Introduction
While the existence of tongue tie (ankyloglossia) has never been questioned, the decision on whether surgery is an appropriate treatment has been the subject of many debates. Even today, the literature available tends to focus on different aspects depending on whether the author is a dentist, lactation consultant, speech-language pathologist, surgeon or general practitioner.
Although there is little consensus of opinion, there is still an ingrained reluctance to recommend surgery. As a result, there are many children who undergo several years of speech therapy with little or no improvement until the tongue tie is detected (often, by chance) and remedied. In fact, the possibility of a tongue tie being the cause should be part of the differential diagnosis performed when a speech pathologist sees a new patient. Surgical treatment of the structural defect should be the next step to be considered.
Surgical Options
There are four options available in the choice of interventions in cases of tongue tie:
- Snipping the frenum (sometimes referred to as ‘frenotomy’) of neonates.
- Surgical revision of the frenum (sometimes referred to as ‘frenectomy’, ‘frenulectomy’, or ‘frenuloplasty’) under a general anaesthetic at or after 6 months of age
- Revision of the frenum by laser without a general anaesthetic.
- Revision by electrocautery using a local anaesthetic.
All these methods are equally successful when used in appropriate circumstances.
Snipping
This method has a long history and was recorded as being used by midwives to free the tongue of neonates with feeding difficulties as far back as 1697. Recently, it is being advocated by eminent paediatric surgeons and lactation consultants who see a role for trained midwives, nurses and lactation consultants in using this simple and effective method of releasing a tight frenum that is inhibiting breastfeeding in neonates.
Sucking is reported to improve immediately after the procedure, which causes minimal bleeding or discomfort for the baby, improves the efficiency of latching and prevents the severe pain experienced by mothers during attempts to breastfeed.
This procedure, carried out as an out-patient procedure at the Southampton General Hospital, UK, is described as follows by Mr Mervyn Griffiths, a neonatal and paediatric surgeon, and requires no anaesthetic or analgesic.
“The infant was… wrapped securely in a towel. The infant’s shoulders were firmly held by the palm of an assistant’s hands whose wrists fixed the infant’s head… The author put the tongue tie on the stretch with his left index finger while holding the lower lip clear with his left thumb. The tie was divided completely with sharp, blunt-ended sterile scissors and the floor of the mouth was compressed with a paper towel or gauze square. The infant was… immediately taken to the mother to be fed.”
Results were described as: improving breastfeeding immediately – 57%, and feeding better by 24 hours – 80%. Further research is envisaged, but the results of this study were seen as showing the relevance of tongue tie division as a safe and effective treatment for breastfeeding problems in neonates with tongue tie.
Pros and Cons of Neonatal Snipping
If the only goal were to improve breastfeeding, snipping the tie in infancy would be the obvious solution. No anaesthetic is needed, it is relatively cheap, the infant’s pain is slight, bleeding is negligible, and feeding improves immediately.
However, when ankyloglossia is associated with foreshortening of the genioglossus muscle, as often occurs, merely snipping the lingual frenum may not allow free and coordinated movement of the tongue sufficient for the demands of a gradually growing speech and language structure. As a result, further surgery may legitimately be needed later. Therefore, the possibility that re-evaluation of the situation might become appropriate later, should be emphasized.
Surgery in Hospital
Surgeons generally operate at the earliest at 6 months, when the baby is felt to be better able to handle a general anaesthetic. This postponement of surgery has the disadvantage of prolonging the period of feeding difficulty and strengthening habits of abnormal tongue movement.
However it avoids the possibility of an infant reacting badly to the general anaesthetic necessary for this more complex procedure. The presence of important blood vessels in the area makes it preferable for the patient to be anaesthetised, to avoid the possibility of accidentally cutting these vessels and causing excessive bleeding.
One child seen recently was a 5-year old who had been snipped at 2 weeks of age. His feeding was no problem after the operation, but the hidden agenda still operated in other areas, and when interviewed, he had very poor speech and still functioned like a child with a tongue tie. He had poor tongue posture, salivary profusion, and limited awareness of lingual movements. His two brothers aged 3 years and 16 months, were also tongue tied, but as the mother attributed the 5-year old’s problems to ‘unnecessary surgery’ in infancy, she refused intervention for all the siblings.
Surgery under a General Anaesthetic
Surgery in hospital usually involves a half-day stay, fasting prior to the operation, approximately 4 minutes under a general anaesthetic, and soluble stitches along the incision. There is usually discomfort until healing is complete and this may take approximately 10 days, after which speech therapy may be commenced. The procedure is very safe and there are no contra-indications.
Laser Surgery
This relatively new option is suitable for neonates, older children and adults. No general anaesthetic is used, but an analgesic gel might be applied. The procedure is very quick, taking only 2 to 3 minutes to perform, but some cooperation from the patient in keeping still is required.
There is virtually no bleeding, no pain, no risk of infection and the healing period can be as short as 2 hours. It is best to have this procedure performed by a specialist in the area of laser dentistry who is familiar with tongue tie revision.
The patient returns for speech therapy in 2 days.
Revision by Electocautery
This method does not require a general anaesthetic and can be performed as an outpatient service with a local anaesthetic. Hence, it is a economical and safe option which can be used to revise mild tongue ties, i.e. when blood vessels are not heavily involved, and tethering of the tie is not extensive.
Its proponents describe it as a viable office-based procedure in cases of mild Ankyloglossia.
Second Revision
Some tongue ties are much more severe than others and may require more than one procedure to completely release the tongue. This is uncommon, but not unknown and a later operation can deliver completely successful release.
Management and Speech Therapy
Speech symptoms in tongue-tied patients vary enormously, and speech therapy without surgical intervention in such cases is at best a lengthy process, and at worst, expensive, frustrating for patient and therapist, and unsuccessful. Following surgery, speech therapy to address areas of difficulty identified in the assessment process should begin as soon as possible after healing is complete.
Articulation of specific sounds may be consistently defective, particularly where pronunciation requires lingual elevation, as in T, D, and N and these errors can be addressed with conventional therapy exercises. However, it is more important to address issues such as the ability of the tongue to transfer from one articulatory posture to another.
Coordination of the orofacial musculature is a major issue and errors may be puzzling in their inconsistency; rapid utterance invariably exaggerating problems. Home practice is essential. Speech therapy must include a strong emphasis on improving oral kinaesthesia and DDK (Disdiadochokinesis) without which no significant improvement in speech will be achieved.
Voice problems have been observed to occur because of stress and forceful phonation resorted to in an effort to be understood. In many patients dysphonia was observed to abate spontaneously after successful tongue tie surgery. The frequent presence of difficulties of phonation and anomalies of voice have been commented on by Mukai, Mukai & Asaoka (1993) who report having studied Ankyloglossia in 655 infants and seen improvement after surgery.
Their research states that surgeons who had operated on both babies and adults with tongue tie reported that their clientele had experienced difficulties which embraced a range of problems from respiratory difficulties and deviation of the epiglottis and larynx, to problems with phonation. They also identified an increased risk of SIDS in the neonates.
Delays in language acquisition have also been noticed among some young patients, possibly due to a habitual lack of practice of mature language structures, longer sentences, new and longer words. The child who can only coordinate short phrases will continue to use simple forms, or telegraphic speech for the sake of being understood. The longer these maladaptations have lasted the more the patient will cling to them, and motivation will need to be boosted for progress to be maintained.
Conclusion
Optimal management of tongue tie including timely and appropriate surgical intervention followed by speech therapy when indicated has the capacity to deliver pleasing results, often in a shorter time than expected.