Continuing Education Activity
Ankyloglossia, also known as tongue-tie, is a short lingual frenum that interferes with normal tongue movement. It is an uncommon congenital oral anomaly that can cause difficulty with breast-feeding and speech articulation. It is classified according to Kotlow's classification into 4 classes. This activity explains the pathophysiology, classification, evaluation and management in patients with ankyloglossia. It highlights the role of the interprofessional team in treating and decreasing long term morbidity in patients with ankyloglossia.
- Describe the pathophysiology, genetics and classification of ankyloglossia.
- Outline the evaluation in a patient with ankyloglossia.
- Explain the management strategies in a patient with ankyloglossia.
- Explain the importance of a cohesive, interprofessional team approach to caring for patients with ankyloglossia.
Ankyloglossia, also known as tongue-tie, is a short lingual frenum that interferes with normal tongue movement. Prevalence has been estimated to be from less than 1% to 10%. This significant wide range can be attributable to the lack of diagnostic criteria for tongue-tie.
A genetic cause of ankyloglossia has been reported as X linked cleft palate syndrome. A gene mutation on TBX22 causes this.
The frequency seems to be higher in males, with a male to female ratio of 1:1.1 to 3:1. Most cases are believed to be sporadic rather than genetic, and commonly it is an isolated anomaly; although, associations with other genetic disorders have been reported.
There is no standard definition of ankyloglossia, and multiple classifications exist. When examined, the ‘free tongue’ length in newborns should be greater than 16 mm. Measurements of less than 11 mm indicate moderate ankyloglossia and less than 7 mm indicates severe ankyloglossia. However, this measurement may not be useful in infants. The term posterior ankyloglossia is used when the frenulum is attached at the middle to the posterior aspect of the undersurface of the tongue. Taking into consideration the anatomy and function, there are many assessment tools for classification.
One of them is the Hazelbaker Assessment for Lingual Frenulum Function. This tool uses a scoring system using anatomy and function.
- Anatomy: Appearance of tongue when lifted, elasticity of frenulum, length of lingual frenulum when tongue lifted, attachment of lingual frenulum to tongue and attachment of lingual frenulum to inferior alveolar ridge
- Function: Lateralization, lift of tongue, extension of the tongue, spread, cupping of tongue, peristalsis, snap-back
It consists of 10 points for frenulum appearance and 14 points for tongue function.
History and Physical
The clinical presentation of symptomatic ankyloglossia varies; however, the biggest concern, as well as research and data collection, focus on breastfeeding difficulties that include prolonged feeding, difficulty latching, and irritability while feeding. These all lead to poor weight gain. During breastfeeding periods, it has also been reported that mothers with infants with this conditions have a higher risk of significant nipple pain, which could lead to frustration and the start of formula feeding in newborns. With the American Academy of Pediatrics campaign to exclusively breastfeed babies up to 6 months of age, ankyloglossia and its management have gained more attention due to the difficulties that babies encounter when breastfeeding is attempted.
There are concerns that ankyloglossia can persist beyond the neonatal period. While some authors describe the possibility of speech related issues due to decreased tongue mobility, others disagree. However, concerned parents frequently ask their pediatricians about future problems with articulation. As the speech develops, some children may exhibit difficulties with the sounds of several letters or a combination of letters: l, r, t, d, n, z, th, and sh. It is quite difficult to predict which patients will have articulation problems, or if in fact, this association exists.
Other reported problems in patients with ankyloglossia include difficulty eating certain foods that include licking (ice cream), playing certain wind instruments (examples include flutes, clarinets, tubas, trumpets), and orthodontic problems (open bite and malocclusion).
Among complications, self-esteem and psychological issues can also be a concern in patients with tongue-tie.
Making the diagnosis for ankyloglossia is not difficult. However, management has many controversies, and it can be very confusing for parents, and they seek different opinions. The best approach for any physician who encounters this issue is to weigh the benefits for the patient. If the condition is not causing any problems during the neonatal period, observation is the best treatment option. If other causes of difficulty feeding have been ruled out, then a frenotomy can be offered as a treatment option. Only a trained and qualified healthcare provider should do this procedure. Regarding those patients who present with articulation problems, the decision is more difficult, and evaluation and therapy with a speech pathologist can be recommended.
Treatment / Management
The biggest question for physicians dealing with patients with ankyloglossia remains whether to treat or not to treat. There is evidence that supports treatment in symptomatic patients.
When physicians choose treatment over observation, frenotomy is the most commonly used procedure. This procedure is quick and can be done in an outpatient setting.
The procedure involves holding the tongue up to make the frenulum tight, then cutting through the fascia-like tissue along a line parallel with, and close to the tongue. The cut is made in a single motion as is done very quickly, less than a second. The infant is restrained by swaddling or in a Papoose board, with an assistant holding the child's head for better support. The timing of frenotomy varies from 6 days to 18 days of age. In a study of 200 infants undergoing frenotomy without analgesia, researchers found that 18% cried during the procedure and 60% after the procedure. According to an article titled Do tongue ties affect breastfeeding? by Griffiths, the mean crying time for frenotomy was 15 seconds. Some physicians choose to give sucrose before the procedure, to minimize and help with pain. Rarely the frenulum grows back.
Before deciding to treat patients with tongue tie, physicians should keep in mind other differential diagnoses that could present with feeding difficulties and failure to gain weight. A lactation nurse should always be involved in the care and assessment of these patients and to help mothers with feeding techniques.
Risk and complications of frenotomy are uncommon but have been described. Bleeding is the most common and usually resolved with local pressure. A family history of bleeding disorders should be assessed before the procedure, and in older patients, a history of bleeding should be elicited.
Another procedure used to treat ankyloglossia is frenuloplasty. However, it is rarely performed, and it does require general anesthesia.
A systematic review published in Pediatrics Journal 2015 titled Treatment of Ankyloglossia for Reasons Other Than Breastfeeding: A Systematic Review by Sivakumar Chinnadurai, MD mentioned some data points to the fact that there is no need for treatment. However, since the short frenulum will likely elongate spontaneously with use and stretching, there is no sufficient data to support this statement. In this particular review, authors concluded that among children with ankyloglossia, there is limited evidence to suggest intervention for this condition, and there is not enough data to support that frenotomy is associated with positive outcomes in other issues besides breastfeeding.
Prognosis for a patient with ankyloglossia is good, and overall, patients develop normally. As mention in this article, some complications could include low self-esteem, but that can be easily addressed.
Pearls and Other Issues
Ankyloglossiaoccurs most commonly in males.
The most commonly feared complication among physicians is difficulty with breastfeeding that leads to failure to gain weight.
In the majority of patients in whom ankyloglossia is an incidental finding, the best management is observation and reassurance.
In cases where medical management is necessary, frenotomy is the treatment of choice, can be done in an outpatient setting, and is a very simple procedure with few side effects.
Enhancing Healthcare Team Outcomes
Ankyloglossia is commonly encountered by the nurse practitioner, primary care provider, pediatrician and the internist. Making the diagnosis for ankyloglossia is not difficult. However, management has many controversies, and it can be very confusing for parents, and they seek different opinions. The best approach for any healthcare worker who encounters this issue is to weigh the benefits for the patient. If the condition is not causing any problems during the neonatal period, observation is the best treatment option. If other causes of difficulty feeding have been ruled out, then a frenotomy can be offered as a treatment option. Only a trained and qualified healthcare provider should do this procedure. Regarding those patients who present with articulation problems, the decision is more difficult, and evaluation and therapy with a speech pathologist can be recommended. Overall, most patients benefit from observation; surgery is more likely to cause more harm than good.