Dysphagia

https://doi.org/10.1007/s00455-019-10040-x

CLINICAL CONUNDRUM

Posterior Tongue Tie, Base of Tongue Movement, and Pharyngeal

Dysphagia: What is the Connection?
Laura Brooks1,4   · April Landry1,2 · Anita Deshpande2 · Cinzia Marchica2 · Anthony Cooley1,3 · Nikhila Raol1,2

Received: 22 April 2019 / Revised: 25 June 2019 / Accepted: 20 July 2019

© Springer Science+Business Media, LLC, part of Springer Nature 2019

Abstract
Ankyloglossia, or tongue tie, and its impact on the oral phase of feeding has been studied and debated for decades. How-
ever, the impact of posterior tongue ties on the pharyngeal phase of swallowing is not well documented in the literature.
A videofluoroscopic swallow study (VFSS) allows for visualization of the oral, pharyngeal, and esophageal phases of the
swallow. When decreased base of tongue movement, impaired pharyngeal pressure generation, and presence of pharyngeal
residue are noted during a VFSS, a neurologic etiology can be suspected. However, in the setting of a normal MRI with
normal motor development, other etiologies need to be explored. If it is not neurologic, could it be anatomic? We present a
21-month-old patient with significant pharyngeal phase dysphagia which was most saliently characterized by impaired base
of tongue movement, poor pressure generation, and diffuse residue resulting in aspiration. He was eventually diagnosed
with a posterior tongue tie and underwent a frenulectomy. Results via subsequent VFSS revealed significant improvement
in base of tongue movement, pharyngeal pressure generation, and pharyngeal constriction, resulting in efficient movement
of the bolus through the pharynx into the esophagus, no nasopharyngeal regurgitation, no aspiration, and near resolution of
his pharyngeal dysphagia. Patients with impaired base of tongue movement and impaired pressure generation resulting in
pharyngeal residue in the setting of a normal neurologic workup could possibly present with a posterior tongue tie which
should be examined and included in the differential diagnosis.

Keywords  Dysphagia · Ankyloglossia · Feeding · Quality of life · Pediatrics

Clinical Conundrum including coughing and choking even when breastfeeding.

After an abnormal Fiberoptic/Flexible Endoscopic Evalua-
LM was born without complication at 37 weeks of age. He tion of Swallowing (FEES), he was discharged home with a
presented to the emergency department with respiratory fail- nasogastric tube with frequent small volume, practice oral
ure requiring intubation at 9 days old. He was found to have trials. Follow-up examination via Videofluoroscopic Swal-
Respiratory Syncytial Virus (RSV), Pneumonia, and right low Study (VFSS) 4 weeks after discharge revealed not only
upper lobe infiltrates. He was intubated for 8 days. His first persistent aspiration, but also impaired base of tongue move-
bedside swallowing assessment was performed at 2 weeks ment, nasopharyngeal regurgitation, impaired pharyngeal
of age and he presented with significant signs of aspiration constriction resulting in inefficient clearance of the bolus
through the upper esophageal sphincter with significant and
diffuse pharyngeal residue. This is not a typical presentation
* Laura Brooks for an infant recovering from RSV with or without intuba-
laura.brooks@choa.org tion, and is more typically associated with neurologic/neu-
1 romuscular disorders [1]. Over the next 17 months, he was
Children’s Healthcare of Atlanta, Atlanta, GA 30322, USA
closely followed by our aerodigestive team and underwent
2
Department of Otolaryngology‑Head and Neck Surgery, microlaryngoscopy, bronchoscopy, esophagogastroduo-
Emory University School of Medicine, Atlanta, GA 30322,
USA denoscopy with biopsies, supraglottoplasty, interarytenoid
3 injection, and gastrostomy tube placement. His VFSSs
Department of Pediatrics, Emory University School
of Medicine, Atlanta, GA 30322, USA throughout that time continued to show similar results with
4 no improvement despite daily oral practice of all viscosities,
Atlanta, USA

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 L. Brooks et al.: Posterior Tongue Tie, Base of Tongue Movement, and Pharyngeal Dysphagia
outpatient speech therapy, and maturation. His MRI was
unremarkable and his motor development was age appro-
priate. His 4th unchanged VFSS was in May 2018 (Fig. 1).
What is the Etiology?
It was hypothesized that the poor base of tongue movement
could possibly be associated with an anatomic etiology.
Further intraoral examination revealed a posterior tongue
tie with restricted elevation and lateralization. His mother
endorsed difficulty with articulation and lingual range of
motion, and frequent use of his pacifier during mealtime.
It was hypothesized that this posterior tongue tie interfered
with his base of tongue movement to such a degree that
he could not adequately and efficiently propel the bolus
through the pharynx, resulting in residue and aspiration. In
June 2018, he went to the operating room for a frenulec-
tomy. Immediately after the procedure, his mother reported
the following changes: increase in intake of thin liquids,
decrease in use of pacifier, decrease in cough when drink-
ing, and increase in lingual range of motion. His follow-up
VFSS was conducted in August 2018 and revealed the fol-
lowing results (Fig. 2): significant improvement in swallow
function, significantly improved base of tongue movement
Fig. 1  Pre-surgery video fluoro-
scopic swallow study with thin
liquids demonstrating reduced
base of tongue movement,
diffuse residue, poor pressure
generation, nasopharyngeal
regurgitation, and aspiration
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resulting in only minimal residue in the valleculae with thin
liquids, trace residue in valleculae and pyriform sinuses
with purees, no pharyngeal residue with solids, no naso-
pharyngeal regurgitation, adequate pharyngeal constriction
and pressure generation, and efficient movement of bolus
though the pharynx and upper esophageal sphincter. The
study was conducted without the use of his pacifier. Three
months after his surgery he was advanced to a full oral diet,
no longer using his gastrostomy tube for supplemental nutri-
tion or hydration. There were no further respiratory infec-
tions. His mother reported the following additional changes
in his quality of life: discontinued use of his pacifier, elimi-
nation of frustration when he drinks liquids, ability to eat a
variety of food textures—particularly mixed consistencies
such as soup without choking, and significant improvement
in articulation.
Discussion
Ankyloglossia and its impact on the oral phase of feeding
has been studied and appreciated for decades. However,
the impact of tongue ties on the pharyngeal phase of swal-
lowing is not well understood. Swallowing is a complex
task involving sensory and motor neural control, with
L. Brooks et al.: Posterior Tongue Tie, Base of Tongue Movement, and Pharyngeal Dysphagia

Fig. 2  Post-surgery video
fluoroscopic swallow study
with thin liquids demonstrating
resolution of nasopharyngeal
regurgitation and aspiration, as
well as improved base of tongue
movement, efficient movement
of bolus through the pharynx,
minimal to no residue

the sensory stimuli assisting in bolus location and aspi-
ration prevention, and the neuromotor function assisting
in pressure formation that is required for bolus propul-
sion [2]. The base of tongue retracts against the posterior
pharyngeal wall, and this pressure generation helps move
the bolus efficiently through the upper esophageal sphinc-
ter [3]. Reduced base of tongue movement can result in
impaired pressure generation, poor pharyngeal constric-
tion, inefficient movement of the bolus through the phar-
ynx and upper esophageal sphincter, and diffuse pharyn-
geal residue all placing the patient at risk for aspiration
[4]. While these findings can be associated with neurologic
etiologies, it is important to consider an anatomic etiol-
ogy for impaired base of tongue movement particularly in
the presence of normal physical development and normal
MRI.
Acknowledgements  Nikhila Raol is supported by the American Soci-
ety of Pediatric Otolaryngology Career Development Award. There
is no conflict of interest pertaining to the award. The parents of LM
signed an “Authorization to Release Protected Health Information for
a Case Report.” Our IRB acknowledged this study with a Non-Human
Subjects Research Determination form.
Funding  There is no funding associated with this paper to disclose.
Compliance with Ethical Standards 
Conflict of interest  The authors declare that they have no conflict
of interest. There are no financial disclosures associated with this
paper.
Informed Consent  Informed consent was obtained from all indi-
vidual participants included in the study.
References
1. Van den Engel-Hoek L, de Groot IJ, de Swart BJ, Erasmus CE.
Feeding and swallowing disorders in pediatric neuromuscular
diseases: an overview. J Neuromuscul Dis. 2015;2(4):357–69.
2. McCulloch TM, Jaffe D. Head and neck disorders affecting
swallowing. GI Motility online. 2006.
3. Matsuo K, Palmer JB. Anatomy and physiology of feeding and
swallowing: normal and abnormal. Phys Med Rehab Clin North
Am. 2008;19(4):691–707.
4. Logemann JE. Evaluation and treatment of swallowing disor-
ders. College Hill Press, pp. 214–27. 1983.
Publisher’s Note Springer Nature remains neutral with regard to
jurisdictional claims in published maps and institutional affiliations.

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 L. Brooks et al.: Posterior Tongue Tie, Base of Tongue Movement, and Pharyngeal Dysphagia

Laura Brooks  M.Ed. CCC-SLP, BCS-S Cinzia Marchica  MD

April Landry  MD Anthony Cooley  MD

Anita Deshpande  MD Nikhila Raol  MD, MPH

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