Posterior Tongue Tie and Its Treatment

by , last modified on 11/4/16
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tongue tie

Anterior tongue tie (otherwise known as ankyloglossia) is when the tip of the tongue is anchored to the floor of the mouth. This most common type of tongue tie can be visually seen, but there is another type of tongue tie which cannot be easily observed.

Known as submucus tongue tie or posterior tongue tie, the tongue tie is hidden UNDER the mucus lining of the tongue/mouth. You can't see this type of tongue tie, but you can feel it if you run the finger underneath the tongue from side to side where the tongue tie would be. One would feel a tissue band (speed-bump sensation with finger sweep) where the tongue tie would be.

Another sign that suggests a posterior tongue tie is when the tongue tip dimples down when the tongue protrudes as shown in the picture above.

Often, patients with posterior tongue tie are mis-diagnosed with a short tongue.

Symptoms of posterior tongue tie are similar to "normal" tongue tie and include:

  • Trouble with breast-feeding in newborns
  • Swallowing problems
  • Speech difficulties (though not as problemmatic compared with anterior tongue tie)


Regardless whether dealing with a newborn or an older child/teenager, the treatment is the same. But when it comes to newborns, tongue tie can lead to feeding problems which can be quite distressing to both baby and mother.

tongue tie

Although the tongue tip (shown in green) may be completely free in infants with only posterior tongue tie, the reason why it may still cause breast-feeding difficulty is because the mid-aspect of the tongue (shown in purple) is still stuck to the floor of the mouth. Normally, a baby requires use of the ENTIRE tongue for effective feeding and swallowing. With significant posterior tongue tie, the mid-tongue (shown in purple) may be unable to touch the roof of the mouth leading to a less than effective suck and swallow. Even for an adult, swallowing would be difficult if only the tongue tip was used and the back part of the tongue was immobile.

As such, one can not simply dismiss posterior tongue tie even if the tongue tip may be able to extend past the lips because the problem is further back. Watch video to see how the tongue affects breastfeeding. Here is a video of an ultrasound of a breastfeeding infant in real-time demonstrating how important a role the posterior tongue plays.

Normal tongue tie
Green is where the normal tongue tie is located causing restricted tongue motion denoted in light green. Posterior tongue tie is shown in blue which restricts tongue motion denoted in light blue.
Normal Breast Feeding
Posterior Tongue Tie Preventing Infant From Sucking and Swallowing Effectively

 

Upper lip tie may also be present causing breast-feeding problems due to an inadequate seal of the infant mouth to the breast.

Posterior tongue tie treatment is recommended ONLY if it is causing a problem. If no symptoms are exhibited, one does not need to pursue any treatment unless there is a concern for future inadequate milk supply. Furthermore, a minor posterior tongue tie may not need to be treated if an upper lip tie and/or anterior tongue tie is present and corrected first.

Treatment

Treatment of posterior tongue tie is fairly straightforward, but a bit more involved compared with anterior tongue tie. If the child is less than 12 months of age, it may be possible to perform in the clinic under local anesthesia only. If between the ages of 1-12, sedation in the operating room is generally performed as the child is usually uncooperative (needs to keep mouth open AND tongue still). However, if child is cooperative, can be performed at any age in the clinic without sedation. If >12 years of age, the procedure can generally be performed in the clinic as long as the patient is fully cooperative.


videoWatch Video on Posterior Tongue Tie Surgery Using Coblation Method

Steps to procedure:

Step 1:

To numb the area, a tiny needle is used to inject 1% lidocaine with epinephrine to where the posterior tongue tie is located.

posterior tongue tie

Step 2:

Incision is made where the black line is drawn which overlies the posterior tongue tie. (In reality, the incision is much shorter than this, but for illustration purposes shown long here.)

In our office, tongue tie releases are most commonly performed using a LASER or scissor technique. Depending on the situation/location, we also employ coblation or needle point cautery to do the release. The laser we use in our clinic is a 1064nm diode laser. Read more about LASER vs scissor technique. Although there are pros and cons to each technique, regardless of the method used, outcomes are excellent.

Generally speaking, with posterior tongue ties, the preference in our clinic is to use a laser. Read more about LASER vs scissor technique.

Incision

Step 3:

The incision is carried down through the mucosa, through the posterior tongue tie, down to the tongue musculature. When completed, there will be a diamond shaped wound with muscle seen as shown in the picture.

diamond

Step 4:

On a case-by-case basis, a decision is made to place a fast-absorbing suture to close the incision. If placed, this stitch will slowly dissolve away within a week and does not require manual removal.

The incision is sutured closed typically to help prevent abnormal tissue growth (granulation tissue) as well as speed healing.

stitch placement

Step 5:

If placed, suturing the incision in a vertical orientation also further lengthens the tongue tip (remember, the incision was initially horizontal in step 2).

stitched

Step 6:

Within about 2 weeks, everything should be completely healed!

healed

 

Click here to see some pictures of what the wound looks like after the procedure.

After Care

After the procedure, tylenol or motrin alone (if even that) is enough for pain control if > 6 months. Infants < 6 months do not typically require anything, but coconut oil, Hyland's Teething Gel, or Orajel Naturals (not regular Orajel) may be applied for pain control. Rarely, if tylenol or motrin needed, dosing chart below.

No antibiotics are needed unless formula fed only. The area may ooze for a few hours after the procedure but typically any active bleeding should stop within 15 minutes. Some transient bleeding may also occur after performing stretch exercises for a few days. The baby may immediately resume breast-feeding without restrictions right after the procedure.

It is not unusual for a white eschar to appear over the wound. Do not worry if this happens. It is just a scab that is wet (recall what a scab looks like on your hand if you get it wet... it turns white). It will disappear in about 1-2 weeks.

Stretching exercises 5x per day for the first 2 weeks must be performed to prevent reattachment. Stretching exercises mainly entails pushing the tongue tip towards the roof of the mouth while pinching the wound closed (lift method). The motion is analogous to a forklift. The upward pressure should be exerted for about 2 seconds each time. Once a day, sweep a finger under the tongue to assess for reattachment due to scarring. If scar reattachment starts to occur, instead of the lift method, resort to the push method which entails pushing a finger over the wound towards the back of the mouth (this may temporarily choke/gag the infant).

If a suture is placed, stretching exercises do not need to be performed. However, if the stitch comes out prematurely and the incision opens, stretching exercises should be performed. Otherwise, the stitch will typically either dissolve away or fall off in about 5-10 days.

I also encourage all parents to follow-up with a lactation consultant within a week after the procedure. Good lactation consultant practices local to our office include:

• Premier Lactation Services (provides private home visits, weekend visits, and free phone consultations)
Angela Love-Zaranka, IBCLC, RLC
INOVA Loudoun Lactation Center
• Julie Oswald, IBCLC as part of Whole Child Pediatrics
• Fauquier Health Lactation Consultants (540-316-4011)

Post-procedure instructions can be downloaded here.

If your baby has a posterior tongue tie, please contact our office for an appointment.

High Palate and Upper Lip Tie

Sometimes, even if the tongue tie is released (whether anterior or posterior), breastfeeding problems may persist. Ignoring maternal factors that may be present, the most common reasons why breastfeeding problems may continue afterwards are due to an upper lip tie and/or high palate.

More info on upper lip ties can be found here.

However, regarding the high palate, this issue is when the roof of the mouth is positioned higher than normal. Given the elevated position, the tongue has to raise much higher than normal in order to compress the nipple against the roof of the mouth. Even if the tongue tie is released, the tongue may STILL have trouble elevating high enough to effectively breastfeed in such infants. Although tongue tie release may still be helpful, outcomes are not as good or as predictable. If you take a look at the image below, the red arrow points to a normally positioned palate/roof. In infants with a high palate, the palate/roof may be positioned in a higher location where the orange line drawn.

Unfortunately, there's no good simple way to address breastfeeding difficulties in such infants who have a high palate if tongue tie release does not help. Typically, the next best step is to work with a good infant feeding specialist (SLP) and/or infant occupational/physical therapist. In the Northern Virginia area, I typically suggest seeing:

• Deborah Kotin, SLP in Leesburg, VA (703-858-6667)

References:

Breastfeeding improvement following tongue-tie and lip-tie release: A prospective cohort study. Laryngoscope. 9/19/16. DOI: 10.1002/lary.26306

Management of posterior ankyloglossia and upper lip ties in a tertiary otolaryngology outpatient clinic. Int J Pediatr Otorhinolaryngol. 2016 Sep;88:13-6. doi: 10.1016/j.ijporl.2016.06.037. Epub 2016 Jun 18.

Breastfeeding difficulties and oral cavity anomalies: The influence of posterior ankyloglossia and upper-lip ties. Int J Pediatr Otorhinolaryngol. 2015 Jul 31. pii: S0165-5876(15)00368-7. doi: 10.1016/j.ijporl.2015.07.033.

The effects of office-based frenotomy for anterior and posterior ankyloglossia on breastfeeding. Int J Pediatr Otorhinolaryngol. 2013 May;77(5):827-32. doi: 10.1016/j.ijporl.2013.02.022. Epub 2013 Mar 22.

Tongue-tie in the newborn: early diagnosis and division prevents poor breastfeeding outcomes. Breastfeed Rev. 2015 Mar;23(1):11-6.

Evidence of improved milk intake after frenotomy: a case report. Pediatrics. 2013 Nov;132(5):e1413-7. doi: 10.1542/peds.2012-2651. Epub 2013 Oct 7.

Frenulotomy for breastfeeding infants with ankyloglossia: effect on milk removal and sucking mechanism as imaged by ultrasound. Pediatrics. 2008 Jul;122(1):e188-94. doi: 10.1542/peds.2007-2553. Epub 2008 Jun 23.

Tongue movement and intra-oral vacuum in breastfeeding infants. Early Hum Dev. 2008 Jul;84(7):471-7. doi: 10.1016/j.earlhumdev.2007.12.008. Epub 2008 Feb 11.

Ankyloglossia (tongue-tie): a diagnostic and treatment quandary. Quintessence Int. 1999 Apr;30(4):259-62.

Diagnosing and understanding the maxillary lip-tie (superior labial, the maxillary labial frenum) as it relates to breastfeeding. J Hum Lact. 2013 Nov;29(4):458-64. doi: 10.1177/0890334413491325. Epub 2013 Jul 2.

Tylenol and Motrin Infant Dosing Chart

For Tylenol (may give every 4 hours, but no more than 5 doses in 24 hours): Infant and Children's liquid tylenol are identical in concentration. Suppositories also available by prescription.

6-11 Pounds --> 40 mg which is 1.25 ml (1/4 teaspoon of infant liquid Tylenol)

12-17 Pounds --> 80 mg which is 2.5 ml (1/2 teaspoon of infant liquid Tylenol)

18-23 Pounds --> 120 mg which is 3.75 ml (3/4 teaspoon of infant liquid Tylenol)

For Motrin (ibuprofen) (may give every 6 hours, but no more than 4 doses in 24 hours): Please note that infant drops are NOT the same concentration as Children's liquid which is more concentrated.

12-17 Pounds --> 50 mg which is 1.25 ml (1/4 teaspoon of infant drops)

18-23 Pounds --> 75mg which is 1.875ml (1 syringe of infant drops)

24-35 Pounds --> 100mg which is 2.5ml (1/4 teaspoon of infant drops)

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