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Indian Pediatrics 2003; 40:404-405 

Tongue-tie: An Update


 

Tongue-tie, also known as ankyloglossia inferior, is a relatively common congenital abnormality of lingual frenulum. It has been defined as a condition in which the tip of tongue cannot be protruded beyond the lower incisor teeth because of short frenulum linguae. It is very difficult to assess actual incidence, because of wide spectrum of presentation ranging from very thin band to fully developed ankyloglossia. The number of mothers convinced that their infant is tongue tied far exceeds the number of babies who really have the condition. Reported incidence of tongue-tie varies from 0.04 to 0.1% and the male: female ratio is 2.6:1(1). Tongue-tie usually presents as a sole anomaly, but very rarely may be associated with cleft palate or Pierre-Robin syndrome(2). The earliest report of tongue-tie division is by Mark who wrote that "and the string of his tongue was loosened and he spake plain" (Mark 7:35), since then literature is full of entertaining anecdotes about the tongue-tie. Midwives used to divide frenulum linguae of newborn babies with their fingernails. As long ago as 1794, a surgeon claimed that tongue-tie can be divided in an infant without any pain to child who will be taken to the breast immediately. A grooved director was devised more than a century ago for division of tongue-tie. In 1983, Lao and Ong(3) described a grooved tablespoon for tongue-tie release.

Problems in Tongue-tie

Before deciding whether to treat or not to treat tongue-tie, its effect on tongue function must be evaluated(4).

1. Sucking and swallowing: Literature is full of anecdotal evidence that tongue-tie causes significant breast feeding problems leading to sore nipples, repeated bouts of mastitis, failure to thrive and can prevent development of adult swallowing mechanism(5,6) but studies conducted on swallowing mechanism do not support this argument and unless restriction of tongue movement is quite extreme, it does not interfere with sucking and swallowing.

2. Speech: Speech problem with tongue-tie is frequently overrated, as it has no relation with delay or onset of speech. Sometimes it may cause errors of articulation and affect the expression of lingua-alveolar and lingua-dental consonants like t, d, l, n, r and Th; because pronunciation of these requires opposition of tongue to alveolus or palate. Significantly, more errors of articulation have been found in people with limited mobility of tongue as compared to those with normal mobility. On the other hand, there is enough evidence that good speech is still possible with significant tongue-tie and speech problems can be overcome without frenulotomy with speech therapy(78).

3. Mechanical problems: These are the most underestimated problems of tongue-tie. Lack of mobility of tongue causes inability to perform internal oral toilet, inability to lick lips and child cannot play wind instruments. These are the more valid and scientific indications for frenulotomy(9).

4. Jaw growth: Ankyloglossia minor does not cause any effect on growth of jaw except minor dental abnormality of incisors or mucogingival recession. Ankyloglossia major may cause open bite deformity and prognathism(6,7).

Management

Diagnosis is obvious on inspection, as child is unable to protrude the tongue beyond incisor teeth and there is a pseudocleft at the tip of tongue(8). The presence of a non-disturbing lingual frenulum does not justify its surgical section. The valid indications for frenulotomy have been highlighted above. There is no place for clipping or snipping the frenulum without anesthesia especially in the newborn, as adequate division cannot be achieved by this method. There is no pre-scribed age for frenulotomy. The appropriate age is when the surgeon is convinced that it needs to be done in the best interest of the patient. Many newborn babies appear to have some degree of tongue-tie for about 12 months and their appearance and function soon improves by spontaneous improvement in lingual muscular co-ordination. Release of tongue-tie may sound a minor procedure but has a distinct possibility of bleeding, infection and injury to Wharton’s duct. There is agreement that general anesthesia is needed except in co-operative adult patients in whom local anesthesia can be used(8). Several surgical methods are available but whichever method is used, frenulum should be divided up to the genioglossus muscle and raw area is covered with Z-plasty or V-Y plasty or transverse-vertical frenuloplasty to avoid recurrence of tongue-tie(10). In cases of true ankyloglossia, genioglossus muscle is fibro-tic, and this requires full plastic correction to release the tongue.

Pawan Agarwal,
V.K. Raina,

From the Department of Surgery,
N.S.C.B. Government Medical College,
Jabalpur 482 003,
Madhya Pardesh,
 India.

Correspondence to:
Dr. Pawan Agarwal,

292/293, Napier Town,
Jabalpur 482 001,
Madhya Pardesh,
India.
E-mail:
[email protected]

 References


 

1. Messner AH, Lalakea ML, Aby J, McMahon J, Bair E. Ankyloglossia: incidence and associated feeding difficulties. Arch Otolaryngol Head Neck Surg 2000; 126: 36-39.

2. Jones SE, Derric GM. Difficult intubation in an infant with Pierre Robin syndrome and concomitant tongue-tie. Pediatr Anaesth 1998; 8; 510-511.

3. Lau JT, Ong GB. A grooved table-spoon for tongue-tie release and hernial neck transfixion. Aust NZ J Surg 1983; 53: 61-62.

4. Kotlow LA. Ankyloglossia (tongue-tie): A diagnostic and treatment quandary. Quint Internat 1999; 30: 259-262.

5. Notestine GE. The importance of identification of ankyloglossia (short lingual frenulum) as a cause of breast-feeding problems. J Hum Lact 1990; 6: 113-115.

6. Mendelsohn M. New concept in dysphagia management. Otolaryngol 1993; 22: 5-24.

7. Wright JE. Tongue-tie. J Pediatr Child Health 1995; 31: 276-278.

8. Sarin YK, Zaffar M, Sharma AK. Tongue-tie: myths and truths. Indian Pediatr 1992; 29: 1585-1586.

9. Sanchez - Ruiz I, Gonzales landa G, Perez Gonzalez V, Sanchez F, Prado Fernandez C, Azcona Zorilla I, et al. Section of sublingual frenulum. Are the indications correct? Cir Pediatr 1999; 12: 161-164.

10. Velanovich V. The transverse - vertical frenuloplasty for ankyloglossia. Mil Med 1994; 159: 714-715.

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