Tongue Ties

Grace Kim, MS1, Timothy Koo, BA1, Sri Chennupati, MD1,2 1. Morsani College of Medicine,

University of South Florida 2. Lehigh Valley Health Network

Ankyloglossia, or tongue tie, involves the tongue attaching to the floor of the mouth in such a way that tongue movement is restricted. The incidence of ankyloglossia has been rising overall, with an estimated 834% increase in diagnoses in the US from 1997 to 2012.1 While the cause is unclear, the increasing incidence of ankyloglossia does not seem to be due to environmental or developmental factors but rather a result of the social push promoting breastfeeding in recent years.1,2,3 Untreated ankyloglossia can lead to impaired breastfeeding and speech impediments, which can have psychosocial effects later in life. However, the treatments for ankyloglossia are not without risk, bringing up the question of when and if to correct the tongue-tie.

In most infants, the lingual frenulum, the thin tissue connecting the tongue to the floor of the mouth, attaches posteriorly. Ankyloglossia occurs when the lingual frenulum attaches near the tip of the tongue and/or is short, thick, or rigid, thereby preventing movement of the tongue. Its prevalence is estimated to affect 4-11% of infants.4 Although the exact cause is unknown, it is believed that genetics play a role, as ankyloglossia has been found to run in families.3

The methods employed to correct ankyloglossia range from a simple in-office procedure to a surgical procedure under general anesthesia. Lingual frenotomy is the cutting of the frenulum close to the base of the tongue to separate the tongue from the floor of the mouth. It is a straightforward procedure that can be done with sterile scissors, although some clinicians prefer using a laser, and does not require anesthesia.5 Due to its simplicity, these types of frenotomies are often done in the office and are performed by various healthcare providers, including midwives, surgeons, and dentists. For severe cases, more invasive surgical techniques can be implemented, such as frenectomy and frenuloplasty. While frenotomy does not require local or general anesthesia, a frenectomy with myotomy and frenuloplasty do require local anesthesia and possibly intravenous sedation, especially for young children. Frenectomy with myotomy involves not only cutting the lingual frenulum, but also dividing some of the underlying mucosa and muscle layers to provide a better release of the tongue. Frenuloplasty is a surgical method that lengthens the frenulum by creating flaps, repositioning them, and suturing them together in a manner that provides greater length. Studies have shown that frenuloplasty has decreased risk of recurrence and hypertrophy compared to frenectomy with myotomy and frenotomy, along with better outcomes for feeding, maternal pain, and speech.6,7 Despite this, lingual frenotomy remains the treatment of choice for uncomplicated ankyloglossia in infants due to its less invasive nature, efficiency, and lower cost.

Early correction of ankyloglossia is important as it can impact infant health and development, as well as maternal psychological health. Infants usually present to the physicians’ office with difficulty breastfeeding, which manifests as irritability, difficulty latching or maintaining suction on the nipple, longer feeding times, and poor weight gain. The restricted tongue movement can affect speech later in life, create difficulties with eating, and can even alter the structure of the

jaw and teeth, which can have lasting social and psychological impacts as the child becomes older.8,9 Furthermore, mothers of children with ankyloglossia who breastfeed report higher rates of breast pain and mastitis. Difficulty in breastfeeding can significantly impact maternal psychological health. Negative breastfeeding experiences have been linked to postpartum depression and the increased societal pressure to breastfeed has exacerbated feelings of anxiety and depression.10,11 Thus, the inability to breastfeed due to ankyloglossia can negatively impact maternal bonding with the child and cause stress and depression in new mothers.4

Despite the benefits of correcting ankyloglossia, risks from surgical interventions include bleeding, infection, scarring, damage to adjacent structures, adhesion formation, and recurrence, as well as risks associated with anesthesia.12 The procedure should be performed by a trained clinician, in order to minimize complications and adverse outcomes. Furthermore, the cost must be taken into account. A basic frenotomy can cost $850, and more complex procedures requiring general anesthesia can add on at least another $500, in addition to hospital charges which can be as high as $8000. The expense is further complicated by varying insurance coverage.2

The decision to intervene has been complicated by the lack of a formal definition of ankyloglossia and what is considered pathologic. This has resulted in a lack of consensus regarding the treatment

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indications for less severe cases of ankyloglossia.5,13 The current indications for frenotomy are symptom dependent and are largely determined by subjective maternal reports. Furthermore, the reports of the actual benefit, particularly in the long-term, provided by frenotomies have been mixed. The reliability of the results of studies has been called into question due to their limitations, which included small sample sizes and short follow-up periods.1,4,5,13,14,15

In the past, there have been attempts at a grading system based on anatomy (Coryllos system), which did not necessarily predict trouble with breastfeeding. However, the Hazelbaker Assessment Tool for Lingual Frenulum Function and the Bristol Tongue-tie Assessment Tool have provided a way to categorize ankyloglossia based on function.13,15 More recently, a consensus statement was released by the American Academy of Otolaryngology--Head and Neck Surgery.16 It included statements regarding the definition of ankyloglossia, its contribution to difficulty in breastfeeding, the indications for surgical correction, and the procedure itself. The development of grading tools and the consensus statements will standardize the guidelines for both research and clinical practice.

Frenotomies should be performed after other causes of difficulty breastfeeding have been ruled out and conservative interventions have failed.16 These include support from lactation specialists, feeding evaluations, and speech therapists. Studies have shown that it is possible to decrease frenotomy rates through targeted interventions, education of healthcare professionals, patients and parents, and a standardized step-bystep program. With the implementation of these methods, a study showed that 62.7% of surgical referrals for frenotomy did not undergo surgical procedures

and another showed a 7.8% decrease in frenotomy rates from 2015 to 2017.2,15 Ankyloglossia can have many detrimental effects on both the mother and child. However, with the surge of public interest in breastfeeding, ankyloglossia has made its way into the mainstream consciousness as the culprit for infant feeding difficulty; as a result, diagnoses of ankyloglossia and frenotomies have risen. Frenotomy is a relatively simple procedure, but a more conservative approach with a thorough evaluation should be taken when confronted with a probable ankyloglossia diagnosis. To this end, there have been strides in recent years to standardize definitions and guidelines for ankyloglossia, and in the near future, frenotomy rates may begin to decrease.

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