Paediatrics · Easy
This case is fictional and exists for study. It describes no real patient.
2 years · male
A 24-month-old boy is brought to the clinic by his mother due to concerns about his speech development. She notes that he is not yet using any single words with meaning, whereas his older sibling was speaking in short sentences by this age. He frequently turns up the volume on the television and does not respond when called from another room, though he responds well to visual cues. He has had three episodes of acute otitis media in the past year. Physical examination reveals bilateral dull, retracted tympanic membranes. His gross motor, fine motor, and personal-social skills are appropriate for a 2-year-old.
Vital signs
- HR
- 102 bpm
- BP
- 92/58 mmHg
- RR
- 22/min
- Temp
- 36.7 °C
- SpO₂
- 99%
Examination findings
- Bilateral dull, retracted tympanic membranes with reduced mobility on pneumatic otoscopy
- Gross motor, fine motor, and personal-social developmental milestones appropriate for 24 months
Question 1 of 3
Which of the following is the most likely underlying cause of this child's speech delay?
The child presents with speech delay, a history of recurrent acute otitis media, and clinical features of otitis media with effusion (dull, retracted tympanic membranes). Turning up the TV volume and failing to respond to auditory cues when out of line-of-sight are classic indicators of conductive hearing loss. Autism spectrum disorder is unlikely as social skills are normal. Global developmental delay is excluded because fine motor, gross motor, and social domains are age-appropriate. Selective mutism involves persistent failure to speak in specific social situations despite speaking in others, which does not fit this presentation.
Teaching point: Conductive hearing loss secondary to otitis media with effusion (glue ear) is the most common cause of isolated speech and language delay in early childhood.
Question 2 of 3
Which of the following best describes the pattern of developmental delay in this child?
At 24 months, a child is expected to speak 20 or more words and join two words together. This child has no single words, indicating impaired communication skills. However, his gross motor, fine motor, and personal-social domains are completely normal for his age, making this an isolated speech and language delay. Global developmental delay requires significant delay in two or more developmental domains (e.g., motor, cognitive, speech, social).
Teaching point: Isolated speech and language delay involves impairment in communication alone, whereas global developmental delay requires significant delay in two or more developmental domains.
Question 3 of 3
Which of the following is the most appropriate initial investigation to assess this child's presentation?
Formal audiological evaluation (such as health-visitor distraction testing, visual reinforcement audiometry, or tympanometry) is the essential first-line investigation for any child presenting with speech and language delay to rule out hearing impairment. Neuroimaging (MRI), genetic testing (chromosomal microarray), and metabolic screening (TSH) are reserved for children with global developmental delay, neurological deficits, or dysmorphic features.
Teaching point: Formal hearing assessment is the essential initial investigation for any child presenting with delayed speech and language development.
Key learning points
- Conductive hearing impairment secondary to glue ear is the most frequent cause of isolated speech delay in toddlers.
- Hearing assessment must be performed in all children presenting with speech and language delay before assuming a primary neurodevelopmental disorder.
- Global developmental delay is defined as significant delay in two or more developmental domains, distinguishing it from isolated domain delays.
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