International Journal of Pediatric Otorhinolaryngology 88 (2016) 13e16

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International Journal of Pediatric Otorhinolaryngology

journal homepage: http://www.ijporlonline.com/

Management of posterior ankyloglossia and upper lip ties in a tertiary

otolaryngology outpatient clinic
Lara Benoiton a, *, Maggie Morgan b, Katherine Baguley a
a
Department of Otoarlyngology, Wellington Public Hospital, 56 Riddiford Street, Newtown, Wellington 6021, New Zealand
b
Neonatal Intensive Care Unit, Wellington Public Hospital, 56 Riddiford Street, Newtown, Wellington 6021, New Zealand

a r t i c l e i n f o a b s t r a c t

Article history: Objectives: Recent studies have shown an association between ankyloglossia (tongue tie) and upper-lip
Received 11 March 2016 ties to breastfeeding difficulties. Treatment is commonly multidisciplinary involving lactation consul-
Received in revised form tants and surgical management with tongue tie and upper lip tie release. There is currently limited data
15 June 2016
looking at posterior ankyloglossia and upper lip ties.
Accepted 16 June 2016
Available online 18 June 2016
Methods: Consecutive patients seen at an ENT outpatient clinic for ankyloglossia and upper-lip ties from
May 2014eAugust 2015 were assessed for an outpatient frenotomy. Breastfeeding outcomes were
assessed following the procedure.
Keywords:
Ankyloglossia
Results: 43 babies were seen and 34 patients had a procedure carried out. Babies ranged from 2 to 20
Upper lip tie weeks old with the median age being 6.6 weeks. The most common presenting complaint was latching
Frenotomy issues (85%) with mothers' painful nipples being the second (65%). 21 patients (62%) had a tongue tie
release, 10 (29%) had both a tongue tie and upper lip tie divided, whereas 3 (9%) had an upper-lip tie
alone divided. 29 (85%) of the patients who had a procedure carried out had an immediate improvement
in breastfeeding, while 28 (82%) had a continued improvement at 2 weeks follow up.
Conclusions: Frenotomy for posterior ankyloglossia and upper lip ties is a simple procedure that can be
carried out in an outpatient setting with apparent immediate benefit. Otolaryngologists are likely to have
an increasing role to play in the evaluation and management of ankyloglossia and upper lip ties in babies
with breastfeeding difficulties.
© 2016 Elsevier Ireland Ltd. All rights reserved.

1. Introduction ankyloglossia and upper lip tie frenotomies [4,9,12,13]. Unfortu-

Ankyloglossia or tongue-tie is a congenital condition charac-
terized by a lingual frenulum that can limit tongue movement [1,2].
Contemporary studies have shown a link between ankyloglossia
and breastfeeding difficulties, with an improvement in breast-
feeding outcomes following tongue-tie release procedures [3e8].
Ankyloglossia can be classified as the more obvious anterior
ankyloglossia, with a thin web-like lingual frenulum inserting at or
just behind the tongue tip. or the less obvious posterior ankylo-
glossia, which is thicker and further back from the tongue tip [9,10].
Upper lip ties are characterized by a thickened labial frenulum
which restricts lip splay [4,11]. Recent studies have shown
improved breastfeeding outcomes following posterior
* Corresponding author. 3/120 Rintoul Street, Newtown, Wellington 6021, New
Zealand.
E-mail address: larabenoiton@yahoo.com (L. Benoiton).
nately there is currently limited literature of this condition and its
management.
The aim of our study was to assess the outcomes of office-based
frenotomy for the management of posterior ankyloglossia and lip
ties as managed by our multidisciplinary service.
2. Methods
2.1. Study design
A prospective audit was performed of patient outcomes
following frenotomy for ankyloglossia and/or upper lip tie in an
outpatient setting between May 2014eSeptember 2015. Data
including patient demographics, breastfeeding concerns and post-
frenotomy outcomes were collected prospectively on a dedicated
database. Where incomplete, patient records were reviewed for
further detail.

http://dx.doi.org/10.1016/j.ijporl.2016.06.037
0165-5876/© 2016 Elsevier Ireland Ltd. All rights reserved.
14 L. Benoiton et al. / International Journal of Pediatric Otorhinolaryngology 88 (2016) 13e16
2.2. Referral process
Outpatient frenotomy for posterior ankyloglossia and upper lip
tie is performed by a paediatric Otolaryngologist. This service is in
collaboration with five public hospital-appointed lactation con-
sultants who assess and refer babies for whom they are unable to
perform a frenotomy within their current scope of practice. This
includes (i) infants beyond the age of 6 weeks, (ii) those with a
posterior tongue tie, or (iii) those with an upper lip tie. Assessment
of babies involves a comprehensive discussion with the mother
regarding breastfeeding concerns and confirmation that vitamin K
has been given. The Hazelbaker Assessment Tool is used to assess
lingual function by the lactation consultants prior to a referral to
our outpatient service [14]. Our referral process was customised
after discussion with other centres offering similar services to help
recognise possible pitfalls, including unnecessary appointments
(Fig. 1). Mothers with active mastitis or nipple infections are
advised to postpone their appointment or breastfeed from the
unaffected side until the infection is cleared.
2.3. Inclusion criteria
Mothers and babies referred by a lactation consultant with
ankyloglossia and/or lip tie contributing to significant breastfeed-
ing (or occasionally bottle-feeding) concerns were included.
Mothers with breastfeeding concerns were also motivated to
continue breastfeeding.
2.4. Exclusion criteria
Patients with comorbidities which added significant risk to the
frenotomy including (i) known coagulopathy, and (ii) significant
craniofacial anomaly with risk of tongue base obstruction, were
excluded.
2.5. Intervention and follow up
Verbal consent was obtained from the parents following a dis-
cussion of breastfeeding concerns and to rule out exclusion criteria.
Possible complications of bleeding, infection, and scarring were
discussed, as well as the possibility of non-resolution of breast-
feeding concerns. Parents were not present for the procedure. The
baby was swaddled and laid flat on the bed with the assistant
holding the baby's head midline. Using a headlight and magnifi-
cation, the tongue was elevated using a metal grooved elevator. The
submandibular ducts were identified and the lingual frenulum
clamped and released twice using fine mosquito clamps. The
lingual frenulum was then sharply divided with scissors between
the clamped areas. A gauze swab was then placed in the wound and
digital palpation used to apply pressure for haemostasis, and
Fig. 1. Referral process within our DHB.
confirm that the frenulum was released back to tongue muscle.
For an upper lip frenotomy, the upper lip frenulum was clamped
and released twice as above and sharply divided between, with a
gauze swab held on the wound until haemostasis was achieved.
1 mL of sucrose was given via a 1 ml syringe to settle the baby
post-procedure if required. The parents were then brought into the
room and an attempt at breastfeeding was made with guidance
from the lactation consultant. The wound was checked prior to
discharge from clinic. No analgesia or antibiotics were prescribed.
The parents were given a printed handout of stretching exercises to
be carried out at home for the following two weeks or until com-
plete wound healing had occurred.
2.6. Follow up
Mothers were followed up by a lactation consultant by either
clinic appointment or phone call within 24 h if a breastfeed was not
able to be carried out in clinic, and at 2 weeks. Information
regarding mothers' ability to continue breastfeeding and/or
improved breastfeeding outcomes were collected and entered in
the database.
3. Results
43 patients were seen at our outpatient clinic and 34 had a
procedure carried out between May 2014eAugust 2015 (Fig. 2).
Most of them were males (n ¼ 21, 62%) and of New Zealand Euro-
pean ethnicity. The median age was 6.6 weeks with a wide range of
2e20 weeks. The most commonly reported breastfeeding issues
included poor latching (n ¼ 29, 85%), mothers' painful nipples
(n ¼ 22, 65%) and poor weight gain (n ¼ 14, 41%) (Table 1).
14 of these patients had a previous anterior frenotomy carried
out prior to their outpatient clinic appointment. Most patients
(n ¼ 20, 59%) had a posterior ankyloglossia only, with 3 (9%) pa-
tients having an upper lip tie only. The remaining patients had a
combination of either both posterior ankyloglossia and an upper lip
tie (n ¼ 10, 29%) or anterior and posterior ankyloglossia (n ¼ 1, 3%).
The 9 patients who did not have a procedure carried out were
either found to not have significant ankyloglossia or upper lip ties,
or breastfeeding had improved.
Outcomes following frenotomy are outlined in Table 2, with
immediate improvement in 29 (85%) patients. At 2 week follow up
28 (82%) patients had improvement in breastfeeding. Follow up
was not obtained for 1 patient due to loss of contact with the
mother. Two frenotomies were revised, one at two weeks and one
at several months. There was no apparent difference in de-
mographics or outcomes between the types of procedures carried
out. No complications occurred.
 L. Benoiton et al. / International Journal of Pediatric Otorhinolaryngology 88 (2016) 13e16 15

Fig. 2. Study patient flow.

4. Discussion
Table 1
Patient demographics and characteristics. There has been increased awareness that breastfeeding confers
Demographic N (%) improved infant and maternal health outcomes. Breast milk offers
unique nutritional and non-nutritional benefits that optimise in-
Females 13 (38%)
Males 21 (62%)
fant growth and development [15]. Ankyloglossia is associated with
New Zealand European 25 (74%) difficulties in breastfeeding including failure to thrive, maternal
Age at clinic visit (weeks) 6.6 (range 2e20) nipple pain and risk of cessation of breastfeeding [10]. This is
Symptoms possibly related to an ineffective latch caused by ankyloglossia [10].
Latching issues 29 (85%)
Previous studies have shown improvements in breastfeeding out-
Painful nipples 22 (65%)
Poor weight gain 7 (21%) comes following frenotomy for anterior ankyloglossia [2,3,7].
Clicking noises 4 (12%) However, posterior ankyloglossia is still an under-recognised
Unsettled feeding 2 (6%) problem with limited studies discussing its effects on breastfeed-
Mean Hazelbaker score ing and outcomes following frenotomy [4,12]. Upper lip ties are
Appearance 4.7 (range 1e8)
Function 8.1 (range 4e14)
characterized by a thickened labial frenulum which restricts the
Previous anterior frenotomy 14 (41%) movement of the upper lip. This may cause ineffective latching
Ankyloglossia only causing maternal nipple pain and ineffective milk transfer [13].
Anterior and posterior 1 (3%) Surgical division of upper lip ties is also considered in the pre-
Posterior 20 (59%)
vention of midline diastena formation, or in the prevention of post
Posterior ankyloglossia and lip tie 10 (29%)
Upper lip tie only 3 (9%) orthodontic treatment relapse, though this was not considered an
indication, nor was it attempted to be evaluated in our study [11].
Frenotomy of upper lip ties has been linked with improved
breastfeeding, with no documented adverse effects on teeth

Table 2
Patient outcomes.

Procedure Number Immediate improvement Improvement at 2 weeks

Ankyloglossia only
Anterior and posterior 1 1 1
Posterior 20 18 16 (1 lost to followup)
Posterior ankyloglossia and lip tie 10 8 9 (1 initially no improvement but improved at 2 weeks)
Upper lip tie only 3 2 2
Total 34 29 (85%) 28 (82%)
16 L. Benoiton et al. / International Journal of Pediatric Otorhinolaryngology 88 (2016) 13e16
development [4]. Once again, there are limited studies looking at
breastfeeding outcomes following upper lip tie frenotomy [13].
Mothers with breastfeeding concerns in our region are primarily
managed by midwives and lactation consultants, with the majority
managed conservatively. All patients in our study had been
assessed and managed by a lactation consultant prior to referral for
frenotomy. We believe that this initial review and support helped
select the patients who would benefit most from a procedure, as
shown by an 85% improvement in the immediate setting, and of
82% continued improvement at 2 weeks. During the study period
an additional check was created to help limit the number of un-
necessary appointments. This involved a phone call made to each
mother 2 weeks prior to their appointment to ensure that they still
needed to be seen. Continuity of care and follow up was encouraged
by the presence of the lactation consultant at the clinic appoint-
ment, and follow up in person or via telephone. We believe that
offering the parents printed copies of stretching exercises helped
prevent scarring.
Limitations of our study include our small number, which pre-
vented analysis between the different groups of procedures carried
out. Our follow up was relatively short at 2 weeks, though mothers
were given the option to recontact the lactation consultants if they
had any concerns thereafter. While our patients were assessed
using the Hazelbaker score by our lactation consultants, this was
not repeated upon review in our outpatient clinic in assessing
ankyloglossia. The outcome measured was the mothers' subjective
improvement in breastfeeding and continued breastfeeding. This
may hinder comparison of our results to other studies. Multiple
classifications for ankyloglossia and upper lip ties have been sug-
gested, though none are universally used [11,13,16]. Breastfeeding
outcome measurements, including the LATCH tool, have previously
been used to show an improvement following frenotomy [16]. It
would be useful to have a universally accepted tool to compare
outcomes pre and post-frenotomy.
Our study adds to the currently limited literature looking at the
management of posterior ankyloglossia and upper lip ties. We had
improved breastfeeding immediately post procedure and at 2
weeks follow up, with no significant adverse events.
5. Conclusion
Breastfeeding problems are typically multifactorial and largely
managed by midwives and lactation consultants. However, for in-
fants with ongoing breastfeeding difficulties with posterior anky-
loglossia and upper lip ties, an office based frenotomy is an easy and
effective procedure. Prior assessment and post-procedural support
by lactation consultants is imperative in the management of these
infants.
Conflict of interest
The authors do not have any personal or financial conflicts of
interest in this study.
Acknowledgements
We had significant assistance in data collection from the lacta-
tion consultants within our region.
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