1. H&P: Abnormal articulation, rhythm, or volume. Ask about diurnal fluctuations (suggests myasthenia), improvement with alcohol (suggests essential tremor). Assess palatal elevation when pt says a long “a” or “coca-cola.” Assess ability to hold a tone or sing. Look especially for other cranial nerve signs, dysmetria, tremor, dystonia, or spasticity.

2. Tests: MRI, laryngoscopy, consider EMG of orofacial muscles (hurts).

3. Causes: See also bulbar vs. pseudobulbar palsy, p. 129.