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  • Content
    • 1 - How to prescribe speech therapy
      • 1.1 - Introduction
      • 1.2 - Indication of the speech and language assessment
      • 1.3 - Speech therapy for hearing loss
      • 1.4 - Impairment in written language
      • 1.5 - In the case of children with multiple disabilities
      • 1.6 - Speech therapy in pharyngolaryngeal disorders, including dysphonia
      • 1.7 - Speech therapy in dysphagia
      • 1.8 - Speech therapy and velo-palato-pharyngeal and buccal conditions
      • 1.9 - Speech therapy and neurological disorders
    • 2 - How to prescribe physiotherapy
      • 2.1 - Introduction
      • 2.2 - Maxillofacial physiotherapy and re-education
      • 2.3 - Physiotherapy and facial paralysis
      • 2.4 - Physiotherapy and vestibular re-education
        • 2 . 4 . 1 - Benign paroxysmal positional vertigo
        • 2 . 4 . 2 - Other vertigo-inducing situations
      • 2.5 - Physiotherapy and cervical carcinological surgery
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1 . 3  -  Speech therapy for hearing loss

The role of the speech therapist is indispensable in hearing impairments in children. In adults, who could hear perfectly in the past, the speech therapist is only interested in those who are profoundly handicapped by their hearing loss. In practice, this concerns the severely or profoundly deaf where external or implanted hearing aids are not sufficient enough to restore an adequate audio-phonatory loop. Speech therapy aims, in these cases, to implement all possible means and strategies to enable the better use of auditory perceptions in order to understand and produce oral language.

In children, the warning signs of a hearing impairment must be well known. Prelingual and postlingual hearing loss can be distinguished depending on the date of onset of deafness, i.e., whether it occurred before or after the start of language acquisition. In principle, postlingual hearing loss does not cause any diagnostic problem, as parents rapidly worry about the language regression of their child. On the other hand, prelingual hearing loss is more difficult to diagnose, as there is no specific benchmark for a child who has never started talking. Therefore, it is imperative that the physician is aware of the major developmental stages of oral language. These stages are listed in the corresponding chapter, but it is useful to note the main points :

• as early on as the 6^th month in utero, mothers note certain reactions from the embryo to noise. We now know that from this point onwards the embryo hears their mother's voice and even the voice of another person, typically the father, if he talks in contact with the mother's abdomen;
• at birth, babies are sensitive to ambient noise and react in a well-known way to noises that startle them. These are archaic reflexes, such as Moro reflexes where the baby spreads his arms in response to external noise;
• from the age of 3 months, the baby starts to produce sounds. These are often cries of joy and stereotypical noises ("aheu");
• from the age of 4 to 5 months, the infant babbles: the sounds produced interest the infant and play a role in modulating intonation;
• at approximately 6 months old, the baby reacts to its first name. At between 6 and 9 months, there is babbling with a doubling of consonants, preferentially "baba". The imitation of sounds and intonations begins. During this period, the baby gives an object on demand;
• at 12 months, the baby pronounces a few words, at least one, often dada or mama;
• at between 18 and 20 months, the child combines two or three words forming metaphrases and already has a vocabulary of approximately 50 words;
• from 20 months onwards, vocabulary grows quickly, and at 3 years, language becomes fluid. The child understands "I" and is able to produce real sentences with subject/verb/object;
• at 5 years old, the child is able to tell a complete story by producing elaborate phrases.

This schema may vary from one individual to another, but overall, if a delay is noted, it is essential to evoke a delayed language acquisition and, above all, impaired hearing.

Here, we must emphasize the particular importance of the physician in paying attention to the parents' perception regarding the hearing capability of their child. One should not be falsely reassured by parents who think that their child's hearing is not impaired when an obvious language delay is noticed. Contrarily, the utmost importance should be given to parents worried about their child's hearing, especially if they already have other children, or if there are risk factors for hearing loss (family history, complex pregnancies, notably with twins, difficult labor, neonatal infections, ICU hospitalization, etc. see hearing loss in children).

At this point, the diagnosis of prelingual hearing loss is so difficult to establish that many errors are made. The development of the auditory cortex, which is essential in language development, is dependent on being able to hear over a very specific period of time.

In practice, if a child does not hear before a certain age, 5 years being the fatal date for a hearing aid, it is not possible for that child to acquire correct oral language skills, regardless of the means of auditory rehabilitation implemented. That is why neonatal hearing assessments are so important as long as precaution is implemented when announcing a diagnosis and that constant and effective technical and psychological support is given.

It is therefore, above all, through a language delay or phonation disorder that the diagnosis of hearing loss is established. It is important to specify certain definitions :

• delayed language development is evoked when the above-mentioned stages of the acquisition schema are not respected. At most, if the diagnosis were made late, a 3-year-old child would have difficulty in organizing words to making sentences. The child would also have understanding difficulties;
• the delayed speech includes an impaired pronunciation of words, by default of correct pronunciation of certain phonemes, or difficulty in combining or organizing the phonemes that make up a word (inversion or omission of phonemes, confusion, or simplification);
• articulation is deemed impaired when there is a permanent and systematic error in the pronunciation of certain phonemes (for example, a lisp).
• stuttering is an impairment of the rhythm of speech with repetition of certain syllables or phonemes, making it impossible to produce the next expected sound;
• dysphasia is a serious condition of language development, possibly ascribable to centrally impaired hearing.

Speech assessment primarily serves to specify the language delay, its type, and to consider appropriate speech and language therapy management. While the physician should raise the question of hearing loss when faced with language impairment, it is not uncommon for the diagnosis to be made by the speech therapist following an assessment requested for school difficulties, for example.

In prelingual children, the speech therapist's assessment also evaluates the appetence of the child to communicate and listen to ambient noise, if he has some remaining auditory function. Once a hearing aid is fitted, be it an external aid or cochlear implant, the speech therapist assesses the progress in the child's communication and language. The speech therapist's help is often well received to adjust the settings of the hearing aid.

Postlingual deafness occurs in children who became deaf after language development was initiated (the association of words in metaphrases was already acquired). In this case, the role of the speech and language assessment is also to specify the delay, i.e., to assess the language level of the disabled child.

In any case, the role of speech and language therapy is to help the child catch up and better understand surrounding sounds by any other means. Lip reading is of fundamental interest. Help can be given using specific codes formed with fingers on lips when pronouncing words to facilitate and refine the deciphering process of lip-reading. This coded language, known as cued speech, is of paramount importance in the case of deafness corrected by a cochlear implant. Emphasis is currently on the effectiveness of a multimodal approach to speech therapy rehabilitation in deafness, which is both auditory and visual.

In deaf adults, speech and language therapy is used to help the patient understand his conversational partner and ambient sounds better. The external hearing aid has made such progress that speech therapy is only required in the case of profound deafness. However, even in the stages of less severe deafness, speech therapy may be justified, at least for learning how to lip read, in order to make understanding easier, but also to facilitate subsequent care in the event of foreseeable worsening of the condition.