Teaming Up to Correct Tongue Tie

blog 5By Robyn Merkel-Walsh

Bobby, age 34 months, was brought to my office for a history of feeding issues. At birth he could not latch on to the bottle, and had to be spoon-fed formula, because his suck was too weak. His pediatrician recognized that he was tongue-tied—he had ankyloglossia—but two consulting otolaryngologists determined that surgery was not necessary despite functional problems.

His parents knew something was wrong, but after lactation specialists and physicians offered no solutions, they just compensated at home. Unfortunately, we see this situation often because physicians and speech-language-pathologists often do not receive extensive training on how to identify or treat tongue-tie.

Over time, Bobby developed food aversions and sleep problems, and drooled persistently. His sibilant production was not developing. Mealtimes became stressful, as he had little lingual mobility for managing solids. Once he chewed his food, he could not move the bolus to the tongue surface to prepare it for the swallow. He started avoiding many foods and ate only small, crunchy solids.

I referred the parents to Anthony Jahn, a well-respected otolaryngologist with whom I frequently collaborate because he understands the important relationship between structure and function. He determined that Bobby’s tongue-tie was quite pronounced, with a heart-shaped tongue tip. Bobby also had enlarged tonsils and adenoids that further complicated his situation. Because the tonsils were immunologically active, Dr. Jahn decided to remove only the adenoids and perform a frenectomy. The tethering frenulum was released from its attachment to the ventral surface of the tongue, and the resulting defect was closed.

Post-surgical treatment with Bobby included pre-feeding, feeding, oral placement therapy and frenulum stretching activities. The goals of his treatment included bolus mobility, lingual range of motion and tongue tip elevation for lingual alveolar phonemes. Despite surgery and therapy, his tongue tip was still heart-shaped, and he struggled to move food from the chewing surface to the tongue blade to prepare for the swallow.

I recommended that Bobby’s parents return to Dr. Jahn, who determined that the genioglossal muscle was not adequately released in the previous procedure, and that abnormal scar tissue had developed. Dr. Jahn and I discussed a z-plasty procedure based on research on ankyloglossia. Z-plasty is common in plastic surgery and involves the creation of two triangular flaps of equal dimension that are then transposed. In cases of tongue-tie with genioglossal restriction, it reduces the chance of scar tissue formation.

After the second surgery, Bobby made excellent progress in treatment. Using the same therapeutic techniques as the first surgery, he increased lingual range of motion, improved bolus management and improved placement for lingual alveolar phonemes.

Both Dr. Jahn and I learned a great deal from this collaboration:

·       Tongue-tie is not a one-size-fits-all condition. Surgical considerations must include appearance, function and involvement of the genioglossus muscle. SLPs must communicate with otolaryngologists, and specifically describe motility and function so that the surgeon can select the correct procedure.

·       Pre- and post-surgical oral motor interventions can be diagnostic as well as therapeutic.The SLP is more specifically trained to look at feeding skills and the oral placement of speech sounds to determine if a tongue-tie is, in fact, impeding feeding and speech. This information, of course, must be communicated to the surgeon in an open dialogue.

·       Surgery does not necessarily mean spontaneous recovery. The otolaryngologist and SLP must work together to improve feeding and speech issues. Post-surgical therapy is particularly important, as abnormal scar tissue can develop if the tongue is immobile after surgery. Post frenulemectomy cases should be seen by an SLP immediately.

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