Overview

Ankyloglossia (or tongue-tie) is a congenital condition in which the lingual frenum (connective tissue between your tongue and the floor of the mouth) is shortened or thickened, causing motion restriction of the tongue. Timely diagnosis is essential to avoid potential complications related to breastfeeding, speech, and oral hygiene. Paediatricians play a vital role in the early identification, appropriate management and referral, and parental education about the condition. In this article, the paediatricians’ role will be briefly discussed so that parents can understand what to expect from their healthcare provider. 

Introduction

Ankyloglossia is a condition that is present at birth and is characterised by the shortened or thickened band of tissue that attaches the tongue to the floor of the mouth (lingual frenum or lingual frenulum), leading to tongue movement being hindered.¹ No specific reason is known regarding the cause of this. However, potential risk factors can include cleft palate syndrome, rare syndromes (e.g. Kindler), and maternal use of cocaine. Prevalence is higher in males, and fluctuates from 0.1% to 10.7%.² 

The most common tools used to classify the condition into more specific types are the Coryllos classification and the Hazelbaker Assessment Tool for Lingual Frenulum Function (HATLFF), which categorise tongue-tie based on attachment and mobility as well as function and frenulum structure, respectively.² It must be noted that a universal definition of the disorder has not been stated yet, but a common clinical statement has been agreed on.³ 

Anterior ankyloglossia

The “classic” type has the frenulum being attached at the tip of the tongue or close to it, resulting in limited tongue movement due to the shorter length.⁴

Posterior ankyloglossia

This type is marked by the attachment of the frenulum further back on the underside of the tongue, resulting in limited tongue movement. It must be noted that the diagnosis of this type remains controversial because other terms and descriptions are also used.^3,4

Signs and symptoms

Symptoms vary depending on the severity and the age they appear, but they most commonly include:⁵

• Maternal discomfort while breastfeeding or inadequate/incomplete milk secretion
• A newborn with poor latching or irritability while breastfeeding
• Poor weight gain in an infant⁵
• V-shaped or heart-shaped deformity of the infant’s tongue when sticking it out²
• Trouble pronouncing consonants and sounds: “s, z, t, d, j, l, ch, zh, th, dg,” and “r”^2,5
• Difficulties with kissing, licking, and eating substances like ice-cream²
• Issues with chewing, gagging, and/or choking on foods²

Diagnosis

Tongue-tie is usually diagnosed after birth. Paediatricians assess the baby to identify possible anatomical variations of the tongue, which may cause functional issues. In addition, a healthcare provider will ask for the child’s medical history, including questions regarding the child’s breastfeeding habits, speech and oral function, as well as about the mother’s breastfeeding experience.⁶ The examination will include a thorough assessment of both the internal and external oral structures, along with neurological and cardiac checks. 

Treatment

Treatment includes both conservative and surgical options.²

Conservative management 

In some babies, tongue-tie may resolve spontaneously.¹ Additionally, if the condition does not cause trouble, options include observation, a breastfeeding or bottle-feeding device, and speech therapy.^2,8

Surgery 

Surgery is the gold standard for cases that have not responded to conservative treatment or that demonstrate breastfeeding or speech issues. One procedure that can be performed with or without anaesthesia is a frenotomy (or frenulotomy), which involves an incision of the frenulum and only lasts around a minute on average.^1,7 Another procedure that can be used for more complicated cases is frenuloplasty, which involves incision of the frenulum and repositioning it.⁷

The role of paediatricians

As has been discussed in this article thus far, paediatricians play a paramount role in the early diagnosis and treatment of ankyloglossia. Since they are usually the first providers to conduct newborn checks, they can also assess for the condition. In addition, by taking a thorough medical history and conducting appropriate physical examinations, they can rule out other underlying conditions, and evaluate the frenulum’s position as well as the tongue’s motion. This is done to determine whether or not the breastfeeding or speech difficulties are attributed to tongue-tie. Appropriate scoring tools (Coryllos, HATLFF) should be used to assess the condition’s severity. At this point, it must be noted that due to the use of various definitions of tongue-tie, overdiagnosis can occur and must be taken into consideration. 

When a diagnosis is established, the parents should be appropriately educated and informed about the treatment options. The potential advantages of conservative treatment should be highlighted, and appropriate referral to otorhinolaryngologists, lactation consultants, or speech-language pathologists (SLPs) must occur depending on the patient’s needs. In more complex cases, the surgical options and their complications should be discussed, even if they are uncommon (e.g., bleeding, airway obstruction, oral aversion, scarring, or damage to nearby structures).² Lastly, it must be noted that paediatricians will continue monitoring the child after treatment and ensure that all functions are developing normally. 

FAQs

Is my child going to need surgery?

If tongue-tie does not cause any issues, surgery or treatment in general may not be needed.^2,6,8

What can I expect for my child post-surgery?

If the child is operated on with frenotomy, one can expect that it will most likely feed almost immediately. In the case of frenuloplasty, speech therapy and tongue exercises may be required.⁷

Can tongue-tie be prevented?

There is no such evidence to date.⁶

Can tongue-tie be confused with other disorders?

Ankyloglossia causes breastfeeding difficulties, which can be present due to other disorders. Therefore, it is essential to rule them out.² They can include, but are not limited to:

• Retrognathia: The lower jaw rests further on the back than normal to the upper jaw
• Cleft palate: An opening exists in the roof of the mouth 
• Laryngopharyngeal reflux: The stomach acid refluxes up to the throat
• Bilateral vocal fold paralysis: The vocal cords are unable to move properly due to nerve problems
• Laryngomalacia: The tissue above the voice box softens and causes obstruction, leading to stridor (noisy breathing)
• Pyriform aperture stenosis: Narrowing of the pyriform aperture (bony opening of the nose) due to an upper jaw overgrowth
• Choanal atresia: Narrowing of the back of the nose, causing difficulty breathing

What is the outlook for the condition?

Early diagnosis and treatment assist in preventing breastfeeding issues. A frenotomy is a low-risk procedure and can help the baby as well. However, the exact prognosis of the disorder is not known. If another disorder is present and is not treated prior to a frenotomy, patient outcomes are poorer.^2,6

Summary

Ankyloglossia (or tongue tie) is a congenital disorder where the lingual frenum (or frenulum) is shortened or thickened, causing motion restriction of the tongue. Despite the cause still being unknown, maternal drug use and some genetic syndromes seem to be linked to the condition. It is more common in males, and there are two main types: the anterior and posterior ankyloglossia. 

Diagnosis occurs through the use of the scoring tools, Coryllos classification and Hazelbaker Assessment Tool for Lingual Frenulum Function, physical examination, medical history, as well as assessment of breastfeeding and speech issues. Symptoms vary according to severity and timeframe, but most commonly include breastfeeding pain, poor infant latching, and speech and feeding issues. Treatment options entail conservative and surgical management. 

Paediatricians play a crucial role in diagnosis, and management as well as referral to appropriate specialists. Early diagnosis and management improve outcomes, but complications should be discussed with the caretakers.