Tongue-tie is an abnormality present from birth in which the membrane linking the tongue to the floor of the mouth (lingual frenulum) is too short. This prevents the tongue from protruding past the lower gums. Tongue-tie can occur to varying degrees, from minor shortening to complete fusion of the tongue to the floor of mouth. Sometimes patients with tongue-tie may have other abnormalities of the mouth such as a high arched palate or recessed chin. Tongue-tie is usually an isolated finding in otherwise normal infants.  Up to 5% of all babies have some form of tongue-tie. 

Tongue-tie is usually diagnosed during a routine baby exam either in the hospital or the pediatrician’s office. The most common symptom of tongue-tie in infants is difficulty with breast-feeding due to problems latching on to the nipple. As the child grows older, speech difficulties may develop.  Children with tongue-tie may have problems articulating of the sounds requiring elevation of the tongue, such as /l/ and /th/. A short frenulum may inhibit normal swallowing by preventing the tongue from coming into contact with the roof of the mouth. This may eventually lead to a protruding lower jaw due to repeated efforts to thrust the tongue forward while swallowing. These repetitive efforts may also cause the lower incisor teeth to move forward. Older children may experience social stigma due to a “forked-tongue” appearance. Certain social experiences, such as licking an ice cream cone or kissing may be difficult. 

Tongue-tie is diagnosed by physical exam. The physician evaluates the patient’s ability to protrude the tongue beyond the lower dental ridge. During protrusion, the tip of the tongue may become grooved and heart-shaped as the short frenulum pulls against the midline. 

Two schools of thought exist regarding treating infants and children with tongue-tie. The first is a “wait and see” approach.  It is possible that compensatory behaviors may allow children to develop normal speech and swallowing over time without treatment, thus avoiding surgery.

 

Another approach is to perform surgery (frenulectomy) at the time of diagnosis. Surgery may avoid speech problems that may develop and become more difficult to correct as the child grows older. Surgery may also avoid the other social and cosmetic effects of tongue-tie may persist, even with normal speech. Frenulectomy is usually a simple procedure, lasting no more than a few minutes. In the newborn, this can be done in the office without sedation using local anesthetic. Older children will usually require a general anesthetic. Recovery is usually rapid, with resumption of breast-feeding or liquid diet immediately after surgery.

 

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Branchial Cleft Cysts are epithelial (skin) lined cavities filled with mucous that form a mass along the side of the neck. These are congenital (abnormality during fetal development) cysts, resulting from a failure of gill-like embryonic structures (branchial arches) to disappear during maturation of the fetus, as they normally should. This results in a persistent pouch, which later can fill with fluid. Although the cyst is present at birth, it may not present until years later. 

Branchial cleft cysts typically appear between childhood and young adulthood as a slow-growing, painless mass on the side of the neck. Infection of the cyst causing an abscess may be the presenting complaint. Depending on the size, it may cause trouble swallowing and shortness of breath. Two percent may be bilateral.

 

The four types of branchial cleft cysts are named after the branchial arches that they arise from -- first, second, third, and fourth. The first branchial cleft cyst has two types: type I and type II. Type I first branchial cleft cysts are rare, and represent a duplication of the external ear canal. These can be near the facial nerve, which is responsible for movement of the face. A type II first branchial cleft cyst is more common and can present as a mass just below the angle of the jaw. The cyst can have a persistent tubular structure through the parotid gland (the large salivary gland located on the face) with close association to the facial nerve. The tubular structure may end at or in the external ear canal. Second branchial cleft cysts are the most common and may present as a painless mass under the jaw line but in front of or under the large neck muscle know as the sternocleidomastoid muscle. Third and fourth anomalies are rare. The third may present as a mass in the lower lateral neck while the fourth may drain into the throat.

 

Branchial cleft cysts create problems as they enlarge or become infected. Abscess formation often leads to emergency incision and drainage to control infection. Consequently, this can lead to additional scarring, making eventual definitive surgery more challenging. Dissection of the deep tubular remnants of these cysts from around the facial nerve and other nerve and vascular structures of the neck is important to prevent their recurrence.