Otolaryngologists Are Still Debating the Effectiveness of Tongue Tie Treatment

In 2020, a clinical consensus statement was published by the American Academy of Otolaryngology–Head and Neck Surgery (AAO-HNS) on ankyloglossia in children (Otolaryngol Head Neck Surg. 2020;162:597–611). Fast forward to today, and the consensus statement, rather than being a guideline, reflects “that there is still a great deal of controversy and research needed in the area of ankyloglossia,” said Anna H. Messner, MD, lead author of the article.

“Otolaryngologists are completely on board that everybody has a frenulum and that just having a frenulum does not mean you’re tongue tied,” said Dr. Messner, a professor at Baylor College of Medicine and division chief of otolaryngology–head and neck surgery at Texas Children’s Hospital in Houston.

Interest in the treatment of ankyloglossia (tongue tie) has continued to grow since ENTtoday first reported the rise in diagnosis and treatment in 2019 (www.enttoday.org/article/explainingthe- dramatic-rise-in-tongue-tie-andlip- tie-treatment). One of the disputes among clinicians has been on how to define tongue tie. In recent years, the definition has generally been divided into two classifications: anterior (types 1 and 2) and posterior (types 3 and 4).

There’s no controversy surrounding the diagnosis of type 1 or type 2 tongue tie, the experts agreed. The definition of posterior tongue tie, however, is extremely controversial, Dr. Messner noted. The consensus statement defines ankyloglossia “as a condition of limited tongue mobility caused by a restrictive lingual frenulum.” Anterior tongue tie refers to a lingual frenulum that extends to the tip of the tongue, or near the tip, that restricts tongue mobility, the consensus statement said.

The consensus group, however, was unable to reach agreement on the definition of posterior ankyloglossia or a grading system for ankyloglossia. “Typically, the term ‘posterior ankyloglossia’ describes a lingual frenulum that attaches to the posterior aspect of the tongue and decreases tongue mobility,” stated the consensus group.

A New Definition

However, one proponent of the diagnosis of posterior ankyloglossia has argued that posterior tongue tie is really a misnomer. “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,” noted Bobak A. Ghaheri, MD, an otolaryngologist at the Oregon Clinic in Portland, Ore. Posterior tongue tie is the less visibly obvious type. “You need to evaluate the function of the middle of the tongue,” he said. “Can it move up [toward the roof of the mouth], which is what’s needed for successful breast and bottle feeding? Once you understand the function of the tongue, then you look for a limitation of function.”

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

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.

“That is great question, because training varies so much,” noted Dr. Truong. “I think it should be someone who knows the anatomy well and can take care of any complication, including major bleeding, infection, risk to the airway, and damage to local structures in the mouth.”

“We’re skilled at recognizing the pertinent structure underneath the tongue,” Dr. Messner added. “Also, most insurance plans will cover the procedure when it is performed by an otolaryngologist, which improves access to the procedure.”

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 lifesaving procedure. —Mai Thy Truong, MD

Dr. Ghaheri also believes that otolaryngologists should be the ones performing these procedures. “It should absolutely be otolaryngologists, because we are the masters of the airway.” A pediatric dentist doesn’t have the level of training in airway management and may not know that the airway might be at risk, he added.

In addition, pediatrics experts agree that the procedure should be performed by someone who understands the basics of breastfeeding mechanics (Pediatrics. 2008;122[1]:e188–e194).

It’s All in the Technique

Perhaps the better question to ask is what technique should be used, noted Dr. Truong. “When I train residents on this procedure, the most important thing is to lift the tongue and expose the frenulum well. I snip the frenulum and then apply pressure and reevaluate to make sure that I’ve safely removed all of the frenulum. In the majority of cases, [a complete frenotomy] requires more than one cut,” she said. “It’s also important that residents understand the mechanics of breastfeeding, so we review ultrasounds of a breastfeeding infant and discuss maternal issues, such as varying nipple anatomy and issues of milk supply. I encourage working with a lactation consultant.”

Dr. Messner agreed. “I think that when a frenotomy is done properly on a type 1, type 2, or even a prominent type 3 tongue tie, the incision must lyse the entire frenulum but not go into the musculature of the tongue. It’s a matter of doing a complete frenotomy versus a non-complete procedure.”

“As residents, we’re taught to use a pair of hemostats to crush the frenulum and then cut it after we squeeze out the blood flow, which can actually cut muscle,” Dr. Ghaheri said. “With my technique, you go around the muscle, cutting the mucus membrane, not cutting into any muscles at all.”

What instrument to use is also a hotly debated issue. According to the AAOHNS consensus statement, “There is insufficient evidence to support claims that one technique of frenotomy, such as laser, is superior to other techniques.”

“The main difference is that some providers use sharp instruments like scissors, and others use in-office lasers. The level of pain that the child experiences after the procedure may be very different depending on the instrument used,” said Dr. Truong. For example, histologic studies that compared a CO2 laser to a scalpel on a bovine tongue found that the laser created a deeper injury as compared with the scalpel (Head Neck Surg. 1997;116:379–385).

Dr. Ghaheri agreed. “You absolutely do not need a laser to perform a posterior tongue tie release. You just need to know how to do it safely.” Dr. Ghaheri prefers to use the laser to do these procedures because of the volume of cases he performs. “Probably 90% of my practice is performing frenotomies.”

Although Dr. Truong is trained in laser use and does use them for other procedures, she chooses not to use them for frenotomies. “I do respect, however, that every surgeon has their preferred tool that they feel works best for them.”

Post-Procedure Care

There’s also debate regarding the need for post-procedure care after frenotomy. Although some clinicians prescribe a regimen of stretches and a massage technique after the procedure, the AAO-HNS consensus statement found no evidence to support post-procedure care regimens (i.e., stretching, massaging, manual elevation of the tongue by parents).

Massage and stretching regimens can be onerous for parents, Dr. Messner noted. “Many parents are told they need to do this every four hours for three to six weeks, depending on the particular practice,” she said. In a recent study by Bhandarkar and his colleagues, the authors retrospectively compared breastfeeding or recurrence rates between infants who had post-frenotomy massage and those who did not (Matern Child Health J. 2022;26:1727–1731). The authors found that the overall recurrence rate was 0.66%, with no statistically significant difference between the two groups. Breastfeeding rates were also similar between the massage and non-massage groups, but only 43.5% of those advised to massage adhered to the regimen.

“The consensus statement recommends no aftercare because the overwhelming majority of otolaryngologists perform only anterior releases, where there is no wound [and therefore no need to perform stretches],” Dr. Ghaheri said. “If a full release is done, however, a diamond-shaped wound develops, and appropriate wound aftercare optimizes tongue mobility and improves tongue elevation through stretches and exercises.”

Dr. Truong, who conducted a case study review of major complications following tongue tie release (Int J Pediatr Otorhinolarngol. 2020;138:110356) was surprised by the findings. “I wasn’t expecting to find such severe complications,” she said.

The general consensus among clinicians has been that the risks of performing frenotomy are minimal, Dr. Truong said. “Our research really opened my eyes to how aggressive this procedure can be. Some of the children in the report were quite harmed.” Indeed, of the 47 major complications in the study, four involved hypovolemic shock, and there were four cases of apnea, four cases of acute airway obstruction, and two cases of Ludwig angina. Dr. Truong acknowledged possible selection bias in the study, but it does provide an honest look at complications and their effects on neonates.

Exploring Other Causes

Dr. Messner noted that, before performing a frenotomy, “it’s appropriate to evaluate the infant for other potential sources of breastfeeding problems.” These might include nasal obstruction, airway obstruction, laryngopharyngeal reflux, and craniofacial anomalies. Parents should also be cautioned about the risks and benefits of the procedure. “Frenotomy isn’t always effective in relieving maternal pain and breastfeeding difficulties,” she said.

“This procedure isn’t without complications,” Dr. Truong said. “We all feel pressured to make sure we cut as much [of the frenulum] as possible [to free the tie], but this may also increase the risk of complications. So, we have to watch that pendulum—if it seems like the pendulum has swung to one extreme, we should all look for the place in the middle. However, at the end of the day, supporting a breastfeeding mother and her infant needs to be our top priority.”

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Nikki Kean is a freelance medical writer based in New Jersey.