Atlas of Procedures in Neonatology, 4th Edition

Miscellaneous Procedures

54

Lingual Frenotomy

Kathleen A. Marinelli

  1. Definitions
  2. Lingual frenulum—a fold of mucosa connecting the midline of the inferior surface of the tongue to the floor of the mouth (1)

Generally thin, membranous, and avascular in the newborn (Fig. 54.1)

  1. Ankyloglossia (tongue tie)—a congenital oral abnormality, characterized by an abnormally short, thick, and/or tight lingual frenulum (1,2 and 3)
  2. “Ankyloglossia” derives from the Greek agkylos—crooked, and glossa—tongue.
  3. Many different variations of tongue tie
  4. Differing degrees of severity
  5. May restrict mobility of the tongue tip
  6. Lingual frenotomy (tongue clipping)—a minor surgical procedure, appropriate for treatment of significant ankyloglossia in infants

Can be accomplished at the bedside or in an outpatient clinic setting (4,5 and 6)

  1. Frenuloplasty or frenectomy—more complicated surgical procedures employing Z-plasty technique or with removal of tissue
  2. Reserved for older children, adults, or infants with a complicated lingual frenulum, such as a thickened frenulum containing genioglossus muscle
  3. Performed in the operating room, by a surgeon, under conscious sedation or general anesthesia
  4. Purpose
  5. Lingual frenotomy—performed when the presence of ankyloglossia restricts or impedes an infant's ability to suckle successfully
  6. Most common in breastfeeding infants
  7. Occasionally seen in infants using an artificial teat
  8. Other problems related to ankyloglossia that may manifest in older children and adults (2,3,7,8,9,10 and 11).
  9. Mechanical problems

Gingival recession, mandibular diastema, malocclusion, prognathism, difficulty with intraoral toilet (licking the lips, sweeping food debris off teeth)

  1. Articulation errors in speech
  2. Social effects
  3. Difficulty playing a wind instrument, licking an ice cream cone or lollipop, etc.
  4. Can lead to social embarrassment and the need for the more complicated frenuloplasty procedure outside the neonatal period
  5. Background
  6. There is much controversy surrounding ankyloglossia regarding:
  7. Definitions
  8. Range from vague descriptions of a tongue that functions with a less than normal range of activity to a specific description of a frenulum that is short, thick, muscular, or fibrotic (3) (Figs. 54.1 and 54.2)
  9. A range of methods to describe and quantify tongue tie have been proposed, including methods of measuring the anatomic differences, to quantifying observations.
  10. Clinical significance (1,2,6,12,13)
  11. Prior to the introduction and widespread use of breast milk substitutes in the early twentieth century, breastfeeding was necessary for survival.
  12. Release of tongue tie was commonly performed by the midwife at delivery (12,14).
  13. Tongue tie does not generally pose a problem for the more passive process of bottle feeding.
  14. With a decrease in breastfeeding rates, frenotomy became unnecessary.
  15. With the current resurgence in breastfeeding, and increasing knowledge of the risks of breast milk substitutes, tongue tie is again emerging as an entity that interferes with successful breastfeeding.
  16. A recent article surveying >1,500 pediatricians, otolaryngologists, lactation consultants, and speech pathologists concluded that there is little consensus among and within these groups

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regarding the significance or management of ankyloglossia (15).

  1. Need for surgical intervention (2)
  2. Some babies with tongue tie can breastfeed successfully with no surgical intervention (1,16).
  3. Each breastfeeding dyad is a unique combination of many factors, including the infant's intraoral structures, adequacy of suckling, and the size, shape, and elasticity of maternal nipples.
  4. An emerging body of literature suggests that for those mother–baby dyads who are experiencing difficulty breastfeeding associated with the presence of tongue tie, frenotomy is a safe, effective, and immediate means of providing relief of symptoms and supporting breastfeeding (12,13,16,17,18,19 and 20).
  5. Timing of surgical intervention: To facilitate breastfeeding, it can be done in the first days of life, or anytime thereafter if problems emerge.
  6. Incidence of tongue tie ranges from 0.02% to 4.8% in various studies (1,2,11,15,17,20,21).
  7. There appears to be a genetic predisposition in some families.
  8. Most studies report approximately a 2:1 male predominance.
  9. In a recent study, 22% of 425 North American pediatricians surveyed indicated they had performed frenotomies; however, only 10% reported being taught the technique during residency (15).
 

FIG. 54.1. Newborn with significant ankyloglossia. Note heart-shaped tongue, inability to raise tongue tip toward roof of mouth.

  1. Indications
  2. In the neonate, presence of ankyloglossia, usually in a breastfeeding infant, causing one or more of the following (11,16,17,21):
  3. Maternal nipple trauma, pain
  4. Poor latch
  5. Ineffective suckling; continuous suckling
  6. Weight loss or poor infant weight gain
  7. Early weaning
 

FIG. 54.2. Grooved retractor used to raise tongue and visualize the frenulum. Notice how thin and membranous the anterior edge is.

  1. Contraindications
  2. Presence of genioglossus muscle or vascular tissue in the frenulum with no thin membranous tissue for incision

Refer to appropriate surgeon for consideration for frenuloplasty.

  1. Limitations
  2. If the difficulty with breastfeeding was not caused by the tongue tie, release of the tongue tie will not result in improvement.

Even when tongue tie is the cause, attention must be paid to latch and suckling after release to ensure the best outcome.

  1. Equipment
  2. Blanket or towel for swaddling
  3. Sterile iris scissors

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  1. Sterile grooved retractor (optional—see below) (Fig. 54.2)
  2. Gloves
  3. Gauze pads
  4. Topical anesthetic gel for oral use (optional—see below)
  5. Cotton swab
  6. Precautions (Fig. 54.2)
  7. Ensure, by careful examination of the frenulum, that there is no vascular or muscular tissue in the field of incision. Transillumination may be used to enhance visualization.
  8. Avoid submandibular duct orifices lateral to the frenulum.
  9. Avoid the thicker, more posterior part of the frenulum, which carries the blood supply.
  10. Technique (2,3,7,12,15,20,21) (Figs. 54.2 and 54.3)
  11. Place the infant on a firm surface.
  12. Firmly swaddle the infant in a blanket or towel with the arms swaddled in at the sides.
  13. Have an assistant standing at the head of the infant to stabilize the shoulders with their fingers while steadying the head with their palms.
  14. Stand on right side of infant if right-handed.
  15. Visualize the frenulum by positioning light source to the left of the infant, allowing essentially transillumination of the frenulum.
  16. Place two gloved fingers of the left hand below the tongue, on either side of the midline, or position a grooved retractor, to push the tongue up toward the roof of the mouth, exposing the frenulum.
  17. Inspect the frenulum for any vascular or muscular structures.

Frenotomy should be done only if the frenulum is thin, transparent, and with no other structures present.

  1. Utilization of local anesthesia (optional):
  2. With no anesthesia, there is minimal, brief discomfort (6,11,12,15,20,22) because the frenulum is poorly innervated.

Babies frequently squirm with positioning but usually do not cry during procedure.

  1. Alternatively, topical anesthetic gel can be applied to the frenulum with a cotton swab.
 

FIG. 54.3. Grooved retractor used to raise tongue. Iris scissors make incision.

  1. Divide the membranous frenulum with iris scissors (Fig. 54.3):
  2. Begin at the free border, proceed posteriorly, closer to the tongue than to the floor of the mouth.
  3. Occasionally, a single cut will free the tongue sufficiently.
  4. Usually, 2 to 3 small, sequential cuts (1 to 3 mm) are required.

Each subsequent cut allows improved retraction and visualization for the next cut.

  1. Divide frenulum anterior to the vascular bundle until tongue is freed and can extend past lower alveolar ridge and lips (Fig. 54.4).
 

FIG. 54.4. After incision, minimal blood noted. Tongue now extends past lower alveolar ridge.

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  1. Control any bleeding (usually minimal) with direct pressure applied with a sterile gauze pad.
  2. Inform mother that breastfeeding may resume immediately.

Mothers frequently note an immediate and dramatic improvement in breastfeeding, with reduced discomfort, improved latch, stronger suckling, and absence of the clicking sounds frequently produced by the tongue-tied infant when attempting to breastfeed.

  1. Antibiotic therapy is not required.
  2. Postoperatively, a white fibrin clot may form.

Reassure parents that this is not a sign of infection.

  1. Arrange follow-up in 1 to 2 weeks to check healing of the incision.
  2. Complications (2,4,11,12,15,20,22)
  3. Extremely rare when performed by practitioner familiar and comfortable with the procedure
  4. Excessive bleeding virtually never occurs unless deep lingual arteries and/or veins are severed.
  5. Infection
  6. Recurrent ankyloglossia due to excessive scarring
  7. Generally less severe than original presentation
  8. Often amenable to revision surgery
  9. Glossoptosis (tongue swallowing) due to excessive tongue mobility

Theoretical concern; has never been reported in modern literature

References

  1. Hall DMB, Renfrew MJ.Tongue tie. Arch Dis Child. 2005;90:1211.
  2. Lalakea ML, Messner AH.Ankyloglossia: does it matter? Pediatr Clin North Am. 2003;50:381.
  3. Kupietzky A, Botzer E.Ankyloglossia in the infant and young child: clinical suggestions for diagnosis and management. Pediatr Dent.2005;27:40.
  4. Hansen R, MacKinlay GA, Mansen WG.Ankyloglossia intervention in outpatients is safe: our experience [letter]. Arch Dis Child.2006;91:541.
  5. Naimer SA, Biton A, Vardy D, Zvulunov A.Office treatment of congenital ankyloglossia. Med Sci Monit. 2003;9:CR432.
  6. Wallace H, Clarke S.Tongue tie division in infants with breastfeeding difficulties. Int J Pediatr Otorhinolaryngol. 2006;70: 1257.
  7. Kummer AW.Ankyloglossia: to clip or not to clip? That's the question. ASHA Leader. 2005;10:6, 30.
  8. Lalakea ML, Messner AH.Ankyloglossia: the adolescent and adult perspective. Otolaryngol Head Neck Surg. 2003;128:746.
  9. Lalakea ML, Messner AH.The effect of ankyloglossia on speech in children. Otolaryngol Head Neck Surg. 2002;127: 539.
  10. Marchesan IQ.Lingual frenulum: classification and speech interference. Int J Orofacial Myol. 2004;30:31.
  11. Messner AH, Lalakea ML.Ankyloglossia: incidence and associated feeding difficulties. Arch Otolaryngol Head Neck Surg.2000;126:36.
  12. Griffiths DM.Do tongue ties affect breastfeeding? J Hum Lact. 2004;20:409.
  13. Wright JE.Tongue-tie. J Paediatr Child Health. 1995;31:276.
  14. Horton CE, Crawford HH, Adamson JE, et al. Tongue-tie. Cleft Palate J.1969;6:8.
  15. Messner AH, Lalakea ML.Ankyloglossia: controversies in management. Int J Pediatr Otorhinolaryngol. 2000;54:123.
  16. Hogan M, Westcott C, Griffiths M.Randomized, controlled trial of division of tongue tie in infants with feeding problems. J Pediatr Child Health. 2005;41:246.
  17. Ricke LA, Baker NJ, Madlon-Kay DJ, et al. Newborn tongue tie: prevalence and effect on breast-feeding. J Am Board Fam Pract.2005;18:1.
  18. Marmet C, Shell E, Marmet R.Neonatal frenotomy may be necessary to correct breastfeeding problems. J Hum Lact. 1990;6:117.
  19. Notestine G.The importance of the identification of ankyloglossia (short lingual frenulum) as a cause of breastfeeding problems. J Hum Lact. 1990;6:113.
  20. Masaitis NS, Kaempf JW.Developing a frenotomy policy at one medical center: a case study approach. J Hum Lact. 1996;12:229.
  21. Ballard JL, Auer CE, Khoury JC.Ankyloglossia: assessment, incidence, and effect of frenuloplasty on the breast-feeding dyad.Pediatrics. 2002;110:e63.
  22. Amir LH, James PJ, Beatty J.Review of tongue-tie release at a tertiary maternity hospital. J Pediatr Child Health. 2005;41:243.