Question
I’m an adult medical SLP and my coworker (who does peds) asked me about a pt and this isn’t my wheelhouse. Almost 5 year old without trouble swallowing. Was diagnosed with aerophagia. Has gulping sound with swallowing only when laying down and sleeping. Belches and farts a lot. Not a picky eater/does not avoid foods. Had a tongue tie clipped years ago. Closed mouth posture at rest, but pt chews with her mouth open and she is unable to perform tongue clicks. Pt had an EGD.
I told her to check for anatomy and recommend ENT. Could this be a posterior tongue tie thing? What else should we do or look for? They mentioned us (on the adult side) performing her VFSS because our c-arm is here. From quick search here, seems treatment is somewhat behavioral? But again this only happens when she sleeps or lays down flat.
Catherine’s Answer:
Is she otherwise normally developing? I wonder if there are any global sensory-motor issues that may be part of the differential. Is she followed by PT or OT? What is her articulation like? What did EGD show? Any clinical signs suggestive of EER/GER? The altered swallowing while recumbent or sleeping and aerophagia suggest potential GI issues may be part of her bigger picture.
Insights from a pediatric team will be essential. Multiple etiologies are possible for what you describe, so lost of questions need to answered. Gathering the data set would include: OT/PT to rule-out sensory-motor issues. A pediatric SLP experienced in feeding/swallowing could look from multiple perspectives. The, based on that data set and the team’s impressions, potentially a bodyworker consult and/or myofunctional therapy consult. It’s possible that tethering, if it was present in the past, was not fully or correctly released years ago — could lead to the aerophagia commonly associated with TOTs. ENTs often disagree about whether TOTs even “exist”, and what constitutes tethering, so I find the above rehab-focused team can often look at function most effectively, once ENT weights in. But again tethering may no be part of the differential.
A VFSS may objectify alterations in swallowing physiology resulting from any tethering that may or may not be readily apparent. What you observed clinically is not uncommon in 5 years old with persistent TOTs, even post op. This article by one of my SLP friends/colleagues at Children’s Healthcare of Atlanta may be helpful –Brooks, L., Landry, A., Deshpande, A., Marchica, C., Cooley, A., & Raol, N. (2020). Posterior tongue tie, base of tongue movement, and pharyngeal dysphagia: what is the connection? Dysphagia, 35, 129-132. Another resource is Functional Assessment and Remediation of TOTs by Lori Overland and Robyn Merkel-Walsh, MA, CCC-SLP. Know that what you have observed clinically may be unrelated to any tethering. But there are possible implications of tethered oral tissues for the hyolaryngeal network, for motor learning and for the postural network — which underpin and therefore can affect all functional components of feeding/swallowing. Know there is controversy about tethered oral tissues across all disciplines; all perspectives should be valued. A good differential by a pediatric team will help sort this out and optimize function.