Complications of Tethered Oral Tissue in Preterm Infants

Significance Statement

The management of tethered oral tissue in infants can vary among providers. Some clinicians advise early surgical intervention to prevent abnormal development. Others recommend utilizing muscle training strategies to improve outcomes. However, preterm infants may require earlier and invasive surgical consideration as they possess fewer compensatory resources than term babies for proper growth and development.

Premature infants are at a baseline disadvantage with resources to ensure proper growth and development. In this case series, 9 infants (6 of which were preterm) presented with symptoms of dysphagia and were referred for video-fluoroscopic swallow study at Norton Women’s and Children’s Hospital in Louisville, Kentucky. The average age of the babies was 5.7 months of age, and based on clinical observations during the study, each was recommended for formal evaluation of tethered oral tissue (TOT). All preterm infants demonstrated penetration or aspiration on the 8-point Penetration/Aspiration Scale. ¹ This suggests that preterm infants may be at greater risk for complications related to dysphagia and may require prompt referral and evaluation for surgery.

TOT occurs when the lingual frenulum, labial frenulum, and/or the buccal frenulum are congenitally tight resulting in a spectrum of restricted movement that can influence feeding skill and swallow safety. ² The stages of swallowing are divided into 3 distinct phases—oral, pharyngeal, and esophageal phases. ³ Interruption or difficulty at any of these stages can present with dysphagia leading to penetration or aspiration. Penetration of a bolus occurs when the bolus enters the airway above the true vocal cords during the pharyngeal phase of swallowing. ⁴ Aspiration of a bolus also occurs during the pharyngeal phase of swallowing; however, the bolus passes below the true vocal cords. ⁴ These distressing experiences can inadvertently interfere with normal neurocognitive development in infants, leading to feeding aversion and subsequently poor weight gain.

The management of TOT can range in degree of invasiveness. If surgical intervention is indicated, then infants can undergo frenotomy, frenectomy, or frenuloplasty. ⁵ Frenotomy, also referred to as frenulotomy, is commonly performed in the newborn age using scissors or a laser to create a simple incision of the frenulum. ⁶ Frenectomy is a procedure that involves the complete removal of the lingual frenulum. Frenuloplasty is a more complex surgery that is conducted once the infant is at least a year old in which there is some form of tissue rearrangement. ⁷ In older infants and children, a nonsurgical technique called myofunctional therapy (MFT) has emerged as an effective treatment for TOT in conjunction with surgical management. ⁸ MFT utilizes massage, stretches, and exercises to improve function and efficiency. In infants, this modality can help stimulate and train the sucking reflex to promote breast or bottle feeding.

Overall, the algorithms used to drive clinical decision-making about which intervention is best for individual infants remain unclear. Experts are still exploring which method or combination of methods are most efficient and effective. The findings of our case series launched a larger study among preterm infants, which is currently underway (Figure 1).

Figure 1.

(A) Photo depiction of an 11-month-old infant at the time of surgery who presented with lingual TOT. The infant struggled with latching onto a breast, tolerating a bottle, choking on saliva and milk at all times of the day, and gaining little weight for several months. Infant birth weight was 7.8 pounds. Infant weight at 11 months was 14.7 pounds. (B) Photo depiction of infant after laser excision of lingual tethered tissue. TOT, tethered oral tissue.