Considerations when diagnosing

Sandra, I am an SLP in the Tampa Bay area.  I recently evaluated a 13 year old who cannot produce “r”.  He received therapy in elementary school.  I cannot make a definitive determination if the frenum is shortened.  I have seen children with ankyloglossia in the past and it was quite evident.  He seems to be on the borderline.  He can make the isolated tongue movements but cannot produce a good “r”.  I have not had a child experience this much difficulty isolating this sound. Are there any guidelines for measuring the length?  In  addition, a hypersensitive gag complicates matters. Any suggestions would be greatly appreciated. M.

Hi M, I’m glad you were able to find us and ask these important questions.  Determining tongue tie (ankyloglossia) when it isn’t the “obvious” type is somewhat tricky.  In fact, we teach it in detail during our 28 hour intensive courses and I also developed a short course to focus on tongue tie and sucking habits.  The reason I mention this is to let you know that there are a lot of considerations involved in the diagnosis. The length of the lingual frenum might or might not be important.  For example, visualize a very tiny frenum that is flexible, attaches to the lower part of the tongue and also to the floor of the mouth well behind the lower alveolar ridge.  This might not pose any problem whatsoever and allow for ample lingual excursions.   Then visualize a lingual frenum that is lengthy and flexible, but is attached too far anterior onto the tongue or is embedded into the tongue and is also attached onto the lower alveolar ridge.  This might pose problems even though it is much longer than the earlier one I described.  These are just two considerations.  When it comes to a tongue where the frenum is pulling on the tip or restricting lingual movements horizontally or vertically or laterally…that might need a frenectomy. In the case of a 13 year old young man who cannot produce an /r/, I would lean toward frenectomy even if it were a borderline case since the articulation problem has been impacting his life for a very long time.  I don’t know if you have seen my CEU online course with  (Northern Speech Services).  I wrote a course on /r/ production called   R: From Basics to Habituation.  Here’s a link in case you are interested: https://www.northernspeech.com/search/?search=holtzman It is my finding using my past examinations that a hyper-gag might be common with ankyloglossia.  I do not have formal research yet, but rather just my experience with patients.  There are incidences of gagging, choking, feeling like the food is clogging up the “throat,” etc. Please let me know if this helps or if you have further questions.