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90th publication sjm- 7th name
1.
© 2019 |Published
by Scholars Middle East Publishers, Dubai, United Arab Emirates 286 Saudi Journal of Medical and Pharmaceutical Sciences Abbreviated Key Title: Saudi J Med Pharm Sci ISSN 2413-4929 (Print) |ISSN 2413-4910 (Online) Scholars Middle East Publishers, Dubai, United Arab Emirates Journal homepage: http://scholarsmepub.com/sjmps/ Case Report Frenectomy of Posterior Tongue Tie with Muscle Dissection: A Case Report Dr. Priyesh Kesharwani1, Dr. Abhishek Sharma2, Dr. Dushyanth Paul3, Dr. Kapil Kumar Kardwal4, Dr. Kunal Marwah5, Dr. Umesh Kaswan6, Dr. Rahul Vinay Chandra Tiwari7 1MDS Oral and Maxillofacial Surgeon, Consultant and Private Practitioner DENT-O-FACIAL Multispeciality Clinic, Mira road, Thane-Mumbai, India 2PG Student, Department of Oral & Maxillofacial Surgery, Subharti Dental College & Hospital, Subharti University, Meerut, U. P, India 3Professor, Department of Oral and Maxillofacial Surgery, Sri Sai College of Dental Surgery, Vikarabad, Telangana, India 4PG Student, OMFS, Surendra Dental College & RI, Sriganganagar, Rajasthan, India 5PG Student, Department of Oral & Maxillofacial Surgery, Subharti Dental College & Hospital, Subharti University, Meerut, U. P, India 6PG Student, OMFS, Surendra Dental College & RI, Sriganganagar, Rajasthan, India 7FOGS, MDS, Assistant Professor, Department of Oral and Maxillofacial Surgery, Sri Sai College of Dental Surgery, Vikarabad, India *Corresponding author: Dr. Priyesh Kesharwani | Received: 06.04.2019 | Accepted: 15.04.2019 | Published: 20.04.2019 DOI:10.21276/sjmps.2019.5.4.2 Abstract Ankyloglossia, or tongue-tie, refers to an abnormally short lingual frenulum, causing difficulty in speech articulation due to limitation in tongue movement. In this article, we report a case of a 16-year-old female with posterior anklyoglossia, and anterior mucosal covering, who complained of difficulty in speech. Following which she underwent frenectomy procedure under local anesthesia without any complications. Finally, she was given speech therapy sessions. Keywords: Ankyloglossia, Muscle Dissection, Tongue Tie. Copyright @ 2019: This is an open-access article distributed under the terms of the Creative Commons Attribution license which permits unrestricted use, distribution, and reproduction in any medium for non-commercial use (NonCommercial, or CC-BY-NC) provided the original author and source are credited. INTRODUCTION Ankyloglossia, or tongue-tie, is a developmental anomaly, where the lingual frenulum is abnormally short and tight (posterior ankyloglossia) or abnormally attached anteriorly to the ventral surface of the tongue (anterior ankyloglossia), “tying” the tongue to the floor of the mouth [1]. In general, Heller et al defined it as a condition in which the tongue cannot make contact with the hard palate or cannot protrude more than 1–2 mm past the mandibular incisors [2]. The Academy of Breastfeeding Medicine Protocol defines ankyloglossia as „a sublingual frenulum which changes the appearance and/or function of the infant‟s tongue because of its decreased length, lack of elasticity or attachment too distal beneath the tongue or too close to or into the gingival ridge‟ [3]. Ankyloglossia has an incidence of rate of 4-5%, and is more common in males, with male to female ratio of 2.5: 1.0 [4]. It has been reported to cause feeding difficulties, dyspnea from forward dislocation of the epiglottis and larynx; speech articulation problems involving lingual alveolar sounds /l/ and interdental sounds /th/; and social and mechanical problems [1]. Tongue tie can be classified based on Kotlow‟s classification (Table-1) [5]. For a quantitative assessment of ankyloglossia, Hazelbaker Assessment Tool for Lingual Frenulum (Table-1) [5] (HATLFF) was developed and has been proven to be highly reliable. The management of ankyloglossia requires an interdisciplinary approach concerning different health care providers such as oral surgeons, paediatricians, otolaryngologists and speech therapists. The surgical procedures are classified as frenotomy (simple cutting of the frenulum) frenectomy (complete excision of the frenum), and frenuloplasty which involves excision of the frenum along with correcting the anatomy [6]. Case Report We report a rare case of posterior ankyloglossia in a 16-year-old female patient. She reported to the Department of Oral Surgery with difficulty in speech since birth. The ENT and general physical examination was conducted to rule out any abnormality. The patient‟s family and medical history were non-contributory. Initial intra oral examination did not reveal an obvious aberrant frenum, however on further palpation and retraction, a short and thick fibrous cord was noted posterior to the anterior mucosa of the tongue (Figure-1). Clinically, ankyloglossia was categorised as Class III ankyloglossia (Kotlow‟s criteria) as the tongue showed limited protrusion and elevation. Hazelbaker‟s assessment tool gave a functional score of 10 and appearance score of [7]. Also, patient‟s speech was analysed to identify
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Priyesh Kesharwani et
al; Saudi J Med Pharm Sci, April 2019; 5(4): 286-290 © 2019 |Published by Scholars Middle East Publishers, Dubai, United Arab Emirates 287 defective syllables in her speech. The difficulty in articulation was noted with consonants like s, r, z. As the patient wants to pursue her career in singing, accurate pronunciation of every syllable was of utmost important to her. After obtaining informed consent, conventional frenectomy procedure was done under local anaesthesia with 2% lignocaine hydrochloride and 1: 80,000 adrenalines. After achieving objective symptoms, a suture was passed at the middle of the tongue to control its movements (Figure-2), one hemostat was inserted at the under surface of the tongue and another at the floor of the mouth to clamp the frenum. Incision was placed above and below the hemostasis to remove the intervening frenum, leaving a diamond shaped wound (Figure-3). A combination of blunt and sharp dissection of the muscle fibers was carried out with the hemostat without disturbing the veins of either side of the frenum. The wound edges were approximated with 4-0 black braided silk simple interrupted sutures (Figure-4) to achieve primary closure and minimize scar tissue formation. The patient was discharged with post-operative instructions and was prescribed Cap Amoxicillin 500mg thrice a day for 3 days and tab ketorol DT 10mg thrice a day for 3 days. After 1 week, no complications were reported, sutures were removed and the patient was referred to the speech therapist. Table-1:Kotlow’s Classification Type Movment of the tongue Clinically acceptable, normal range of free tongue movement Greater than 16 mm Class-I: Mild ankyloglossia 12 to 16 mm Class-II: Moderate ankyloglossia 8 to 11 mm Class-III: Severe ankyloglossia 3 to 7 mm Class-IV: Complete ankyloglossia Less than 3 mm Table-2: Hazel baker’s assessment tool for appearance and function of the tongue Appearance Function Appearance of tongue when lifted Lateralization 2: Round or Square 1: Slight deft in tip apparent 0: heart or V-shaped 2: Complete 1: Body or tongue but no tongue tip 0: None Elasticity of frenulum Lift of tongue 2: Very elastic 1: Moderately elastic 0: Little or no elasticity 2: Tip to mid-mouth 1: Only edges to mid-mouth 0: Tip stays at lower alveolar ridge or rises to mid-mouth only with jaw closure Length of lingual frenulum when tongue lifted Extension of tongue 2: >1 cm 1: 1 cm 0: <1 cm 2: Tip over lower lip 1: Tip over lower gum only 0: Neither of the above, or anterior or mid-tongue humps Attachment of lingual frenulum of tongue Spread of anterior tongue 2: Posterior or tip 1: At tip 0: Notched tip 2: Complete 1: Moderate of partial 0: Little or none Attachment of lingual frenulum to inferior alveolar ridge Cupping 2: Attached to floor of mouth or well below ridge 1: Attached just below ridge 0: Attached at ridge 2: Entire edges, firm cup 1: Slide edges only, moderate cup 0: Poor or no cup Peristalsis 2: Complete, anterior or posterior 1: Partial, originating posterior or tip 0: None or reverse 14= perfect score, 11= acceptable if appearance item score is 10. Frenotomy is necessary function score is <11 and appearance score is <8.
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Priyesh Kesharwani et
al; Saudi J Med Pharm Sci, April 2019; 5(4): 286-290 © 2019 |Published by Scholars Middle East Publishers, Dubai, United Arab Emirates 288 Fig-1: Pre Operative View of Posterior Ankyloglossia Fig-2: Passing Suture through the Tip of the Tongue Fig-3: Complete Excision of Fraenum
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Priyesh Kesharwani et
al; Saudi J Med Pharm Sci, April 2019; 5(4): 286-290 © 2019 |Published by Scholars Middle East Publishers, Dubai, United Arab Emirates 289 Fig-4: Sutures DISCUSSION The lingual frenulum is a short mucosal membrane with underlying connective tissue connecting the ventral surface of the tongue to the floor of the mouth. The etiopathogenesis of tongue-tie is unknown. The mucosa covering the anterior two-thirds of the tongue is derived from the first pharyngeal arch, and developmental anomaly with the same could result in abnormal frenulum length and attachment. Frenulum being a connective tissue structure, a developmental anamoly of collagen and connective tissue in the anterior portion of the tongue could lead to ankyloglossia. The condition could be detected in patients with Ehler -Danlos Syndrome (EDS) [7]. Posterior frenula is located posterior to the anterior mucosal covering of the ventral surface of the tongue and floor of the mouth, creating a mucosal covering. This poses as a diagnostic challenge, so the mucosa is retracted posteriorly to reveal the frenum. The frenulum is not a very vascular or sensitive structure; however, it is surrounded bilaterally by the lingual arteries and nerves that course on the ventral surface of the tongue and run deeper to the intrinsic musculature. These structures should be avoided to preserve the sensation to the tongue and prevent serious bleeding. Care must be taken to avoid damage to the genioglossus muscle and Wharton ducts which run inferior and superficial to this muscle respectively, as injury to the later could result in decreased salivation or stricture of the duct, leading to sialocele formation [8]. Limited movement of the tongue is the most common symptom of ankyloglossia and also most common indication for surgical intervention [9]. Lalakea et al., demonstrated that eight of 14 adults noted one or more mechanical limitations, such as cuts from teeth in the frenulum area or discomfort beneath the tongue, and difficulties with licking the lips, eating an ice cream cone, keeping the teeth clean, and doing „„tongue tricks‟‟. They objectively evaluated the mobility of the tongue with ankyloglossia in adolescents and adults and compared with a control group. In a tongue with normal function and range of movement, protrusion (the maximum extension of the tongue tip past the lower dentition) and elevation (interincisal distance by maximal mouth opening, while maintaining contact of the tongue tip to the posterior surface of the upper central incisor teeth) measured >30 mm, whereas they were nearly half that length when ankyloglossia was present [10]. Prevalance of speech anamolies in patients with ankyloglossia varies -. The difficulties in articulation are evident for consonants and sounds like „„s, z, t, d, l, j, zh, ch, th, dg,‟‟and it is especially difficult to roll an „„r‟‟ [11]. However, it should be recognized that a slight difference in pronunciation cannot always be diagnosed as a speech problem. Studies evaluating the efficacy of surgical invertention, reported an improvement in their speech articulation among 40-90% of the patients. These patients were instructed to perform postoperative tongue exercises‟. Another approach reported was the observation of the vocal cords with laryngofiberscope during phonation. After the surgery, patients had a louder voice [12]. CONCLUSION The exact clinical significance and management of anklyoglossia is still unclear. In many children, this condition is asymptomatic, and may resolve spontaneously, or affected children may learn to compensate adequately for their decreased tongue mobility. For ankyloglossia with speech problems, more long term controlled trials should be conducted to compare results after tongue-tie surgery to results of special training provided by speech pathologists without any kind of surgery. REFERENCES 1. O‟Callahan, C., Macary, S., & Clemente, S. (2013). The effects of office-based frenotomy for anterior and posterior ankyloglossia on
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al; Saudi J Med Pharm Sci, April 2019; 5(4): 286-290 © 2019 |Published by Scholars Middle East Publishers, Dubai, United Arab Emirates 290 breastfeeding. International journal of pediatric otorhinolaryngology, 77(5), 827-832. 2. Heller, J., Gabbay, J., O'hara, C., Heller, M., & Bradley, J. P. (2005). Improved ankyloglossia correction with four-flap Z-frenuloplasty. Annals of plastic surgery, 54(6), 623-628. 3. Amir, L. H., James, J. P., & Donath, S. M. (2006). Reliability of the hazelbaker assessment tool for lingual frenulum function. International breastfeeding journal, 1(1), 3-9. 4. Morowati, S., Yasini, M., Ranjbar, R., Peivandi, A. A., & Ghadami, M. (2010). Familial ankyloglossia (tongue-tie): a case report. Acta Medica Iranica, 48(2), 123-124. 5. Bhattad, M. S., Baliga, M. S., & Kriplani, R. (2013). Clinical guidelines and management of ankyloglossia with 1-year followup: report of 3 cases. Case reports in dentistry, 2013. 6. Suter, V. G., & Bornstein, M. M. (2009). Ankyloglossia: facts and myths in diagnosis and treatment. Journal of periodontology, 80(8), 1204- 1219. 7. Bhattad, M. S., Baliga, M. S., & Kriplani, R. (2013). Clinical guidelines and management of ankyloglossia with 1-year followup: report of 3 cases. Case reports in dentistry, 2013. 8. Chu, M. W., & Bloom, D. C. (2009). Posterior ankyloglossia: a case report. International journal of pediatric otorhinolaryngology, 73(6), 881-883. 9. Brinkmann, S., Reilly, S., & Meara, J. G. (2004). Management of tongue‐tie in children: A survey of paediatric surgeons in Australia. Journal of paediatrics and child health, 40(11), 600-605. 10. Lalakea, M. L., & Messner, A. H. (2003). Ankyloglossia: the adolescent and adult perspective. Otolaryngology—Head and Neck Surgery, 128(5), 746-752. 11. Queiroz, I. M. (2004). Lingual frenulum: classification and speech interference. The International journal of orofacial myology: official publication of the International Association of Orofacial Myology, 30, 31-38. 12. Mukai, S., Mukai, C., & Asaoka, K. (1993). Congenital ankyloglossia with deviation of the epiglottis and larynx: symptoms and respiratory function in adults. Annals of Otology, Rhinology & Laryngology, 102(8), 620-624.
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