FEATURE OTOLARNGOLOGY
language development are substantially below those from standardized measures of non-verbal intellectual capacity. Symptoms include those for Expressive Language Disorder as well as difficulty understanding words, sentences, or specific types of words, such as spatial The difficulties with expressive and receptive language significantly interfere with academic or occupational achievement or with social communication If developmental disability, a sensory- motor/sensory deficit, or environmental deprivation is present, the language difficulties are in excess of those usually associated with these problems. The delay in the normal acquisition of speech and language can be attributed to so many factors including low intelligence, neurological problems, and long standing illness during first 1-2 years of life etc., but the repair mechanism of the body does help to overcome these and show response in concordance with the abilities now present. Here we present a case where the delayed expressive language disorder did not match with the findings on MRI. Intensive speech and language training did not alter from a three-word vocabulary though there was some improvement in the receptive language. The dilemma was what to do in such a case and how to counsel the parents regarding the prognosis.
CASE REPORT A 4-year old girl was referred from the ENT Department to the Speech & Hearing Unit at the ‘Post Graduate Institute of Medical Education and Research’, Chandigarh, India for speech and language assessment. The parent’s main complaint was the limited speech of the child. There was history of miscarriage of pregnancy but no other significant peri- and post-natal history. The child was left-handed. The child suffered with gross developmental delay. A Behavioral Observation Audiometer revealed normal hearing. The child had been diagnosed with ‘Developmental delay with microcephaly’ by a paediatrician. MRI findings showed encephalomalacic changes in left parieto- occipital region towards the convexity of hemisphere, causing focal dilation of atrium of the ipsilateral ventricle. Hyperintensity was seen in the adjoining white matter s/o oedema. Posterior area
of corpus-callosum appears reduced in bulk. The child’s social quotient suggested a borderline intelligence of SQ=78. An oral-peripheral examination revealed the inability to elevate the tongue and a limited range of lateralization. The child was unable to move the bolus during chewing and sometimes had difficulty swallowing. The velopharyngeal function was normal but the parents’ complained of occasional hyper nasality. The informal assessment of language was based on an interview with the parents; observation of the child; and interaction with her siblings, parents and the clinician. The parameters assessed were semantics, morphemic forms, syntactic structures, and pragmatic skills as communicative intentions. Both comprehensive and expressive aspects were assessed. The comprehensive vocabulary involved nouns, pronouns, verbs, adjectives, and a few adverbs plus prepositions and tense forms (simple present, past, and future). The child was able to understand the syntactic structures like noun phrase, negation, wh- questions and a few complex sentences. Her expressive vocabulary was limited to three words. The child’s frequent mode of expression was vocalisation, gestures, pointing and head nodding. In the formal assessment, Receptive and Expressive Emergent Language Scales (REELS) was administered and it was found the receptive age was 30 months. The expressive age was found to be 14 months. A LPT (Language Profile Test) descriptive showed that the child was able to understand object functions, opposites and identify the objects by name, concept of numbers (up to three) plus adjective forms (comparative e.g. with one is bigger, or more beautiful). The child understood complex sentences and compound sentences (second stage), and negatives and questions. We diagnosed the child as having expressive language disorder.
DISCUSSION Spontaneous recovery or developmental repair As the history of birth asphyxia seems to be the cause of neurological lesions in the left hemisphere, this might have resulted in headedness and preferential use of the left leg. Is there any such change or developmental repair for language behaviour?
Arab Health Show Issue 2012 115
Delay and deviance of language It is clearly indicating towards deviance rather than delay, as there is no change in expressive vocabulary or verbal output in the last 8-9 months although the comprehension is developing.
Motor/coordination disorder MRI findings are not indicative of motor or a coordination disorder, but symptoms like the inability to elevate or lateralise the tongue are not improving even after intense oro-motor-kinesthetic exercises, facilitated with physical assistance (prompt procedure).
Agnosia/visuo-spatial disorder MRI findings showing a lesion in the parieto-occipital are responsible for gnosis and visuo-spatial coordination learning, hence these areas are called association areas. If symptomatic they would have lead to difficulties like: Poor visuo-spatial orientation Difficulty to identify objects, shapes, sizes, distance Inability to identify pictures Poor association between auditory and visual stimuli, etc.
The child does not show any of these problems.
Conclusive queries to consider Why is the condition static? Can the condition be improved? If yes, how? ■
AH
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