Surgical Management

Ankyloglossia Management

Ankyloglossia (tongue-tie) is a condition where limited tongue mobility is caused by a restrictive lingual frenulum. Definition disagreement exists amongst otolaryngology experts, which limits the application of standardized diagnostic criteria. This, paired with factors such as an increased focus on the benefits of breastfeeding, increased awareness of ankyloglossia, and an increase in practitioners who treat ankyloglossia, has contributed to children being over-diagnosed and, in some cases, unnecessary surgery (Messner, Walsh, & Rosenfeld, 2020).

As such, controversy exists regarding surgical management of ankyloglossia in breastfed infants. Frenotomy refers to a simple incision of the lingual frenulum. While frenotomy appears to improve breastfeeding difficulties and maternal pain in some infants with tongue-tie, breastfeeding difficulties may resolve without surgical intervention with adequate lactation and feeding therapist support. The role of frenotomy in non-breastfed infants has not been adequately investigated. Assessment of other causes for feeding difficulties in this population is important (Messner, Walsh, & Rosenfeld, 2020).

Prior to frenotomy consult, a standardized formal assessment of lingual frenulum function and an evaluation by a lactation consultant or lactation practitioner should be completed. Frenotomy may be considered when breastfeeding difficulties are not improving with conservative management. The child should also be assessed for nasal obstruction, airway obstruction, laryngopharyngeal reflux, and craniofacial abnormalities as potential contributors to pediatric feeding disorder. Failure to diagnose and treat these other disorders can negatively impact outcomes after lingual frenotomy (Messner, Walsh, & Rosenfeld, 2020).

There is insufficient evidence to support a specific technique for a frenotomy. Although recognized as a safe and well-tolerated procedure, frenotomy is not without risks and complications such as bleeding, infection, lingual nerve damage (Mills, Keough, Geddes, Pransky, & Mirjalili, 2019), injury to Wharton’s duct, airway obstruction, injury to salivary structures, oral aversion, and scarring (Messner, Walsh, & Rosenfeld, 2020). If surgical intervention is deemed necessary, it should be performed by a physician experienced with the procedure. The physician must possess the necessary training to recognize contraindications to frenotomy and ability to manage post-surgical care (Canadian Paediatric Society, 2015). 

Informed consent should include adequate counselling that surgical treatment does not always resolve feeding difficulties and further assessment of other causes for feeding problems may be required (Messner, Walsh, & Rosenfeld, 2020). 

Frenotomy should not be mistaken for frenuloplasty (incision of lingual frenulum with rearrangement of the tissue) or frenectomy (removal of the lingual frenulum) which are more invasive surgeries. There is limited evidence on the indications, outcomes, and preferred technique for frenuloplasty in older children and adolescents. Improved quality of life related to social and mechanical issues has been demonstrated (Messner, Walsh, & Rosenfeld, 2020).

Surgical Management of Dysphagia and Pediatric Feeding Disorder

Dysphagia is a multifactorial, complex condition that may or may not be caused by a physical malformation that is amenable to surgical intervention (Lawlor & Choi, 2020). Conditions that may benefit from surgical intervention may include but are not limited to:

  • Pierre Robin sequence, also known as Pierre Robin syndrome, Pierre Robin malformation, or Robin sequence
  • Unilateral vocal cord paralysis
  • Esophageal atresia, long gap esophageal atresia, tracheoesophageal atresia
  • Esophageal achalasia
  • Laryngeal cleft
  • Cleft lip and/or palate

Babies born with Pierre Robin sequence are a heterogenous group. They may present with no other abnormality except for the micro- or retrognathic mandible, breathing and swallowing difficulties, with or without cleft palate (and lip), or they may be syndromic or have another genetic abnormality with several other ailments (cardiac, neurological, structural, behavioural, metabolic, etc.) that may present with the same clinical manifestations. There is some evidence that feeding improves with improvement of airway obstruction. After mandibular distraction osteogenesis, 82% of children were feeding exclusively orally where babies with isolated Pierre Robin fared better than the syndromic children (93.7% versus 72.9%). Treatment of cleft lip and palate as a comorbid condition and limited use of repeat instrumental assessments in this population may have impacted the results (Breik, Umapathysivam, Tivey, & Anderson, 2016).

Unilateral vocal cord paralysis, mostly secondary to iatrogenic trauma, has been investigated increasingly for its association with dysphagia and pediatric feeding disorder. Injection laryngoplasty (using several different agents) and thyroplasty may improve protection of the lower airway as documented using standard instrumental assessment along with voice quality. Laryngeal reinnervation is being practised and reported more often, however, more is known about its impact on voice than on dysphagia. Most surgeons will combine injection laryngoplasty with reinnervation, which adds to the difficulty of attributing outcomes to a particular procedure (Butskiy, Mistry, & Chadha, 2015).

With respect to esophageal atresia, use of conventional thoracotomy or thoracoscopy both demonstrated efficacy in establishing some form of oral feeding (Drevin, Andersson, & Svensson, 2021). It is unclear to what extent compensatory strategies were required, such as the use of thickened liquids, and the use of supplemental tube feedings. The heterogenous etiology of long esophageal gap (congenital or acquired) makes it difficult to assess the impact of various surgical techniques on dysphagia and pediatric feeding disorder outcomes (Liu, Yang, Zheng, Dong, & Zheng, 2017). This is also true with respect to esophageal atresia and tracheoesophageal fistula (Yang, et al., 2016).

Surgical management of esophageal achalasia has demonstrated success with Heller’s myotomy (78%), esophageal dilatation (44.9%), and peroral esophageal myotomy (99.3%) (Goneidy, Cory-Wright, Zhu, & Malakounides, 2020) in improving dysphagia outcomes. 

Recently, there is more literature addressing interventions to augment the interarytenoid area, or treatment of type 1 laryngeal clefts. Injection laryngoplasty has been shown to decrease the rate of aspiration from 91% pre-injection to 62% post-injection, with 90% of parents reporting symptom improvement. For those children treated with endoscopic repair, the rate of aspiration decreased from 73% to 28% after repair, with 80% of parents reporting symptom improvement (Reddy, Byun, Downs, Nguyen, & White, 2020).