Three case reports of infants with ankyloglossia affecting breastfeeding

Ankyloglossia is a congenital anomaly which may reduce or restrict the tongue tip mobility. The restricted mobility is caused by an unusual short, thick lingual frenum. This condition may cause various problems in infants including breastfeeding in the new-borns. This case report describes 3 cases of ankyloglossia affecting breastfeeding and highlights the experiences of the mothers and their difficulties in breastfeeding babies with it. Comprehensive feeding examination was accomplished, the primary cause of feeding issues was identified, and frenotomy intervention was provided. Post frenotomy, infants were able to breastfeed easily and this was beneficial in continuation of breastfeeding and pain reduction in mothers.

Cleft Palate and Congenital Synechiae Syndrome: A Case Report

Objective

A 1-day-old baby girl with a cleft of the secondary palate and a soft tissue band connecting the upper and lower jaws and preventing mouth opening was referred to the cleft lip and palate team by her pediatrician. This case represents a further example of an interesting but rare anomaly known as congenital alveolar synechia syndrome that requires early management to allow normal feeding and oral development.

Isolated congenital maxillomandibular synechiae

INTRODUCTION

Congenital maxillomandibular syngnathia, or fusion of the jaws, is a rare condition that has a broad spectrum of presentations. The restricted mouth opening can lead to issues with feeding, swallowing, and respiration resulting in failure to thrive and temporomandibular joint ankylosis. Early recognition and treatment is necessary for proper growth and development.

CASE REPORT

We report a 1-day-old male with isolated bilateral soft tissue alveolar fibrous bands. He presented with difficulty feeding secondary to trismus. No bony or muscular involvement in the synechiae was noted and the remainder of the physical exam was unremarkable. The bilateral alveolar synechiae were divided under local anesthesia using surgical scissors. The patient immediately showed improvement in mouth opening and had resolution of his feeding problems. He is now gaining weight and developing appropriately.

DISCUSSION

The accompanying review of the literature demonstrates only 11 cases worldwide of isolated maxillomandibular fusion. Depending upon the composition of the synechiae, simple surgical division under local anesthesia can be curative.

Clinical inquiry: does frenotomy help infants with tongue-tie overcome breastfeeding difficulties?

No evidence exists for improved latching after frenotomy, and evidence concerning improvements in maternal comfort is conflicting. At best, frenotomy improves maternal nipple pain by 10% and maternal subjective sense of improvement over the short term (0 to 2 weeks).

Congenital alveolar synechiae with cleft palate

Congential maxillomandibular fusion or jaw adhesions is a rare entity. It is often associated with other congenital anomalies like cleft palate and is characterized by restricted mouth opening. This unusual presentation of congenital alveolar synechiae is highlighted in a 15 days old baby boy. Under inhalational anaesthesia his fibrocartilagenous adhesions were excised and endotracheal tube was then placed. Good recovery without any residual scars or adhesions and a 25 mm mouth opening was achieved.

Ankyloglossia its impact breastfeeding

This article contrasts two very different experiences of one mother breastfeeding her two sons to demonstrate the potential impact of ankyloglossia on breastfeeding. When too restrictive, ankyloglossia, also known as tongue-tie, can cause the newborn to ineffectively suckle at the breast. Breastfeeding difficulties can occur, such as long feedings or damaged nipples. When nurses, lactation consultants and other providers recognize this situation, they can refer women for further care and treatment, which can ultimately lead to breastfeeding success.

Office frenotomy for neonates: resolving dysphagia, parental satisfaction and cost-effectiveness

OBJECTIVE

To determine parental satisfaction and cost-effectiveness of having a frenotomy performed in the office setting versus in the operating room under general anesthesia.

METHOD

After obtaining IRB approval at The Children's Hospital of Philadelphia (CHOP), we performed a retrospective chart review of patients having a frenotomy in the office between 2003-2008. 55 patients met the criteria and 25 were consented and their parents interviewed.

CONCLUSION

All participants reported an improvement in feeding within one day and up to two weeks following the procedure. Parents also reported being somewhat satisfied to very satisfied with having the frenotomy performed in the office versus under general anesthesia. There were no complications reported. Performing the frenotomy in the office provided patients with satisfaction as well as cost savings. The surgical fee for a frenotomy in the office is $850 and is the same as if the procedure is performed in the operating room. Performing a frenotomy under general anesthesia includes extra cost which consists of an anesthesia fee of $500-$900 and hospital charges ranging from $500-$8,000. Performing the frenotomy in the office on our 25 patients has resulted in a cost savings of more than $240,000 and the avoidance of general anesthesia in the first few weeks of life. Office frenotomy should be considered in children with ankyloglossia who present with difficulty nursing in the first week of life.

The effect of tongue-tie division on breastfeeding and speech articulation: a systematic review

OBJECTIVE

To systematically review the outcomes of tongue-tie division procedures in patients with ankyloglossia with the goal of (1) deriving clinically oriented insights into the effect of tongue-tie division procedures and (2) identifying needs in knowledge to stimulate further research.

DATA SOURCES

Medline, EMBASE, and Cochrane databases were searched without any limitations, for studies published between 1966 and June 2012.

REVIEW METHODS

Studies were included (level 4 evidence or above) if subjects of any age had ankyloglossia and underwent tongue-tie release. Outcome measures of interest were any subjective or objective measures of breastfeeding and speech outcomes, or reports of adverse events.

RESULTS

In all, 378 abstracts were generated from the literature searches; 20 studies met the criteria for data extraction and analysis. Of those, 15 studies were observational and 5 were randomized controlled trials. Tongue-tie division provided objective improvements in the following: LATCH scores (3 studies); SF-MPQ index (2 studies); IBFAT (1 study); milk production and feeding characteristics (3 studies); and infant weight gain (1 study). Subjective improvements were also noted in maternal perception of breastfeeding (14 studies) and maternal pain scores (4 studies). No definitive improvements in speech function were reported. The only significant adverse events were recurrent tongue-ties that required repeat procedures.

CONCLUSION

Ankyloglossia is a well-tolerated procedure that provides objective and subjective benefits in breastfeeding; however, there was a limited number of studies available with quality evidence. There are no significant data to suggest a causative association between ankyloglossia and speech articulation problems. Aspects of ankyloglossia that would benefit from further research are described, and recommendations for tongue-tie release candidacy criteria are provided.

Reconstruction of intraoral defects with superior labial artery musculo-mucosal flap: a preliminary clinical study

OBJECTIVES

In this article, we present the use of the superior labial artery musculo-mucosal (SLAMM) flap for intraoral reconstruction.

PATIENTS AND METHODS

The study included five patients (2 females, 3 males; mean age 36 years; range 11 to 56 years) who consulted at our clinic between October 2008 and January 2010. Five oral defects were reconstructed with the SLAMM flap. Three patients underwent reconstruction with SLAMM flap following oncologic resection. The other two patients had traumatic defects in the oral cavity which necessitated flap application. First, the distal end of the flap was incised and the superior labial artery was identified after dissection. After ligation of the artery, the mucosa, submucosa and the cuff of orbicularis oris muscle were elevated. The dissection was extended laterally and anteriorly, depending on the necessary flap size.

RESULTS

None of the patients had partial or total flap necrosis. During the follow-up period, contracture developed in only one patient. Successful reconstruction was observed in all patients.

CONCLUSION

The superior labial artery musculo-mucosal flap is a simple and feasible technique which can be used for reconstruction of intraoral defects.

Transsellar transsphenoidal rhino-oral encephalocele

Transsphenoidal encephaloceles are rare and the transsellar variety is the least common. We present a 1-year-old male patient with transsellar transsphenoidal encephalocele which herniated into the oral cavity through the congenital split palate. The patient was operated on using a combined transcranial and transpalatal approach without mortality or permanent morbidity. Clinical findings, imaging reviews, surgical repair techniques and postoperative morbidity are discussed with the relevant literature. We conclude that repair of a transsphenoidal encephalocele should be coordinated between a team of neurosurgeons and otorhinolaryngologists. Our surgical outcome supports a transcranial approach for the treatment of these difficult lesions, with transpalatal dissection and exposure.

Hemodynamic differences between propofol-remifentanil and sevoflurane anesthesia for repair of cleft lip and palate in infants

BACKGROUND

Propofol-remifentanil anesthesia is widely used in adults but few studies are available in infants. We aimed at comparing the hemodynamic effects of propofol-remifentanil vs sevoflurane-fentanyl anesthesia. In addition, we sought to investigate recovery and whether remifentanil induced acute opioid tolerance.

METHODS

In total, 39 infants 4-6 months old were prospectively enrolled and randomized to receive either a combination of remifentanil and propofol (n = 17) or a sevoflurane-fentanyl anesthesia (n = 22) for surgical repair of cleft lip and palate. In both groups, sevoflurane was used for induction of anesthesia and fentanyl was administered before tracheal extubation. Mean arterial blood pressure and heart rate were recorded every 5 min after induction. We also recorded time from termination of surgery to tracheal extubation, postoperative behavior and the need for analgesia for the first 24 h after surgery. Postoperative observations were blinded.

RESULTS

In the remifentanil-propofol group, the mean arterial blood pressure was higher [58 (51-65) vs 51 (45-55), P = 0.02] and the mean heart rate was lower [111 (108-113) vs 128 (122-143), P < 0.0001]. There were no differences in recovery time or behavior after surgery. In the remifentanil group, a median fentanyl dose of 4 microg x kg(-1) was required to insure a smooth recovery, but there was no difference in morphine consumption during the first 24 h after surgery.

CONCLUSIONS

A high-dose remifentanil-propofol infusion was associated with a higher blood pressure and lower heart rate than sevoflurane-fentanyl anesthesia in infants. Postoperative morphine consumption, recovery time and quality were similar.

Isolated and Syndromic Syngnathism

We present 2 contrasting cases of congenital interalveolar synechiae. The first occurred in the setting of Van der Woude syndrome and was associated with a cleft palate. In the second case, it was an isolated abnormality and there was no contributory family history or syndromic associations. We review the literature on interalveolar synechiae and discuss its management, implications, and genetics. Interalveolar synechiae is a condition with an excellent prognosis; its presence necessitates careful examination for associated abnormalities and syndromes.

Lingual cyst lined by squamous epithelium

Lingual choristomas or foregut duplication cysts are infrequently reported congenital anomalies that typically present in the perinatal period, and can cause respiratory or feeding problems. These cysts are lined by epithelial cells characteristic of the upper aerodigestive tract. We describe two children who presented shortly after birth with lingual cysts lined with squamous epithelium and foci of respiratory epithelium. Unlike previously reported lingual choristomas, these cysts did not contain gastrointestinal epithelium. In both these cases, the lingual cysts were successfully excised via a transoral approach. This article will discuss the histological findings in these two cases, the differential diagnosis and attempt to classify these lesions in the context of existing terminology.

Trismus-pseudocamptodactyly syndrome (Hecht-Beals’ syndrome): case report and literature review

The trismus-pseudocamptodactyly syndrome (TPS) is a rare condition inherited as an autosomal dominant trait with variable expressivity. Clinically the syndrome is characterized by decreased ability to open the mouth and curvature of the fingers at the level of interphalangic joints while attempting dorsiflexion of the wrist (pseudocamptodactyly). A 6-year-old male patient from Guatemala with this syndrome is presented. The surgical treatment consisted of bilateral coronoid amputation to resolve the pseudotrismus. The procedure was successful and the patient achieved normal function.

[Use of Z plasty for ankyloglossia: report of 38 cases]

Z plasty was used in 38 children (male 22, female 16) aged from 0.5 to 6 years with ankyloglossia. There were no infection, dehiscence and tongue adhesion. The wound healed more quickly, and tongue protrusion improved from 13.5 mm preoperatively to 24.6 mm postoperatively. Similarly, tongue elevation improved from 4.8 to 20.6 mm.

Congenital alveolar synechiae — a case report

Congenital alveolar synechiae is rarely seen as an isolated disease. It is generally observed together with various syndromes such as Van der Woude and cleft palate lateral alveolar synechiae syndrome, and is concomitant with other anomalies in the maxillofacial or other regions of the body. Prior to this case report , eight cases of isolated congenital alveolar synechiae have been reported. This paper reports a case of isolated congenital alveolar synechiae in a 10-month-old baby girl. The report concentrates on the clinical features of isolated congenital alveolar synechiae, the likely aetiological causes and the treatment.

Atypical tongue-tie due to congenital tongue-palate fusion

We are presenting a case report of a male neonate brought in an emergency room with feeding inability and signs of respiratory difficulty due to oral passage blockade - a developmental anomaly caused by tongue-palate fusion. Surgical correction instantly relieved respiratory distress and established the normal oral feeding mechanism.

Anaesthetic and airway management in a child with Hanhart's syndrome

Hanhart's syndrome (oromandibular-limb hypogenesis syndrome) is a rare disease characterized by hypoglossia/aglossia, various distal limb defects and micrognathia. Difficult airway due to micrognathia may complicate anaesthetic management in this syndrome. We describe the anaesthetic management of a child with Hanhart's syndrome undergoing plastic reconstructive surgery.

Popliteal pterygium syndrome with syngnathia

We report a case of perioperative management of a neonate with popliteal pterygium syndrome complicated by interalveolar syngnathia. Syngnathia were excised in the operating room without a major anaesthetic. We discuss our management of this case, as well as other possible strategies to secure the airway in neonates with syngnathia. We also reviewed the literature regarding airway management in presence of syngnathia in similar situations.

[Orthognathic surgery. Study of nerve injuries]

The correction of oral and maxillo-facial mal-formations causes lesions to sensitive nerves due to the invasive and traumatic surgery techniques required. Generally neuro-sensory and cutaneous-mucosal defects are reversible, with full recovery within 6-12 months. In a follow-up study (2 and 8 years) we found altered tactile and pain sensitivity in 43% of patients at subjective evaluation, with objective alteration in 17% of the group. Dental sensitivity evaluated by a pulp test showed an increase in for all teeth tested; values were higher for superior than for inferior teeth. Despite the increased pulp sensitivity threshold, due to the surgical damage, no signs of pulp disease were detected. Quality of life was not affected even by such a high subjective change in sensitivity. We therefore believe that patients undergoing orthognathic surgery must be fully informed; they must be made to understand the risks involved, and that damage may occur to sensitive nerves following surgery. All surgeons, including those with experience in the field, should continually seek to improve their skill and learn new techniques, in order to reduce complications to a minimum.

Endoscopic release of intraoral synechiae in popliteal pterygium syndrome

An infant with typical popliteal pterygium syndrome had intraoral fibrous bands binding the maxillary and mandibular alveolar ridges. This resulted in dramatically restricted mouth opening. These bands were divided surgically with endoscopic assistance.

Cleft palate congenital alveolar synechiae syndrome: case reports and review

Five cases of cleft palate with interalveolar synechiae have been previously reported. This is the first report of siblings with this condition, and suggests a genetic aetiology. These patients present with an inability to open the mouth adequately. Initial management is directed towards dividing the intraoral adhesions, which may cause significant problems of airway management. Significantly, the intraoral adhesions resolved spontaneously in one of our patients. This, to our knowledge, has not been reported before.

Midline cleft. Treatment of the bifid nose

BACKGROUND

Midline facial clefts are rare deformities with a wide range of clinical findings from a simple midline vermillion notch to major skeletal malformations, including orbital hypertelorism. The bifid nose is a relatively uncommon malformation that is frequently associated with hypertelorbitism and midline clefts of the lip. The presentation of a bifid nose ranges from a minimally noticeable midline nasal tip central groove to a complete clefting of the osteocartilaginous framework, resulting in 2 complete half noses. We describe our experience with 2 patients with midface clefts who presented with bifid noses and a variety of other congenital abnormalities. The anatomy, extensive treatment, and complications of the bifid nose are discussed.

DESIGN

Retrospective case review and literature review.

RESULTS

Successful creation of an aesthetic nasal contour and normal nasal function was achieved without complication via extensive skin, bony, and cartilaginous resection.

CONCLUSIONS

The bifid nose challenges the rhinoplasty surgeon. A successful outcome is dependent on a thorough understanding of the bifid nasal anatomy, proper patient evaluation, careful preoperative planning, and meticulous surgical technique.

Oral-acral syndrome and its correction using maxillary bone distraction osteogenesis

A rare congenital defect of the anterior part of the maxillary bone and absence of teeth is presented. We describe a patient with oral-acral syndrome and the treatment of the maxillary retrusion using distraction osteogenesis.

Clinical audit activities in surgery

Large scale audits can attract the participation of the majority of surgeons. They require careful planning and must be supported by an infrastructure to co-ordinate the running of the audit and to ensure accuracy of data. Audits can be important sources of information for the development of evidence-based guidelines, and this approach is a good strategy for bringing the lessons obtained from the audit to the profession. Audits that work closely with professional bodies produce the best results and are enhanced by patient representation. Risk stratification is an essential component of comparative studies and should be incorporated to ensure that multi-centre audits are systematic.

[Airway difficulty associated with multiple teratisms of the oral cavity in a newborn infant]

A 13-day-old infant with multiple teratisms of the oral cavity was scheduled for resection of the epignathus. Her oral cavity was occupied by large epignathus, submandibular tumor, congenital bifid tongue and cleft palate, but she had no other congenital abnormalities. We anticipated that an endotracheal intubation would be difficult because of the large size of the tumor in relation to the oral cavity. Initially, awake intubation using a standard laryngoscope was attempted. Although a large elastic epignathus did not interrupt the insertion of the curved laryngoscope blade, the hard submandibular tumors protruded from the submaxillary ramport interfered with mid-line management of the laryngoscope. After several attempts of intubation, a better exposure was obtained and she was successfully intubated using a stylet under deep sedation. We recognized that a careful observation of anatomical abnormalities in the oral cavity is important to keep airway in an infant with multiple abnormalities of the oral cavity.

Congenital bilateral zygomatico-mandibular fusion with mandibular hypoplasia

We report a very rare case of congenital bilateral zygomatico-mandibular fusion with mandibular hypoplasia. Soon after birth, the patient underwent tracheotomy because of upper airway obstruction. At the age of one and a half years, reconstruction of the temporomandibular joint and lengthening of the ramus with a costochondral graft were performed. Only a few cases of congenital bony syngnathia revealed in this case have been described in the literature.

[Diagnostic imaging for therapy planning of orofacial malformations]

Two-dimensional conventional X-rays and computer tomographic imaging systems contribute to the diagnosis and surgical planning of patients with orofacial malformations. The ability to reformat CT scans into three-dimensional osseous and soft tissue surface images has a significant impact on the diagnosis and management of orofacial malformations. Cephalometric evaluation with teleradiography provides precise insight into both the skeletal structures and the soft parts, enabling the radiologist to assess the relationship among the different parts in a given subject, at any given time and in relation to the normal.