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 Continued on page 8
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