulated speech, such as slurring.  Aphasia is impaired expression or comprehension of written or spoken language.  Dysarthria is occasionally confused with aphasia.  It is important to distinguish between a difficulty in articulation of words versus a problem with the production of language, as these have different causes. 28
  • 29. 16/11/17 04:05 AM Dr. Chintan Parmar APHASIA APHASIA  Aphasia is loss of communication skills previously learned and commonly occurs following strokes or in people with brain tumors or degenerative diseases that affect the language areas of the brain.  Aphasia represents a broad class of speech and language disorders resulting from neurological damage. Aphasias can be divided into two main types:-  Expressive (Broca's) aphasia: Affects speech production and is associated with left hemisphere frontal lesions  Receptive (Wernicke's) aphasia: Affects comprehension and is mainly associated with lesions in Wernicke's area of the left hemisphere 29
  • 30. 16/11/17 04:05 AM Dr. Chintan Parmar Some additional types of Some additional types of aphasia aphasia  Conduction aphasia:- resulting from a disconnection of the language perception and disconnection of the language perception and production centres production centres usually resulting from a lesion in the arcuate fasciculus which connects Broca's and Wernicke's areas  Such patients are unable to repeat aloud what they unable to repeat aloud what they hear. hear.  Transcortical aphasia:- Don't affect the speech centres or the connections between them but affect the connection of the speech centres to the rest of the brain.  Word deafness: Disconnecting Wernicke's area from the auditory cortex 30
  • 31.  Anomic aphasia:- difficulty naming objects. Pure forms of this aphasia involve lesions in the angular gyrus.  It is assumed that this results from a disconnection between the sensory modalities and the rest of the brain.  Global aphasia:- Widespread damage resulting in severe impairment of all language and speech functions.  Subcortical aphasia:- lesions of the thalamus. Damage here results in verbal fluency and word repetition problems.  The thalamus appear to be involved in  directing attention to verbal input,  in retrieving information from verbal memory and  to play some role in the regulation of the activity of speech producing muscles 16/11/17 04:05 AM 31 Dr. Chintan Parmar
  • 32. 16/11/17 04:05 AM Dr. Chintan Parmar  In some cases of aphasia, the problem eventually resolves itself, but in others the condition is irreversible.  Head trauma  Alzheimer's disease  Stroke  Transient ischemic attack (TIA)  Brain tumor Brain tumor 32
  • 33. 16/11/17 04:05 AM Dr. Chintan Parmar 33
  • 34. 16/11/17 04:05 AM Dr. Chintan Parmar DYSARTHRIA DYSARTHRIA  Dysarthria is generally apparent in daily conversation where there is difficulty expressing certain sounds or words.  This condition may be caused by taking excess medications such as narcotics, phenytoin or carbamazepine.  Degenerative neurological disorders affecting the cerebellum or brainstem can also cause dysarthria.  Stroke that affects brainstem or cerebellar regions can also cause dysarthria.  Any facial weakness, such as Bell's palsy or tongue weakness, can cause dysarthria.  Poorly fitting dentures Poorly fitting dentures  Alcohol intoxication 34
  • 35. Kluver Bucy syndrome Kluver Bucy syndrome  Anterior portion of the temporal lobe is destroyed in monkeys  amygdala  changes in the behavior  Excessive tendency to examine objects orally  Loss of fear  Decreased aggressiveness  peacefulness  Changes in the dietary habits  Psychic blindness  Excessive sex drive
  • 36. 16/11/17 04:05 AM Dr. Chintan Parmar 36