Can a tongue tie (ankyloglossia) cause sleep apnea, specifically obstructive sleep apnea?

Tongue Tie and Obstructive Sleep Apnea

Tongue tie (ankyloglossia) can contribute to obstructive sleep apnea by causing retrolingual/hypopharyngeal obstruction, and frenotomy may reduce tongue collapse in selected patients with OSA. 1

Mechanism and Evidence

• Ankyloglossia is a condition where an abnormally short lingual frenulum restricts tongue mobility, potentially affecting the tongue's position during sleep 2
• Limited evidence suggests untreated shortened lingual frenulum at birth may be associated with obstructive sleep apnea later in life 2
• In adult OSA patients with ankyloglossia, frenotomy has been shown to improve tongue positioning and reduce tongue collapse during sleep as demonstrated by drug-induced sleep endoscopy (DISE) 1
• After frenotomy, some patients show improvement from complete anteroposterior collapse to partial anteroposterior collapse at the tongue level 1

Management Considerations for Tongue-Related OSA

• For patients with retrolingual/hypopharyngeal obstruction, several surgical approaches may be considered:

  • Hyoid suspension can be recommended as an isolated procedure for OSA patients with retrolingual/hypopharyngeal obstruction 3
  • Tongue base reduction procedures may be necessary in cases of severe macroglossia 3
  • Tongue suspension techniques aim to stabilize the tongue base rather than permanently advance it forward 3

• Non-surgical options should be considered before surgical intervention:

  • Tongue-retaining devices (TRDs) can reduce apnea-hypopnea index by approximately 53% by holding the tongue in a forward position using negative pressure 4, 5
  • Speech therapy and oropharyngeal exercises should be implemented prior to any surgical procedure for patients with ankyloglossia and OSA 1

Surgical Outcomes and Limitations

• Surgical success rates for tongue-based procedures decrease with increasing BMI and AHI 3
• Tongue base soft tissue procedures alone (including tongue suspension) cannot be recommended as a single treatment option for obese patients with moderate to severe OSA 3
• Multilevel surgery (MLS) combining procedures at both the palatal and tongue base levels may be more effective for patients with combined retropalatal and retrolingual/hypopharyngeal obstruction 3

Important Caveats

• The evidence specifically linking ankyloglossia to OSA is limited, with only a few studies directly addressing this relationship 2
• Patients with suspected tongue-related OSA should undergo comprehensive evaluation including drug-induced sleep endoscopy to confirm the level and pattern of obstruction 1, 6
• Post-frenotomy rehabilitation is crucial - patients should undergo speech therapy and oropharyngeal exercises to prevent glossoptosis (tongue falling backward) and maximize improvement 1
• Surgical complications of tongue procedures may include temporary dysphagia, odynophagia, and floor of mouth infections 3

Algorithm for Management

1. Confirm tongue-related obstruction through sleep endoscopy or other diagnostic methods 1, 6
2. For mild cases or initial treatment:
   • Begin with myofunctional therapy and oropharyngeal exercises 1, 2
   • Consider non-surgical options like tongue-retaining devices 4, 5
3. For persistent moderate-severe OSA with confirmed tongue obstruction:
   • Consider frenotomy if ankyloglossia is present 1, 2
   • For more severe cases, evaluate for hyoid suspension or tongue base procedures 3
   • In cases with multilevel obstruction, combine with other appropriate procedures 3, 6
4. Post-treatment follow-up should include polysomnography to objectively assess improvement 3