Makindo Medical Notes

Speech and language problems encompass a wide range of disorders affecting communication. They may arise from developmental, neurological, structural, or psychological causes. Early recognition and referral are key to improving outcomes in children and adults.

📖 Introduction

• Speech refers to the mechanical production of sounds (articulation, fluency, voice).
• Language refers to understanding and using words, grammar, and social communication.
• Problems can occur in isolation or together, affecting learning, social development, and quality of life.
• They may present in childhood (developmental delay) or adulthood (e.g., stroke, degenerative disease).

🔬 Pathophysiology

• Neurodevelopmental basis: delayed maturation of language networks in the brain (Broca’s, Wernicke’s areas).
• Structural causes: cleft palate, hearing loss, vocal cord pathology.
• Neurological injury: perinatal hypoxia, traumatic brain injury, stroke.
• Psychological/environmental factors: neglect, limited language exposure, selective mutism.

⚠️ Causes of Speech and Language Problems

Category	Examples	Clinical Features
Developmental Delay 🧒	Specific Language Impairment (SLI), global developmental delay, autism spectrum disorder.	Late talking, difficulty forming sentences, poor social communication, echolalia.
Structural Problems 🦷	Cleft lip/palate, vocal cord nodules, enlarged tonsils/adenoids.	Nasal speech, articulation errors, hoarseness, swallowing difficulties.
Hearing Loss 👂	Conductive (e.g., otitis media with effusion), sensorineural (e.g., congenital, meningitis).	Delayed speech, poor pronunciation, inattentiveness, reliance on lip-reading.
Neurological Causes 🧠	Cerebral palsy, perinatal asphyxia, stroke, head trauma, degenerative disease.	Dysarthria, aphasia, motor planning problems (apraxia), regression of language skills.
Psychological/Environmental 🧍‍♂️	Selective mutism, neglect, lack of stimulation.	Normal comprehension but refusal to speak; poor vocabulary from limited exposure.

🩺 Clinical Assessment

• History: developmental milestones, perinatal history, family history of speech delay, exposure to languages, regression.
• Associated symptoms: seizures, motor problems, behavioural issues, hearing concerns.
• Examination: ENT (palate, tongue, tonsils), hearing assessment, neurological exam, developmental screening.
• Red Flags: regression of speech, no single words by 18 months, no two-word phrases by 2.5 years, absent social interaction, abnormal neurological findings.

🧪 Investigations

• Hearing assessment: audiometry, tympanometry.
• ENT referral: for structural anomalies.
• Neurological imaging: MRI if regression, seizures, or focal signs.
• Genetic testing: if syndromic features (Fragile X, Down syndrome, etc.).
• Developmental screening tools: Denver II, M-CHAT for autism risk.

💊 Management

• 👩‍⚕️ Speech and Language Therapy (SLT): cornerstone of treatment — articulation, fluency, language development, social communication.
• 👂 Hearing aids/ENT surgery: grommets for otitis media, cochlear implants for sensorineural loss.
• 🦷 Surgical correction: cleft palate repair, removal of obstructing adenoids/tonsils.
• 🧠 Neurological/medical treatment: anti-epileptics, therapy for cerebral palsy, rehabilitation after stroke.
• 📚 Educational support: special educational needs services, classroom accommodations.
• 🧑‍🤝‍🧑 Family support: parental training, psychological support, early intervention services.

📚 Prognosis

• Depends on underlying cause and early intervention.
• Many children with isolated language delay “catch up” by school age.
• Neurodevelopmental and neurological causes may persist but can improve with therapy.
• Early detection and SLT significantly improve outcomes and long-term communication skills.

📚 References

• NICE Guidelines – Developmental Speech and Language Disorders in Children.
• Bishop DVM. Uncommon Understanding: Development and Disorders of Language Comprehension in Children. Psychology Press.
• Kanner L. Speech Disorders in Children. Cambridge University Press.

💡 Summary: Speech and language problems may arise from developmental, structural, neurological, or psychological causes. History, examination, and hearing assessment are essential first steps. Speech and language therapy is the mainstay of treatment, with ENT, neurology, and educational input as needed. Early recognition and referral dramatically improve outcomes.

Cases — Speech and Language Problems

• Case 1 (Aphasia after stroke): 🧠 A 68-year-old man is admitted with sudden right-sided weakness and difficulty speaking. He produces short, effortful phrases with preserved comprehension = Broca’s aphasia. CT brain shows left MCA infarct. Management: Acute stroke protocol, aspirin, secondary prevention, intensive speech and language therapy (SALT). Outcome: Gradual improvement in expressive language with therapy; communication supported using writing and gestures.
• Case 2 (Dysarthria in Parkinson’s disease): 🤲 A 72-year-old woman with Parkinson’s disease has progressively slurred, quiet speech. Family note “monotone” voice and difficulty being understood. Management: SALT referral for voice and articulation therapy, optimisation of dopaminergic medication, advice on pacing speech. Outcome: Speech volume improves with “Lee Silverman Voice Therapy” techniques; patient uses a voice amplifier for groups.
• Case 3 (Childhood speech delay): 👶🗣️ A 4-year-old boy is brought by parents with concerns about limited vocabulary and unclear speech. No hearing concerns reported, but he struggles to form sentences compared to peers. Hearing test shows glue ear (otitis media with effusion). Management: ENT referral; grommets inserted. SALT sessions for expressive language and articulation. Outcome: Vocabulary expands rapidly after hearing improves; ongoing therapy supports clear sentence development.

🧑‍⚕️ Teaching Commentary

Speech and language problems may arise from: • Central neurological causes (stroke, TBI, neurodegeneration → aphasia, dysarthria). • Peripheral/motor causes (cranial nerve lesions, Parkinsonism). • Developmental or hearing-related causes in children. Assessment by SALT is key, often supported by imaging, audiology, and multidisciplinary care. 🌟 Early identification and intervention can dramatically improve quality of life and social functioning.