How To Assess The Impact Of A Tongue Tie On Patients: Osteopathic Considerations.

Why The Tongue Is So Important

The tongue is the only muscle, or really group of muscles, in the body that has one freely moveable end. Not only is it attached to most fascial planes directly or indirectly, but it also has attachments on the hyoid bone, mandible, temporal bones, and other structures in the head. Structurally it can affect the digestive tract and respiratory tract. It has innervation from five cranial nerves – the  trigeminal, facial, glossopharyngeal, vagus, and hypoglossus nerve. The tongue is complex and its involvement in swallowing and speaking are some of the most important functions to survive and communicate.

Lingual frenulums often produce tongue ties (ankyloglossia) in adults. Even if minor and considered “insignificant,” the frenulum inhibiting the normal function of the tongue seems to have powerful impacts on the overall structure of the body. The tongue tie will tighten the fascia associated with it and will often anchor the hyoid bone superiorly under the mandible. This pulls the trachea and esophagus superiorly with it. By producing so much tension in the front if the body, it pulls the body downs to a kyphotic posture and pull the shoulders forward. I strongly believe that this is what is often the culprit with the “bad posture” and as we learn more about this, it will require us to look at the body differently.

Embryologically, the anterior tongue has a right and left side that come together and then extends outward during development. The frenulum is meant to recede completely. If it does not, which is quite common, it will affect the function of the tongue and many of the structures associated with it like the hyoid bone and mandible.

What Patients Are Noting

Instantly after correcting her tongue tie, my mom described being able to stand up straight for the first time in her life feeling “unwound.” She felt tension in her rib cage and spine release that allowed her to pull her shoulders back comfortably. I had a similar experience after having a lingual frenectomy and based on the findings below, I recommended it for my mother. The experience has given me good insight on assessing repercussions of tongue ties. I have had many powerful osteopathic treatments, but nothing has produced the changes and relief I experienced with the lingual frenectomy. Since the procedure, several patients of mine have commented that even though they could not put a finger on it, there was something different about my appearance. A tongue tie can affect far more than we may currently realize. The anatomy will be discussed in detail in further posts.

The effects of tongue ties in adults is something I have been learning more about recently and have found some interesting correlations that I would like to share. Correcting a tongue tie in adults can save an osteopathic provider much time and frustration with many musculoskeletal issues. The best time to correct this is with newborns and infants to prevent future problems. For many of us it is too late to have it done as babies, but we can still benefit from having a tongue tie corrected.

I am finding that the areas listed below if positive as a group tend to be associated to tongue ties. Although the lingual frenulum is a midline structure, it often affects one side more than the other. This can be felt by palpating the frenulum and how it anchors the tongue to the floor of the mouth. The problems described are not a complete list nor does it mean all of these areas are always affected. Lingual frenulums have much variability and can therefore produce different problems in different people.

Evaluation:

Sternum: Place a hand over the sternum and gently “spring” over the sternum. A sternum that does not spring well is positive. In addition, any areas of the sternum that feel dense or harder may be a result of a tongue tie.

Anterior Neck / Sternocleidomastoids: Gently spring over the lateral areas of anterior neck. Lack of pliability and tenderness may be associated with a tongue tie. In addition, gently squeeze the sternocleidomastoids bilaterally throughout. Tenderness and hypertonicity may indicate a tongue tie. The side that feels most dysfunctional is usually associated with the side of the tongue most inhibited by the tongue tie.

Posterior Upper Cervicals: Palpate the OA for range of motion. In addition sweep you fingers left to right lateral to the midline feeling for hypertonicity and tenderness.

Hyoid / Trachea: Translate the hyoid bone side to side. Hyoid should glide freely left to right. Any muscle tension may indicate a tongue tie. The position of the hyoid is also important. A tongue tie may pull the hyoid superiorly. Translate the trachea side to side to the end feel. The side most inhibited by the frenulum will have diminished translation away from it.

Supra Hyoid Area: Palpate the muscles using side to side motions perpendicular to the muscle bellies under the mandible including the digastric muscles. The muscles should feel soft and pliable. Hypertonicity may be associated with a tongue tie. There is not often tenderness felt here.

Floor of Mouth / Tongue: With an index finger, gently palpate the floor of the mouth looking for hypertonicity. Then look for tension at the base of the tongue lifting it up towards the roof of the mouth. The floor of the mouth should not be pulled up when the tongue is lifted towards the roof of the mouth. I have noted that the right side is more often affected. Also pinch the tongue and roll your fingertips looking for any knots. Be gentle as this area can be very sensitive and will be more so based on the severity of the tongue tie. Compare sides for hypertonicity and tenderness and correlate with your other findings.

At this point, evaluate the tongue tie by having the patient put the tip of the tongue to the roof of the mouth and open their mouth as much as possible. Sweep your index back and forth perpendicular to the frenulum. If it feels like you are strumming a guitar string, that is a positive result for a tongue tie.

Masseters / Buccinators: Place your fingertips over the muscle belly of the masseter muscles and glide side to side perpendicular to the muscle fibers. Note hypertonicity and tenderness here. Next do the same on the cheek over the teeth looking for hypertonicity and tenderness.

Other areas where some have felt relief are in the arms, forearms, thoracic spine, lumbar spine, sacrum, pelvis, and psoas muscles to name a few. Although I am just starting to learn about this, some of the patients who are good candidates are reporting dramatic relief. By placing so much tension on the throat and esophagus, could a tongue tie produce a hiatal hernia? I have no evidence but it seems strongly possible from what I have been seeing.

How Does A Frenectomy Fit With Osteopathic Principles?

Osteopathic principles are about structure and function and the body functioning as a unit.  Treatments are aimed at restoring anatomy as much as possible to the ideal perfect. Understanding normal embryologic development, the frenulum is a structure that is meant to regress and not inhibit the normal function of the tongue. Therefore, the frenectomy is about completing the process that nature started to free the tongue so it may function optimally. This allows the body to function more optimally.

After evaluating the above structures, treat nothing but the tongue. Use osteopathic principles to treat the tongue and reassess to see how all those areas have changed or not. The changes are generally minimal compared to having a frenectomy because the tethered tongue cannot be overcome from my experience. Realize that the lingual frenulum will prevent permanent changes from taking place. Have the patient consider a laser frenectomy if they are good candidates. Laser frenectomies have shorter healing times and do not require stitches. As long as it is done well and completely, this can provide the most complete and long-lasting relief. After the frenectomy, re-evaluate how the areas above have changed from before to after. Once healed, recheck the frenulum to see if it has been completely corrected and does not need a revision.