Dr Rodney:
I had a 4 mo old F with this problem today. She had an indentation of the tip of the tongue and a tight frenulum. I ended up refering her to ENT.
Do you guys perform frenotomies at the office?
I never have done one. I found this at the AAFP journal. http://www.aafp.org/afp/990115ap/conference.html
If you do so, what is the room setting (instruments) to do it?
Reply Medicos J club-(wmr):
Frenulotomy has been performed rarely in the Medicos offices, but probably there is no scientific reason to support it. Mothers say that the "tongue tied" infant has difficulty feeding, but there has never been any growth chart data to confirm this. Your case report suggests that the infant was failing to gain weight.
Snip, snip and it is over. Never seen one bleed, but we have done maybe five in the last ten years. Good luck if you hit one of the major veins down there on the base of the mouth or tongue. You will need to have your gauze, needle holder, and suture(vicryl 4-0 on FS-1 needle) ready to go. Electrosurgery and cryo will not help here.
Otherwise curved Metzenbaum or Mayo scissors are the best choice, but suture scissors are more commonly used because most family physician's do not stock Metzenbaums and Mayos in the office. Keeping the surgical field stable with good exposure is always a real treat in a 4-12 month old infant's mouth.
I have not seen one case with a clear indication. Usually our physicians have caved in to the mother's anxiety and the fact that the mobility of the tongue seems restricted by a tight frenulum. I have reviewed two articles on this topic in the last thirty years, and both were rejected. The reference you cited was a case report, but not a peer reviewed publication in the scientific literature.
Other experiences and comments would be appreciated.
With best wishes for a Joyous New Year,
Wm MacMillan Rodney MD
Clinical Professor of Family Medicine
Adjunct Professor Surgery/Emergency Medicine
Meharry/Vanderbilt School of Medicine
Medicos para la Familia
Memphis, Nashville and rural Tn.
www.psot.com
Jairo:
I have one case several years ago in the hospital. Nurse already told the mother "the Plastic surgeon is the one who take cares of this". When I asked about you said that he does it "just the same as Bill said"..................
Also add "No clear indication but you will not convince the mother" :-). If you do procedures, this will be very simple: if I'll have one today, I'll do it with the "caut-coag" of my LEEP machine, with the straight small electrode tip.
The "maestro Bill" approves? :-)
Eduardo Scholcoff Md
Rockford, IL
Used to do them all at StoneCrest - probably a dozen or more in the 4 years I was there. Never had a problem. Neonatal nurses referred them all to me until a couple of Med/Peds (Perkins and McCollum - you know him, Bill) yelled at the nurses and said only ENTs were qualified to do them. They then went to the CEO and I was made to quit under threat of peer review. Still did them in the office though.
So - a bit of gelatinous lidocaine 2% on a q-tip around the frenulum for 3 or 4 minutes (till you get set-up). Then a straight hemostat to crush the bit you want to cut, followed by a quick snip with iris scissors and it's done.
Omar
__
Omar L. Hamada, MD
Omar: I did not think of the thin hemostat. Good idea !!!
Eduardo.
Hi all…The ENT’s do all of their frenotomies in the OR here. So, the pediatricians and lactation consultants send them all to me. I turn a few away but do about 10-12 a year. Some are maternal anxiety but I’d say half of the cases make a definite difference in feeding. Others will have an improved speech pattern. I’ve done them up to 5-6 years of age…all in the office. A little more of a challenge when they have teeth. One little guy couldn’t lick an ice cream cone. He came back an hour later with a cone, asked to see me, and proceeded to lick it big time….grinning the entire time. “Priceless.” Meet Rodney’s criteria? Maybe not, but met mine! Also have done several sent by speech pathologists. Bottom line, it makes a difference most of the time. In one case of a three week old, I told the family I really doubted it would help. I would never have sent the kid to the OR, but it’s so easy to do in the office, and the lactation consultant suggested it, so, I did it. Within 24 hours the kid was breast feeding without difficulty. I know, case report. Means nothing. Okay. But, it works.
Look at the chapter in our book. Gary Newkirk wrote it. I had never seen one done but did one after reading the chapter.
Put some Cetacaine on a Q-tip. Apply it to both sides of the frenulum for a few seconds. They hate the taste even though it smells good. Don’t spray into the mouth… Too much gets in. Use good tissue scissors…I use the 5” Metzenbaum’s. Snip through the thin membrane. I have never seen a significant bleed although most will have a little bleeding. I allow the mother’s to nurse after 10 minutes. Child can go home when bleeding stops. For older kids with teeth, some will need sedation. Put a rolled up 4x4 in the mouth to prevent them from biting on your finger or the instruments.
For what it’s worth. YOU can do it…don’t send them to an ENT.
Jack Pfenninger
I do them in the hospital. You can bovie the bleeders and have full control over your surgical field.That being said, an office approach is very practical. However Bill's point regarding performing this procedure on a "moving target" coupled with a concerned parent who may end up being an assistant may deter an optimal setting. Our ENT's do them in the hospital.
Thomas A Kintanar
Index--tongue tie surgery, frenulotomy
Comments