🩺 Speech Disturbance

Speech disturbance is a broad term encompassing aphasia (impaired language production or comprehension), dysarthria (impaired motor control of the muscles for speech), and dysphonia (disorder of the voice box). In an acute setting, it is most frequently a sign of stroke or TIA, particularly if lateralising to the dominant hemisphere. Recognition is aided by the FAST (Face, Arms, Speech, Time) screen. Prompt identification is vital for accessing thrombolysis or thrombectomy pathways.

Determine the exact onset of the speech problem; sudden onset points toward a vascular event (Stroke or TIA), whereas gradual onset may suggest a space-occupying lesion or neurodegenerative condition. Ask about associated symptoms like limb weakness, facial droop, or sensory changes. Inquire about 'expressive' difficulties where the patient knows what they want to say but cannot, versus 'receptive' difficulties where they cannot understand instructions. Review the medication list for any drugs that might cause sedation or metabolic encephalopathy.

Assess the patient's level of consciousness using the Glasgow Coma Scale (GCS). Observe for facial asymmetry, tongue deviation, or palate weakness (cranial nerves VII, IX, X, XII). Evaluation of speech should include fluency, comprehension, repetition, and naming (checking for nominal aphasia). A full neurological exam of the limbs is required to look for co-existing hemiparesis. Handedness should be established, as the left hemisphere is dominant for speech in almost all right-handed and most left-handed individuals.

Ischaemic Stroke, Haemorrhagic Stroke, Transient Ischaemic Attack (TIA), Brain Tumour, Delirium, Bell's Palsy (isolated dysarthria), Multiple Sclerosis.

Sudden onset, associated limb weakness, decreased level of consciousness, and progressive worsening of symptoms (suggesting raised intracranial pressure).

The priority is urgent neuroimaging (CT head) to exclude intracranial haemorrhage if a stroke is suspected. Routine bloods (FBC, U&Es, glucose, CRP) help rule out metabolic derangement or infection (delirium). An ECG is essential to look for atrial fibrillation as a source of emboli. Further investigations might include a carotid doppler or MRI brain if the CT is inconclusive or if a more detailed view of an infarct is needed. Speech and language therapy (SALT) assessment is the gold standard for refining the diagnosis of dysphasia.

If the patient has 'telegraphic speech' (broken but meaningful), it is likely Broca’s. If they speak fluently but it makes no sense ('word salad'), it is likely Wernicke’s. Dysarthria is a motor problem—if you ask a patient to say 'British Constitution' or 'Baby Hippo', they may struggle with clarity but the grammar remains intact. Always check the onset; sudden speech disturbance is a stroke until proven otherwise. National guidance emphasizes 'Time is Brain'.

Speech disturbance is a core component of the 'Neurology' and 'Acute Medicine' syllabus. Students must be able to classify aphasias (Broca’s vs Wernicke’s) and distinguish dysphasia from dysarthria. Understanding the referral pathway for TIA vs Academy Stroke is crucial for UK exams.