Ankyloglossia (Tongue Tie)

The common term for ankyloglossia is tongue tie. In this condition, the tongue is literally “tied,” or tethered, to the floor of the mouth, sometimes inhibiting both speech and eating. A child is born with this condition.

The tongue is one of the most important muscles involved in swallowing and speech. Without free range of motion, these activities can be impaired. However, the severity of tongue tie varies among children, so the condition may be detected early or later in life. Primary care providers may not always check for this condition at birth or at the initial well-child visits, so tongue tie is sometimes first discovered when parents report difficulty breastfeeding in infants or when an older child is having problems eating or speaking.

Tongue tie is common, affecting nearly 5 percent of all newborns. It is three times more common among boys than girls and frequently runs in families.
Research has shown that a significant number of infants with breastfeeding problems have tongue tie, and that when corrected, those problems may eliminated. A provider cannot always predict, however, whether a mild case of tongue tie might lead to a speech problem, so surgical intervention is not always necessary.

Tongue tie can also be associated with oral hygiene and dental problems, in part because food doesn’t get cleared away naturally by the tongue. While the condition sometimes goes away on its own, the simple surgery to correct it supports a baby’s normal oral development and helps to prevent eating and speaking problems.

Tongue tie occurs when the frenulum (the band of tissue under the tongue) fails to separate from the tongue before birth. This may be caused by genetics. The band stays connected as the child grows because it’s unusually short or thick, creating a tightness to the tongue that limits its mobility. Tongue tie is usually seen as an isolated condition, without any other disorders in a child. However, it is occasionally associated with other syndromes.

Children are born with this condition, but depending on its severity, tongue tie can have a range of effects that are noticeable at different times. Here are the most common signs and symptoms:

• A newborn who has trouble latching on or sucking from the breast; the infant might chew instead of suck (tongue tie poses less of a problem with bottle feeding)
• Mother in significant pain while nursing
• A baby who constantly fusses at the breast
• Poor weight gain and failure to thrive in an infant
• V-shaped or heart-shaped notch at the tip of the tongue when it’s stuck out (because the middle is pulled in by the tight band)
• A toddler’s difficulty in licking a lollipop or ice cream cone, touching the roof of their mouth, moving their tongue from side to side, or sticking out their tongue past the upper gums
• Enunciation problems that continue after age 3, especially when articulating these sounds: “t”, “d”, “l”, “r”, “n”, “th”, “s”, and “z”
• Persistent dental problems, such as a gap between the front lower teeth and tooth decay or gingivitis (gum inflammation) because your child can’t get rid of food debris naturally with her tongue
• Difficulty chewing age-appropriate solid foods
• Gagging or choking on foods
• Pocketing of food or withholding it in the cheeks
• Persistent dribbling

If a parent notices any feeding difficulties in their infant, or speech impediments in their older child, they should bring their child to their primary care provider for an evaluation. The primary care provider will usually be able to make a diagnosis of tongue tie based on a physical exam. The primary care provider will then likely refer your child to an otolaryngologist or an ENT physician (ear, nose and throat specialist). This specialist will confirm the diagnosis and be able to recommend the best treatment. During the evaluation, the otolaryngologist may:

• Ask questions about your child’s feeding behavior
• Perform a physical exam of your child’s mouth and teeth and use a tongue depressor to elevate the tip of your child’s tongue
• Ask your older child to perform various exercises with their tongue to demonstrate maximum range of motion
• Ask your older child to articulate certain sounds, like “n”s and “l”s
• If being evaluated via telemedicine, you may be asked to upload photos of your child’s tongue though the patient portal

While some providers take a watchful waiting approach to see if tongue tie might go away in milder cases, others increasingly recommend a prompt treatment approach, to prevent continues feeding difficulties in an infant, or in an older child more subtle speech difficulties, dental problems, and associated social anxieties.  Most cases of tongue tie are treated as soon as they are diagnosed, and depending on the child’s age, it can be done either in the office or in the operating room.

Tongue tie can be corrected in one of two simple ways:

Frenotomy

This can often be done in the ENT’s office if tongue tie is discovered in a newborn. The physician examines the frenulum and then snips it free with sterile scissors. The procedure is quick and usually bloodless. Most of the time, local anesthesia isn’t used because discomfort is minimal due to few nerve endings and blood vessels in the frenulum. After the procedure, the baby will breast feed while in the office. The breast milk acts as pain relief and an antiseptic. 

Frenuloplasty

If the frenulum is too thick for a frenotomy, a slightly more extensive procedure, called a frenuloplasty, may be recommended. This procedure uses general anesthesia and surgical tools to free the tongue from the thick band or several bands tied to it. The wound is closed with stiches that absorb on their own within a couple of weeks. Your child will go home the same day as the operation and will most likely not need to stay in the hospital overnight.

Possible complications of a frenuloplasty are rare and include bleeding, infection, scarring, or damage to the tongue or salivary gland.

In the vast majority of cases, treatment for tongue tie permanently corrects the condition and prevents the eating, speech, and dental problems that frequently go along with tongue tie. Occasionally, the simple frenotomy procedure fails to eliminate tongue tie and the problem recurs. Follow-up treatment with a frenuloplasty is then recommended.

Older children whose speech was impaired by tongue tie generally overcome their enunciation problems within a year or two, with the aid of a speech therapist.

With an in-office frenotomy procedure, the frenulum is snipped and there is usually no need for a follow-up appointment. In an infant, breastfeeding can provide the pain relief and infection-fighting properties that promote a prompt recovery.

With frenuloplasty, a follow-up appointment may be scheduled to check on your child’s healing in the treated area. There is no need for the removal of stitches, however, because they will absorb on their own.

Your child may be required to do tongue movement exercises to encourage proper movement and reduce the risk of scarring. Depending on your child’s speech, your child’s primary care provider may recommend working with a speech therapist, to correct enunciation problems.