• Varun Sagi

Treating Tongue Tie: Frenotomy Technique and Complications

Updated: Feb 28

Following a thorough evaluation of pediatric patients with ankyloglossia (tongue-tie) – including a detailed history of the mother-baby dyad and a functional exam – it may be appropriate to proceed with surgical management. The surgical approach involves cutting the lingual frenulum in a procedure known as frenotomy (also commonly referred to as frenulectomy or frenulotomy). Acute post-operative management is focused on adequate hemostasis whereas long-term management is aimed at preventing scar formation. Awareness of potential complications can help ensure appropriate treatment should they arise.


We’ve provided the highlight reel below, but you can listen to the full podcast here.


The BackTable ENT Brief

  • A grooved director can be used to raise the tongue towards the palate and allow access to cut the frenulum

  • Hemostasis is often achieved with pressure alone

  • Recent clinical consensus statement has recommended the use of sweat-ease both prior to and after the procedure

  • Complications are rare, but have been reported to include cardiac toxicity from topical lidocaine, methemoglobinemia from ester-based topical anesthetic, staphylococcus floor of mouth wound infection, and sialoceles/ductoceles of the lingual gland when performing a laser-based excision

  • Finger sweep under the tongue during feeding for 1-2 weeks following the procedure can help disrupt scar tissue formation

Disclaimer: The opinions expressed by participants of the BackTable ENT Podcast belong solely to the participants, and do not necessarily reflect the views of BackTable ENT.

Frenotomy procedure set up and technique

Dr. Lene-Voit outlines her set-up and technique when performing an in-clinic frenotomy. She has the child swaddled and has a nurse assist with the procedure. She uses a grooved director to raise the tongue towards the palate and then snips the frenulum anteriorly. Posterior blunt dissection is then done with her finger to minimize risk of cutting into muscle. She has adopted the use of sweet-ease both prior to and after the procedure due to a recent clinical consensus statement which favors such an approach. She typically does not need Afrin or silver nitrate to achieve adequate hemostasis. She encourages feeding following the procedure.


[Ashley Agan]

Do you use Afrin, Felicity? Yeah, what is your technique? Tell us more.


[Felicity Lene-Voit]

I don't know if the Afrin is necessary. I use Afrin because I'm an ENT and we love the stuff, but I honestly don't know if it's necessary. I think pressure is probably fine.


[Ashley Agan]

Do you use silver nitrate? Do you use a hemostat?


[Felicity Lene-Voit]

I don't use either of those unless I have to. I don't think there's evidence about the hemostat, but I see how it's appealing sometimes because you sort of clamped off the vessel already a little bit. But I use a groove director. I lift up the tongue. I have the baby swaddled and have a nurse helping me. I use a headlight and then I snap anteriorly. And then honestly for the posterior dissection I usually mostly do a blunt dissection with my finger to make sure that I released the entire posterior extent because I feel like that way, I have more feedback as to when I've actually gotten to muscle and I don't cut into muscle.


[Felicity Lene-Voit]

And there's been a few things written. Of course, it's impossible to get great data on this in infants, but certainly on anatomical studies some of the sensory nerves are very close to the muscle and right under the mucosa when you get sort of the junction of the tongue and the floor of mouth. And I don't want to cut those accidentally. So I have leaned more towards doing blunt dissection at the end, and then I hold pressure. I look to make sure that I got that diamond shape release in the floor of the mouth. And then I give the baby a sweet ease on a pacifier. Actually, I've switched since the clinical consensus statement came out, which recommended giving sweet ease before also, I've switched, and I give them sweet ease while we're getting set up to prime those happy neuro-transmitters…


[Ashley Agan]

Can you tell us what sweet-ease is for those listeners who may not be aware?


[Felicity Lene-Voit]

It's sugar, water. It's nothing. It's like a simple syrup for babies. They get a cocktail without any alcohol in it. And so we dip their Passy [pacifier] in it, or if they didn't bring a Passy, then I just dip my clean gloved finger in it and let them kind of suck on it. And then do the procedure, give them back the Passy and the sweet ease, hold pressure. I love it when they come with the pacifiers that you can put your finger on the inside because I can hold extra directed pressure in the little hole in the center of the pacifier. And then once I think we have acceptable hemostasis, I have mom feed them. That has a lot of benefits. I feel like it helps with hemostasis additionally and kind of gives them time to stabilize any clot that may be forming.


[Felicity Lene-Voit]

It gives them all the good oxytocin from nursing. It helps mom feel comforted because she gets to snuggle with them and help them through their pain. And, like I said, I don't think that it's too bad for the kids. Knock on wood, I haven't had kids who go on a nursing strike or won't eat or something like that as a result of the procedure. Now there's time, and anything can happen. But I think it's relatively well tolerated.


Potential complications

Dr. Lene-Voit describes potential complications following frenotomy. Given the extent of her posterior dissection – back to the diamond of tissue in the floor of mouth – she occasionally has more bleeding, but it usually resolves with pressure. Other reported complications include cardiac toxicity from topical lidocaine, methemoglobinemia when using an ester based topical anesthetic, and staphylococcus floor of mouth wound infection. Furthermore, there have been reported incidences of sialoceles/ductoceles of the lingual gland when performing a laser-based excision.


[Ashley Agan]

…What kind of complications do you see or have you seen any?


[Felicity Lene-Voit]

I like to cut all the way back. If I'm doing it, I like to get all the way posterior and get that diamond of tissue in the floor of mouth. So I have had, I think, more bleeding from that than sometimes may happen if you don't do that. But it has always stopped with pressure. I haven't had any issues. I have read case reports of babies getting cardiac toxicity from topical lidocaine because it's just so hard to dose in a little bitty infant, and sublingual absorption is first pass and it's kind of unpredictable and very efficient. And then reports of methemoglobinemia if you use, what is it, an ester based topical anesthetic. There's a case report of a baby getting staph floor of mouth wound infection.


[Gopi Shah]

It sounds awful.


[Felicity Lene-Voit]

I know. I've only seen one, but when I read it, I was like, "Okay. Well, keep that in the back of your mind for if a mom calls and says babies got stinky breath." We might have to look at it.


[Felicity Lene-Voit]

One more weird complication that I have read, and this was attributed to use of a laser, so a hot method, I have read about getting floor of mouth sialoceles or ductoceles in the lingual gland outflow tracks from basically a kneeling off the egress points of the ducts when getting too close when cutting the tie.


Post-procedure management

Dr. Lene-Voit, Dr. Shah, and Dr. Agan discuss post-procedure management of children who have undergone frenotomy. There is limited evidence for any specific intervention. Dr. Lene-Voit often advises mothers to do a finger sweep under their child’s tongue during feeding to disrupt scar tissue formation in the 1-2 weeks following the procedure. Revision procedure is rarely needed.


[Gopi Shah]

Do you think that these things scar again in terms of revision?


[Felicity Lene-Voit]

I think they could. It's again frustrating. There's no evidence about what to do post procedure in terms of do you do stretching exercises. There are people who swear by specific mobility exercises. And I don't know. I'm not able to be guided by a randomized controlled trial on this. So I'm curious to know what you guys do. I tell mom for two weeks every time, either before or after, or both baby feed starting the day after the procedure because I don't want the same day of the procedure I don't want them to disrupt any clot if there's clot there, but I tell them to just finger sweep back and forth five or six times and try and break down any potential scar tissue. And that's not much to do. And it's probably not doing anything. And maybe over time I'll change my practice and get more enthusiastic about more exercises.


[Felicity Lene-Voit]

Certainly there are people within the academy of otolaryngology who have been doing ankyloglossia work for a lot longer than I do who strongly believe that they're necessary, but I just haven't been able to find published evidence of a particular protocol that's any better than any other protocol. And so I'm sort of hesitant about adding more to the burden of being a new mom.


[Ashley Agan]

Yeah. I do the same thing and I must say I do not see a lot of patients requiring revision.


[Gopi Shah]

Yeah. I have them just do a little finger sweep under the tongue twice a day for like seven days. You know what I mean? But I agree. I don't have anything too extensive. And in terms of revision, I think I've only seen it in six, seven years maybe twice.


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Podcast Participants:

Dr. Felicity Lenes-Voit is a practicing ENT and an Assistant Professor in the Department of Otolaryngology at UT Southwestern Medical Center.

Host Dr. Gopi Shah is a practicing pediatric otolaryngologist and Assistant Professor of Otolaryngology at UT Southwestern. Host Dr. Ashley Agan is a practicing general otolaryngologist and Assistant Professor of Otolaryngology at UT Southwestern.


Resources Mentioned:

Cochrane Review of Frenotomy for Tongue-Tie in Newborn Infants:

https://www.ncbi.nlm.nih.gov/pmc/articles/PMC6464654/

Clinical Consensus Statement Ankyloglossia:

https://journals.sagepub.com/doi/full/10.1177/0194599820915457


Cite this podcast:

BackTable, LLC (Producer). (2020, October 20). Ep. 08 – Treating Tongue-Tie [Audio podcast]. Retrieved from https://www.backtable.com/podcasts


Medical Disclaimer:

The Materials available on the BackTable ENT Blog are for informational and educational purposes only and are not a substitute for the professional judgment of a healthcare professional in diagnosing and treating patients. The opinions expressed by participants of the BackTable ENT Podcast belong solely to the participants, and do not necessarily reflect the views of BackTable.

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