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April 01, 2015

Tongue Eating Parasite That Later Becomes a Tongue Prosthetic!


The animal world is truly weird... Not sure if humans would accept this form of treatment as an option if tongue reconstruction required.

March 27, 2015

Professional Singers' Vocal Issues after Thyroid Surgery

A study out of Harvard presented the typical vocal outcomes after thyroid surgery in professional singers. No other study has ever looked at this special patient population who are the Olympic athletes of the voice. Non-singers may be completely unaware of any subtle issues with the voice after thyroid surgery. However, for professional singers, even the slightest vocal quiver could be professionally unacceptable.

The main issue with thyroid surgery as it pertains to the voice is that the nerve that controls vocal cord movement goes right thru the thyroid gland. With thyroid surgery, the risk is injury to this nerve which would than affect the voice. Worst case, the nerve could get accidentally cut resulting in permanent vocal cord paralysis.

This study looked at 27 professional singers who underwent thyroid surgery, 60% due to cancer. What they found was return to performance rate was 100%, mean time to performance after surgery was 2.26 months (± 1.61). All three vocal instrument mean scores, pre-op vs. post-op, were unchanged:

• Voice Handicap Index (VHI): 4.15 (± 5.22) vs 4.04 (± 3.85), p = 0.9301
• Singing Voice Handicap Index (SVHI): 11.26 (± 14.41) vs 12.07 (± 13.09), p = 0.8297
• Evaluation of Ability to Sing Easily (EASE): 6.19 (± 9.19) vs 6.00 (± 7.72), p = 0.9348

The vocal parameters most affected from surgery until first performances were vocal fatigue (89%), high range (89%), pitch control and modulation (74%) and strength (81%). Final mean intraoperative EMG amplitude was within normal limits for intraoperative stimulation and had no relationship with time to first professional performance (p = 0.7199).

Overall, the study concluded that
"neural monitored thyroidectomy, including for thyroid malignancy, in professional voice users is safe without any changes in three different voice/ singing instruments, with 100% return to performance." [link]
This information is extremely helpful when counseling professional singers and its possible impact on their voice afterwards.

Thyroidectomy in the Professional Singer-Neural Monitored Surgical Outcomes. Thyroid. 2015 Mar 19. [Epub ahead of print]

March 24, 2015

Atlanta Hawks Guard Kyle Korver Suffers Broken Nose

Image Source
LeBron James suffered a broken nose early last year. This time, it's Kyle Korver's turn when he suffered the same injury March 15, 2015 after taking an offensive foul from Ed Davis. He reported that this was not his first broken nose, but his third. [link]

Regardless of whether you are an NBA player or not, treatment of most nasal and even facial fractures do NOT require surgical repair.

However, in Mr. Korver's case, he did undergo a closed nasal reduction later that same week whereby the surgeon moved the broken nasal bone pieces back into straight alignment.

The key elements that lead towards a decision for facial and/or nasal fracture surgery are the following (not all-inclusive, but general pointers):

- Any functional deficit (i.e., inability to open and close the jaw)
- Change in occlusion (the way teeth come together).
- Double vision (blurry vision does not count).
- Cosmetic deformity due to nasal/facial fracture (bruising and swelling does not count).
- Nasal obstruction not due to swelling.

In any case, when a nose is broken, steps should be taken to further minimize trauma to the nose. For athletes, that usually means wearing a facial mask such that any hits to the face does not connect with the broken nose.

Although LeBron James had his facial mask custom made by Marvel and Kyle Korver had something similarly custom made, for us mere mortals, you can buy one on Amazon.

Kyle Korver Injury: Updates on Hawks Star's Broken Nose and Return.

World Voice Day 2015 Infographic


In celebration of World Voice Day 4/16/2015!

March 22, 2015

How Often Does Tongue Tie Release Improve Breastfeeding? What about Speech?

In the last blog article, we discussed the controversy around tongue tie release that exists from ancient to modern times. According to modern research, cautious support exists for tongue tie release regarding breastfeeding but not speech difficulties. So what did the research actually show?

Statistically, tongue tie release improves/resolves breastfeeding problems ~80% of the time within 4 weeks, often within 48 hours. The percentage is lower if birth defects are present. Summary of the data out there are as follows. Please note that case reports are NOT included given they are considered the lowest quality form of research.

Amir, et al (N=35)
  • 6 (17%) no difference
  • 29 (83%) improved breastfeeding (mean 26 weeks, range 12–46)
  • 18 (51%) better attachment to breast
  • 20 (57%) improved sucking
  • 9 (26%) less pain
  • 6 (17%) improved weight
  • 2 (6%) "other differences"
  • 3 (9%) not breastfeeding
Argiris, et al (N=46)
  • 32 (70%) immediate improvement in breastfeeding
  • 40 (87%) improvement in breastfeeding at 6 weeks
  • 36 (78%) improved latch
  • 19 (40%) reduced nipple pain
  • 30 (64%) improved suck
Berry, et al (N=57)
  • 21 of 27 (78%) in the study group had immediate improvement in breastfeeding
  • 14 of 30 (47%) in the control group had immediate improvement in breastfeeding
Griffiths, et al (N=215)
  • Immediate assessment
  • 123 (57%) improvement in breastfeeding; 92 (43%) no difference
  • At 24h post-treatment
  • 173 (80%) improved breastfeeding at 24h post-treatment; 40 (19%) unchanged;
  • 2 increased difficulties
Hogan, et al (N=57)
  • Study group (frenotomy, n = 28)
  • 27 (96%) improved (85% immediately and 15% within 48 h)
  • 1 remained on a nipple shield with continuous feeds
  • Control group (supportive, n = 29)
  • 1 (3%) improved
  • Frenotomy offered at 48 h (27/28 improved, 77% immediately and 19% within 48 h)
Khoo, et al (N=62)
  • Likert scale from 0 to 10 (0-no difficulty; 10-maximum difficulty)
  • Pre-treatment: 6.1 2.7
  • Post-treatment: 1.9 2.6
  • Lalakea, et al (N=6)
  • 100% reported subjective gains in at least 3 or 6 categories of mechanical tongue function
Lalakea, et al (N=6)
  • 100% reported subjective gaines in at least 3 or 6 categories of mechanical tongue function
Marmet, et al (N=29)
  • 71% reported completely improved breastfeeding (improved latch, suck, nipple soreness,
  • breast soreness, slow weight gain, milk supply)
  • 29% non-responders had ‘‘severe birth defects’’
Masaitis, et al (N=36)
  • 1 week post-treatment
  • 89% breastfeeding; 11% bottle feeding
  • 75% problem resolved completely; 19% partially; 6% no
  • 94% appropriate infant growth rate; 6% slow growth
  • 100% would choose frenotomy again
Miranda and Milroy (N=51)
  • Within 2 weeks of treatment
  • 63% improved breastfeeding
  • 89% improved latch
  • 100% improved nipple pain
  • 100% improved nipple cracking and bleeding
Steehler, et al (N=82)
  • Retrospective report (unspecified time between treatment and interview)
  • 80.4% thought frenotomy was beneficial (86% frenotomy done during first week;
  • 74.3% frenotomy done later; 82.9% continued to breastfeed long-term (mean 7.09 months)
Wallace, et al (N=10)
  • 40% immediate improvement
  • 30% improvement within 2 weeks
  • 30% no improvement
  • 60% breastfed for at least 4 months
What about speech? Here, the research is sparse and the quality of research not as good. It should also be noted that children with tongue tie will often have normal speech as alternative tongue positions can mimic the sounds that traditionally required the most tongue tip movement (/th/, /l/, /s/, and /z/).  For example, the /l/ and /th/ can be produced with the tongue tip pressed down instead of up towards the alveolar ridge (/l/), or protruding out (/th/). Similarly, /s/ and /z/ can also be produced effectively with the tongue tip down.

  • Study group (underwent frenotomy during infancy, n=8)
  • Comparison group (non-treated frenotomy during infancy, n=7)
  • Control group (no history of ankyloglossia, n=8)
  • Outcome measures utilized standardized articulation test assessed by two speech pathologists. Most articulation errors in the comparison group, followed by the study and then control groups, but no significant difference between the groups in articulation errors and speech intelligibility
Heller, et al (N=16)
  • Study group (underwent 4-flap z-frenuloplasty); Comparison group (underwent horizontal-to-vertical frenuloplasty)
  • Outcomes based on tongue measurements and articulation testing by two speech pathologists (10 months post-treatment)
  • Results showed greater gain in frenulum length and tongue protrusion for the study group and better articulation improvements in the study group (no statistical analysis)
Lalakea, et al (N=6)
  • 2 reported subjective improvement in speech
  • 4 did not report any change
Messner and Lalkea (N=15)
  • 4 had normal speech pre-treatment (no change post-treatment)
  • 11 had abnormal speech pre-treatment. Of these, 9 (82%) judged to have improvement; 2 had persistent articulation problems. However, parents reported improved subjective speech intelligibility
The effect of tongue-tie division on breastfeeding and speech articulation: a systematic review. Int J Pediatr Otorhinolaryngol. 2013 May;77(5):635-46. doi: 10.1016/j.ijporl.2013.03.008. Epub 2013 Mar 26.

Does frenotomy help infants with tongue-tie overcome breastfeeding difficulties? J Fam Pract. 2015 February;64(2):126-127.

Ankyloglossia: to clip or not to clip? That’s the question, The ASHA Leader (2005), December 27.

March 20, 2015

MYTH: Does Tongue Tie Cause Breastfeeding Difficulties and Speech Problems?

Although there is both objective and subjective evidence that tongue tie contributes to breastfeeding difficulties and speech problems, when it comes to quality evidence-based research, the data is a bit lacking. And because of this sparseness, tongue tie release is actually considered a controversial topic with both supporters and detractors (personally, I am a supporter of this procedure). Among the detractors, tongue tie release is considered unusual and unnecessary... even bizarre.

So what data is out there currently?

The Holy Bible contains a passage that loosely could be interpreted to suggest tongue tie release:
"And looking up to heaven, he sighed, and saith unto him, Ephphatha, that is, Be opened. And straightway his ears were opened and the string of his tongue was loosened, and he spoke plain." (Mark 7:34-35) [link]
Tongue tie release was considered controversial in ancient history with Aristotle (3rd century BC) and Paul of Aegina (7th century AD) being supportive, but Celus (1st century AD) and Galen (2nd century AD) arguing against. Even in the middle ages, the benefit of tongue tie release was controversial among midwives (who used their fingernail to cut the tongue tie) and surgeons (who used surgical instruments).

This controversy continues even into modern times. In the year 2000, in perhaps the largest survey of lactation consultants (n=350), speech language pathologists (n=400), ENTs (n=423), and pediatricians (n=425),
"69% of lactation consultants, but a minority of physician respondents, believe tongue-tie is frequently associated with feeding problems. 60% of ENTs, 50% of speech pathologists, but only 23% of pediatricians believe tongue-tie is at least sometimes associated with speech difficulties. 67% of ENTs versus 21% of pediatricians believe tongue-tie is at least sometimes associated with social/mechanical issues. Surgery is recommended at least sometimes for feeding, speech, and social/mechanical issues by 53, 74, and 69% of ENTs, respectively, but by only 21%, 29%, and 19% of pediatricians." [link]
In terms of actual evidence-based research, only 20 studies were identified in a pubmed literature search summarized in a meta-analysis published in 2013.
"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." (Abbreviations: IBFAT: infant breastfeeding assessment tool; LATCH: latch, audible swallowing, type of nipple, comfort, and hold; SF-MPQ: short-form McGill pain questionnaire.) [link]
The meta-analysis went on to conclude that:
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... [procedure should be performed only] in newborns with significant ankyloglossia and associated breastfeeding problems who have failed conservative management 

Just because quality data is lacking does not mean tongue tie release should not be performed. In fact,  definitive research may not be possible given bias would be nearly impossible to eliminate. Parents and doctors will have preconceived notions of the kinds of pathology tongue tie may cause and understandably, parents can't help but desire a certain course of action rather than put their child into a randomized research situation. Even the intervention itself cannot be blinded as it will be clear to all which child underwent a tongue tie release or not.

The only truly unbiased participant in any future research attempted is probably the innocent child himself who has no preconceived notions beyond signals the parents may send.

Alternatively, more objective testing may need to be utilized to determine effectiveness or not. For example, breastfeeding improvement based on ultrasound measurements can be further developed and used as an objective test.

In the end, it takes a considered evaluation by all who is caring for the infant and ultimately, the parents need to decide whether tongue tie release is worth pursuing or not. From a parental perspective, what may be the most frustrating part of tongue tie evaluation is the potentially radically divergent opinions that may be proffered by lactation consultants, pediatricians, speech language pathologist, and ENTs.

The effect of tongue-tie division on breastfeeding and speech articulation: a systematic review. Int J Pediatr Otorhinolaryngol. 2013 May;77(5):635-46. doi: 10.1016/j.ijporl.2013.03.008. Epub 2013 Mar 26.

Much Ado about Nothing: Two Millenia of Controversy on Tongue-Tie. Neonatology 2010;97:83–89

Ankyloglossia: controversies in management. Int J Pediatr Otorhinolaryngol 2000; 54: 123–131.

Frenulotomy for breastfeeding infants with ankyloglossia: effect on milk removal and sucking mechanism as imaged by ultrasound. Pediatrics. 2008 Jul;122(1):e188-94. doi: 10.1542/peds.2007-2553. Epub 2008 Jun 23.

Tongue movement and intra-oral vacuum in breastfeeding infants. Early Hum Dev. 2008 Jul;84(7):471-7. doi: 10.1016/j.earlhumdev.2007.12.008. Epub 2008 Feb 11.

Does frenotomy help infants with tongue-tie overcome breastfeeding difficulties? J Fam Pract. 2015 February;64(2):126-127.

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