15/12/2021
I'm reposting this from 3 years ago. It's very technical intentionally - this is the kind of post that could and should be shared with health care professionals to get them to learn more about this topic.
One of the biggest myths I frequently hear is that a cup/bowl-shaped tongue when a baby is crying means that there is a tongue tie. Hopefully, by the time you finish reading this post, you’ll see why that’s not necessarily true.
I’ve written previously about the importance of fully understanding tongue physiology before proper detection can happen. Without that understanding, then the person doing the surgical release of the tongue doesn’t understand the importance of the genioglossus muscle, which is the muscle that’s bound in situations where a tongue tie is present.
The gross oversimplification of tongue tie release has some unfortunate repercussions - everyone seems to think that a tongue tie release is all that is needed to unleash tongue function and normalize feedings. That mindset overlooks one very important factor in feeding success: muscle tension. Remember this one very important point: anything that limits genioglossus movement is going to result in impeded sucking function. What can impede genioglossus movement?
1) anterior tongue tie
2) posterior tongue tie
3) an anterior tongue tie where only the anterior tie was released (posterior tongue tie still present)
4) incompletely released posterior tongue tie (a wound is present but it wasn’t sufficient to allow the genioglossus to fall under the tongue)
5) a completely released posterior tongue tie that reattaches because of poor wound management
6) muscle tension
Options 1-5 above imply that the major problem was a physically restricted tongue in the form of some sort of tongue tie. Option 6 is very overlooked.
The genioglossus muscle is one of several “extrinsic tongue muscles” - these are muscles that are technically distinct from the unnamed, intrinsic muscles of the tongue. Think of the extrinsic tongue muscles as those muscles that help to move the tongue from the outside, whereas the intrinsic tongue muscles are those that change the shape and orientation of the tongue itself. There are 4 extrinsic muscles that act in a similar location - the genioglossus (from the genoid tubercle of the mandible to the tongue), the geniohyoid (from the genoid tubercle of the mandible to the hyoid bone), the hyoglossus (from the hyoid bone to the sides of the tongue) and the mylohyoid (from the mandible to the hyoid bone). These muscles also serve as a sling for the floor of the mouth. These muscles are embedded in common fascial slips that surround them (and can serve as a channel for fast-moving infections in other diseases).
So why all this technical information? What I want to get across is that if the genioglossus muscle isn’t being held by a tie, but is instead tight itself, it will ACT tied. This is where the obstetric and birth histories and proper physical examination are so crucial - was there a rough pregnancy or traumatic delivery? Do the muscles AROUND the tie feel tight? If so, one cannot commit to a tongue tie as being the diagnosis. Similarly, if the muscles around the genioglossus are tight, then they can hold on to the genioglossus and prevent it from moving, again mimicking the signs and symptoms of tongue tie.
It’s not hard for a provider to learn how to do a tongue tie release properly. The real skill comes in knowing when, and more importantly when NOT to, perform a release. If there is significant muscle tension in the region of the tie, and a provider cannot definitively determine that the symptoms are coming from a tie, a surgical release must be delayed until that muscle tension is resolved.
Often, time alone helps. But many parents turn to therapies like infant massage, myofascial release, chiropractic intervention or craniosacral therapy. I admit to anyone who asks that we have no published evidence that these therapies work - that being said, I feel like the massage of those muscles, like the massage of any tight muscles, can be helpful in alleviating that tension. If I encourage a family to delay a treatment, I usually have them return between 2-4 weeks later for reevaluation, and I am almost always able to determine if a tie is present because the muscles are softer. I’ll be honest that 1/3-1/2 of the babies I send away never return because the symptoms that mimicked the tie went away once the muscles relaxed.
Obviously, a baby can have both a tie and tight muscles. As long as the treatment team around the dyad is aware of the possibilities, then effective and appropriate treatment can be rendered.
