If you ask 100 otolaryngologists to point to where a posterior tongue tie is, the majority would think it’s back by the tonsils. It isn’t the back of the tongue; it’s the middle of the tongue. —Bobak A. Ghaheri, MD
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April 2023
In Dr. Ghaheri’s experience, snipping the anterior tongue tie, which he calls a partial release, does not always fully release the tongue. As a result, he noted, mothers will come back still having problems with breastfeeding. “Lactation consultants understand this better than otolaryngologists,” he said. “They’re in the trenches every single day, and they’ll tell me that there’s still a restriction there.”
Dr. Ghaheri comes to this from personal experience. “I was a resident when my first child was born 17 years ago. My wife had terrible nipple pain, mastitis, and was nursing constantly because the baby was always hungry.” Dr. Ghaheri and his wife met with lactation consultants and pediatricians, but it never occurred to him to look under the tongue.
When his second child was born seven years later, the same issues arose. “This time our midwife referred us to Melissa Cole, a lactation consultant who’s an expert on tongue tie as well as oral motor retraining,” said Dr. Ghaheri. “When she examined the baby, she diagnosed posterior tongue tie and lip tie, which I didn’t believe was a condition.” Once the tie was released, however, most of the issues resolved. “I think my energy and passion for this began from remembering how bad it was for my wife.”
Dr. Ghaheri and his colleagues recently published a paper that objectively evaluated bottle-feeding tongue function 10 days after undergoing posterior frenotomy (Otolaryngol Head Neck Surg. 2022;166:976–984). When compared with the control group, infants who underwent frenotomy showed “improved tongue speed, more rhythmic and coordinated sucking motions, and a tongue more capable of adapting to varying feeding demands,” the authors stated.
“I think the truth lies somewhere in the middle,” said Mai Thy Truong, MD a clinical associate professor in the department of otolaryngology–head and neck surgery at Stanford University in California. “Before the renewed interest in breastfeeding, if you were to cut a tongue tie, it was considered quackery. Now the pendulum has swung the other way: If you don’t cut a baby’s tongue tie, you are withholding a life-saving procedure.”
Who Should Perform Frenotomies?
The increase in the number of frenotomies performed in recent years has been attributed to an increase in the diagnosis of posterior tongue tie, as well as an increase in the number of non-otolaryngologists performing the procedures.