When a child's language development does not follow the normal developmental course for no known reasons specific language impairment (SLI) is diagnosed. In contrast, pragmatic language impairment (PLI) refers to children who experience significant difficulties with the use of language. Clinical accounts of PLI have suggested that unlike children with more typical SLI, children with PLI have adequate syntax and phonology and are often verbally fluent. However, they may exhibit a range of linguistic and communicative deficits such as comprehension deficits for connected speech, conversational inadequacies, poor turn-taking, atypical word choices, literal interpretation of figurative language, and poor topic maintenance. There also may be fundamental deficits in social cognition, such as appreciating the thoughts and feelings of others. PLI may be found in SLI children, children with learning disabilities, autism and traumatic brain injuries. Here we review aspects of pragmatic communication skills, the development of emotion recognition, and diagnostic and therapeutic procedures. Otolaryngologists have to be aware of PLI in case children with communication problems are referred to them. This may enable a timely diagnosis and early intervention.