Our analysis found that infants with an anterior tongue-tie were significantly more likely to undergo frenotomy versus those with a mid or posterior tongue-tie (p < 0.005). This is concordant with current international recommendations5 Evidence does support that anterior tongue-tie can impact on feeding and that frenotomy may be of benefit in these infants5,14. At present there is no evidence within the literature to suggest that posterior tongue-ties negatively impact on an infant’s feeding5. Further to this there is no evidence to support that performing a frenotomy in patients with a posterior tongue-tie is of any benefit to the infant while it does expose them to the potential risks of the procedure15. These risks include: infection, bleeding, scarring, salivary duct damage and nerve damage5. Previous studies have shown that ankyloglossia can be associated with poor feeding by reducing an infants’ ability to latch properly for feeding16,17. Thus, they are unable to adequately meet their nutritional requirements leading to failure to thrive. As such, it is important that these infants undergo timely treatment of their tongue-tie. Within our study we found a higher proportion of infants presenting with ankyloglossia associated with failure to thrive underwent frenotomy. Previous studies have demonstrated that frenotomy is of more benefit in those infants that are breastfed5,14. In our analysis, a higher proportion of breastfed infants referred to our clinic with ankyloglossia underwent frenotomy. We observed that infants who underwent frenotomy tended to be younger than those who did not. Again, this is consistent with findings from previous studies18. In agreement with current evidence we would advocate that breastfed infants with anterior tongue-tie and failure to thrive undergo frenotomy at an early stage. Overall, it appears from our analysis that clinicians within our institution were appropriately screening and identifying the infants with suspected ankyloglossia in whom frenotomy was appropriate based on these recommendations.
Over one-third of infants referred to our ENT outpatient clinic for consideration of frenotomy did not require or undergo the procedure. This finding is encouraging given the desire for clinicians to avoid unnecessary invasive procedures in all patients and particularly in infants. Studies have demonstrated that the majority of infants with ankyloglossia are asymptomatic19,20. As such the majority of infants with ankyloglossia do not require further assessment or treatment. The rate of frenotomy performed on infants referred with suspected ankyloglossia to a given clinic or institution varies within the literature14,18. This appears to be largely due to two factors. Firstly, inappropriate screening and referral of infants with suspected ankyloglossia in the community will lead to many infants being seen in a clinic who do not need surgical treatment. This will lead to a low rate of frenotomy being performed in a given clinic as many infants who do not require any treatment are seen by the clinic. Appropriately screening which infants require referral to an ENT clinic for assessment and consideration of frenotomy is critical. This is because in February 2021, there were 67,980 patients waiting to be seen as outpatients at various ENT clinics within Ireland with 31,853 of these patients expected to be waiting more than 18 months21. Infants referred to our clinic with suspected ankyloglossia are seen and treated on an urgent basis in line with international best practice14. If ankyloglossia is impacting on an infant’s ability to feed and develop it is vital that this be corrected as soon as possible. Referral of infants to an urgent ENT outpatient appointment with suspected ankyloglossia that can be manged conservatively has a significant opportunity cost. This includes potential delays in seeing patients with suspected head and neck cancer who also necessitate urgent outpatient ENT appointments. The HSE has attempted to aide clinicians in screening infants with suspected ankyloglossia within the community through dissemination of a HSE ankyloglossia assessment proforma7. We would advocate the use of this proforma to both appropriately identify which infants require further assessment and treatment and to avoid referral of infants who do not need treatment of their ankyloglossia. As the rate of breastfeeding increases among Irish mothers24, we can expect to see the number of ankyloglossia referrals rise in tandem.
The other important determination on the rate of frenotomy within an institution is the clinicians themselves. With a lack of concrete diagnostic and therapeutic criteria, studies have demonstrated significant inter clinician variability in deciding to perform or not to perform frenotomy in infants with ankyloglossia22. In the last number of years performing frenotomy has become a lucrative private practice. Many private clinicians are advertising and performing the procedure while charging parents significant fees. We note that under-6’s primary healthcare is free within Ireland. This is at odds with clinicians charging parents hundreds of euros for consultations and performing of frenotomy in infants privately. An area of particular concern to some authors is these private clinicians offering to divide “posterior” tongue-ties 23. As discussed, the evidence to support dividing these posterior tongue ties is questionable at best with most evidence suggesting posterior tongue ties do not impact feeding. It would not be routine practice in HSE or National Health Service (NHS) clinics to divide these posterior tongue ties due to the lack of evidence to support the practice23.
The present study has a number of limitations. First is the small study numbers. This may have led to underestimation of the effect various factors had on clinicians decision to perform or not to perform frenotomy. Secondly, the only post procedure information collected was procedural complications. No follow up outcome measures were obtained such as increase in infants’ weight or reported improvement in feeding to assess the efficacy of frenotomy in various circumstances. Additionally this study was performed retrospectively which may have led to bias within the analysis. Finally, as previously discussed there is no standardised diagnostic criterion for ankyloglossia. This may have led to some infants included in the analysis after being misclassified with ankyloglossia.
In conclusion we demonstrated that within our institution that infants with anterior tongue-ties, failure to thrive and breastfed infants were more likely to undergo frenotomy. This is concordant with the current available evidence within the literature. Additionally, we demonstrated that over one-third of infants referred to our clinic with suspected ankyloglossia did not require frenotomy. With current long ENT clinic waiting lists within Ireland it is critical that infants with suspected ankyloglossia are properly assessed in the community using appropriate tools such as the HSE assessment proforma to avoid unnecessary referrals.