Is bulbar syndrome always a component of ALS?

Certain variants of ALS do not present with bulbar symptoms. In progressive muscular atrophy (PMA), the bulbar syndrome and its associated symptoms—speech impairment (dysarthria) and swallowing difficulties (dysphagia)—may be largely absent. In other rare forms (e.g., axial ALS), the bulbar syndrome may also develop very late or be mild.