ANKYLOGLOSSIA IN NEWBORN-CASE REPORT

Int J Pharma Bio Sci 2019 July; 10(3): (B) 31-35

This article can be downloaded from www.ijpbs.net

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Case Report Neonatology

International Journal of Pharma and Bio Sciences ISSN

0975-6299

ANKYLOGLOSSIA IN NEWBORN-CASE REPORT

PARAMANANDHAM. P*1, MOHAN. P2 AND RAJA KUMAR P.G3

Professor

1, Pediatric Surgeon

2, Professor&HOD

3

Department of Pediatrics, Shri Sathya Sai medical college and research institute,

Affiliated to Sri Balaji Vidyapeeth University, Ammapettai-603108, Tamilnadu, India.

ABSTRACT

The lingual frenulum is the structure that attaches the tongue to the floor of the mouth. If the lingual frenulum is short, it results in feeding difficulties, pain in mother’s nipple, speech disorientation and also articulation problem. Anterior ankyloglossia is easily detectable, but posterior ankyloglossia doesn’t have the usual appearance of traditional anterior ankyloglossia. It is widely unknown and under diagnosed entity. Hence both the types of ankyloglossia interfere with breastfeeding causing maternal pain.

National

Health Service and Canadian paediatric society recommend treatment if ankyloglossia interfere with breast feeding. The limitation in lingual mobility in newborns can compromise sucking and latching on to the breast. Tongue tie is usually seen in newborns and also in children. In newborn, sometimes it spontaneously regresses. In children, it leads to speech abnormality and language developmental defect. Here we present a case of newborn type I Ankyloglossia. The incidence of ankyloglossia is increasing, a probable cause due to environmental pollutants. Ankyloglossia is of 2 types, Anterior Ankyloglossia and Posterior Ankyloglossia. We can treat this condition medically by simple physical exercises or surgically by frenotomy. Complications of frenotomy are bleeding, infection, scarring. Damage may occur to the tongue or salivary gland. Sometimes, the wound heals with scar formation causing fibrosis and the frenulum may reattach to the base of the tongue. Frenuloplasty is needed when a more robust correction is needed or if the frenulum is too thick for frenotomy. Frenuloplasty must be done under general anaesthesia and the risk of anaesthesia should be weighed against the benefit from surgery.

KEYWORDS: Tongue tie, Ankyloglossia, Frenotomy, newborn ankyloglossia, feeding problem, latching difficulty

Received on: 19-02-2019

Revised and Accepted on: 27.05.2019

DOI: http://dx.doi.org/10.22376/ijpbs.2019.10.3.b31-35

Creative commons version 4.0

PARAMANANDHAM. P*

Professor, Department of Pediatrics, Shri Sathya Sai medical college and research institute,

Affiliated to Sri Balaji Vidyapeeth University, Ammapettai-603108, Tamilnadu, India.



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INTRODUCTION Etymologically, “Ankyloglossia” originates from the Greek words “agkilos” (curved) and “glossa” (tongue)

1.

Ankyloglossia commonly known as tongue tie is a congenital oral anomaly which may decrease the mobility of the tongue tip

2 and is caused by an

unusually short, thick lingual frenulum, a membrane connecting the underside of the tongue to the floor of the mouth. Ankyloglossia or tongue tie can be observed in neonates, children or adults

3. Ankyloglossia is a

congenital anomaly. Ankyloglossia is said to be present when the lingual frenulum is short and causes restriction of movements. Since the condition has to be managed by a team consisting of speech therapists, paediatricians, otolaryngologists, lactational consultants and oral surgeons, different specialists have different definitions and methods to manage ankyloglossia.

CASE REPORT Consent was obtained for publication from the parents. The case was seen in a tertiary care hospital with level 3 NICU in Ammapettai, Kancheepuram. Eighteen years primi gravida mother delivered a female baby through LSCS (Lower Segment Caesarian Section), born on 5/8/2018 at 6.06 pm. Indication being: Non progression of labour.

MOTHER DETAILS

Mother was O+ve, Anemia was corrected by blood transfusion (hb 10.5gm), No family history of DM, HTN or ankyloglossia. LMP-29/10/2017, EDD-5/8/2018, Antenatal ultrasounds are normal.

BABY DETAILS

Cried immediately after birth, female baby, APGAR Score -8/10, 9/10, BBG-O+VE, Baby weight -3kg, No sibling/family history of Ankyloglossia. General condition of baby fair Cry/color/activity:fair. CVS-S1S2 heard, Heart rate -140/min no murmur, Rs –B/L AE equal air entry no added breath sounds, Respiratory rate-48/min. P/A soft, globular in shape, liver palpable -2 cm below right costal margin, spleen not palpable, Umbilicus placed in normal size, CNS- stable sucking and rooting reflex present. Gestational age of baby-40 weeks by new ballard score. No cleft palate or cleft lip. Anthropometric measurements were normal, Baby fed with supervised breastfeeding and expressed breastfeed through palladai, Head circumference -33 cm, Chest circumference-32 cm. Term/Appropriate Gestational Age Female Baby /Ankyloglossia. Paediatric surgeon opinion obtained - if there are subsequent breastfeeding problems surgery advised. Difficulty in speech articulations, Issues in the dentition. To review after 1 year.

DISCHARGE

Baby discharged with BCG, OPV, HEPB Given, Danger signs are explained, Advised to come for regular follow up to Medical op regularly.

DISCUSSION

Ankyloglossia is a congenital condition characterized by abnormally short, thickened, or tight lingual frenulum

that restricts the mobility of the tongue. It is typically an isolated anomaly, but can be associated with other craniofacial abnormalities.

4 It variably causes reduced

tongue mobility, functional limitations in breastfeeding, swallowing, articulations, orthodontic problems including malocclusion, mechanical problems related to oral clearance, psychological test. Anterior ankyloglossia is easily detectable, but posterior ankyloglossia doesn’t have the usual appearance of traditional anterior ankyloglossia. It is widely unknown and underdiagnosed entity. Hence both the types of ankyloglossia interfere with breastfeeding causing maternal pain.

5 National

health service and Canadian paediatric society recommend treatment if ankyloglossia interfere with breastfeeding.

6 Ankyloglossia seems to have genetic

etiology and it is mainly found in male infants (Jamelin et al 2014)

7, but in our case, it is a female baby. Higher

incidence in male babies with a ratio of 1.5-2.6: 1 as by Ballard J et al

8 According to the Coryllos classification

defines four types of frenulum: TYPE 1: Fine and elastic frenulum, the tongue is anchored from the tip of alveolar ridge and it is found to be heart shaped. (Figure 1) TYPE 2: Fine and elastic frenulum, where the tongue is anchored from the 2-4 mm of the tip to almost near the alveolar ridge. (Figure 2) TYPE 3: Thick, fibrous and non-elastic frenulum tongue is anchored from the middle of the tongue to the floor of the mouth. (Figure 3) TYPE 4: Frenulum cannot be seen. (Figure 4)

4

There is also a Type 5, which has sub-mucosal attachment (Figure 5). By using this classification, we diagnosed our patient to have type 2 Ankyloglossia.

EMBRYOLOGY OF THE TONGUE

The tongue is formed in the floor of the mouth by 2 swellings contributed by first and third pharyngeal arches which are demarcated by sulcus terminalis.

9 The

limitation in lingual mobility in newborns can compromise sucking and latching on to the breast. During breastfeeding, difficulty latching can lead on to pain during sucking, poor weight gain (<100 gms/week), excessively long breastfeeding (more than 60 min.) If these symptoms persist, frenotomy can be suggested. But in our case, no maternal pain during feeding and baby has normal weight gain. Maternal pain can be evaluated by the visual analog scale (VAS) Amir et al

10

affirm Coryllos only used anatomical criteria while Hazal backer used functional criteria. Hence classification of Hazelbacker is highly reliable in the recommendation of frenotomy in newborns. Power and Murby 2015 concluded that 50% of breastfed babies with ankyloglossia did not encounter any problems.

11

Suggested orofacial rehabilitation involving stimulation and rooting reflexes and carry out intraoral and extraoral exercises. The areas to be stimulated are palate, tongue, inner surface of cheeks and sucking reflex. Multidisciplinary team is essential in managing babies with ankyloglossia. It is recommended to connect nursing posture during breastfeeding and stimulate sucking and rooting reflexes. Frenotomy is necessary upon the diagnosis of ankyloglossia, interfering with feeding and when done second stimulation before and after treatment.

12 The pathogenesis of ankyloglossia is



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not known. Ankyloglossia can be a part of certain rare syndromes such as X linked cleft palate

13, and Vander

Woude syndrome 14

. Maternal cocaine use is reported to increase the risk of ankyloglossia to more than 3 fold

15.

The incidence of ankyloglossia in various reports ranges from 0.02% as high as 4.8% of term newborns

16.

Surgical techniques for the therapy of the tongue ties can be classified into 3 procedures, a. Frenotomy is a simple cutting of the frenulum b. Frenectomy is defined as complete excision, i.e., removal of the whole frenulum c. Frenoplasty involves various methods to

release the tongue tie and correct the anatomic situation. In addition to surgical intervention, revision of the frenum by laser

17 without a general anesthetic and

revision by electrocautery18

using a local anesthetic have been described. The newborn tongue tip – frenulum distance averaged 9 mm, with an SD of 2.5 mm. Shorter tip frenulum length was correlated with higher maternal nipple pain scores

19. More research

needs to be done to better understand the influence of upper lip tie and posterior ankyloglossia and breastfeeding.

Figure 1

Classical (type 1/ 100%) tongue tie – heart shaped tongue

Figure 2 Type 2/ 75% tongue tie – restricted elevation and extension

Figure 3

Type 3/ 50% tongue tie – may appear normal but symptoms present.



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Figure 4

Type 4/ 0% - fibrous attachment, asymmetry of tongue movement

Figure 5 Sub-mucosal attachment (hidden tongue-tie)

CONCLUSION Tongue tie is an important congenital malformation

that should be diagnosed in the neonatal period. It

should be diagnosed in the neonatal period so that

early therapy may be started. Frenotomy should be

done when indicated. Surgical correction should be

done after weighing the risks and benefits of surgery.

AUTHORS CONTRIBUTION STATEMENT Dr.P.Paramanantham conceived the idea and collected data regarding the patient. Mohan. P and Raja Kumar drafted the manuscript.

CONFLICT OF INTEREST Conflict of Interest declared none.

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ANKYLOGLOSSIA IN NEWBORN-CASE REPORT