Three Year Old Girl with Tongue Protrusion

Question

Answer

I do not recommend that you initiate speech therapy for this three year old girl at this time. You do not have sufficient information at present to generate a treatment plan. What is needed is a thorough evaluation of her airway and other issues by an ENT specialist or a pediatrician.

Let's put the observations you made into perspective: first, THE AIRWAY. 1) A forward rest posture of the tongue serves as a clue to evaluate the status of the posterior airway. 2) A forward, interdental rest posture of the tongue, or even thrusting (if also present), can be an adaptive mechanism to protect the airway and help to keep it open. 3) Your report of not being able to view her uvula or posterior pharyngeal wall during examination is normal for a three year old, but because of your added observation of a forward interdental rest posture of the tongue, this raises a suspicion about the possibility of a reduced size of the oral isthmus, which is bounded above by the soft palate, below by the base of the tongue, and laterally by the faucial pillars. Where the oral isthmus is small, the tongue will logically maintain an open airway by moving and resting forward. 4) At age 3, a child's tonsils and adenoids may already be large. Tonsils and adenoids appear shortly after birth. They can enlarge early and remain large until the process of atrophy (or involution) begins around age 12. The presence of large faucial tonsils can further reduce the size of the oral isthmus in the horizontal plane.

With regard to the specific question you pose about respiratory infections and the impact they may have on the resting posture of the tongue, there is certainly a strong relationship between tongue posture and the status of the airway. Where there is an airway interference, the tongue may posture forward to maintain and protect the airway, as mentioned above. The fact that this child can occasionally withdraw the tongue and assume a lips-together posture is likely not a task that can be maintained for a long period in the absence of airway competence. I do not assign any significance to the observation that she can occasionally retract her tongue and close her lips.

Airway issues and allergies should be identified and addressed by either an ENT specialist or a pediatrician. The first step for this child is to have a thorough medical workup of the airway, and that is the primary recommendation that I would offer at this time. Since this girl has a history of upper respiratory problems and has been treated with antibiotics, there is obvious merit in focusing further on the airway as a source for additional problems that may not as yet been addressed by any physician involved. Without intending to criticize, it may be that the physician involved has only resolved the infections as they have occurred rather than fully documenting other contributing airway issues on a longitudinal basis.

JAW STRUCTURE. You report that the mandible extends farther forward than the maxilla. This is not typical for a three year old and may suggest a developing mandibular prognathism, or perhaps some maxillary retrusion, or a combination of the two. The jaw growth discrepancies you note may relate in part to any unresolved airway issues present. However, some children with syndromes show jaw growth discrepancies as a characteristic of the syndrome. When a jaw discrepancy is seen at age three, no treatment is indicated. The child should be followed by an orthodontist for jaw growth. The general rule in orthodontics is that where there is a deficiency in the maxilla, treatment can be initiated early (but not at age 3), while problems of overgrowth usually are left to run their course before treatment is recommended.

EATING PROBLEMS. Here again, the problems you note in the child overstuffing her mouth and exhibiting difficulty in chewing meats, with gagging occurring during eating, also indicates the need for a medical evaluation. Although the inability to elevate or lateralize the tongue tip under control may not indicate anything untoward in a three year old, it does reinforce a suspicion of a neurological development lag for oral tasks. One way to evaluate this is to engage the child in simple diadochokinetic tasks such as rapid repetitions of "puh" and "buh", then "tuh" and "luh". During the diadochokinetic tasks, focus on the pattern and range of movements of the tongue tip rather than the number of repetitions per unit time. Be prepared to see a mandibular assist on "tuh" and "luh" productions; as the mandible does the work and the tongue follows along. A "mandibular assist" is a normal response up to around age 7 years.

A three year old would naturally show competence in protrusion of the tongue, while elevating the tongue tip under control would not be expected to have matured as an oral task. Remember that the primitive movement pattern of the tongue is a protrusion that even children with a neurological disorder can accomplish successfully. With age, children usually progress from horizontally-directed movements of the tongue to a controlled capacity to elevate the tongue tip at appropriate times for specific speech sound productions.

One more thing about eating - you did not mention any swallowing problem with this child. The overstuffing and gagging suggests to me that she may also exhibit some difficulty in swallowing, or perhaps a tongue thrust swallow that often accompanies a forward, interdental rest position of the tongue. In the face of a small oral isthmus, if present, a tongue thrust swallow may be normal and would not be indicated for change; that is, as a bolus of food is passed through the oral isthmus, the tongue may need to move forward to provide room. This would be viewed as a tongue thrust swallow. If you do address eating problems along the way, the details of swallowing pattern will become pertinent to your evaluation and treatment, and the size of the oral isthmus will influence your treatment strategy.

SPEECH. The sound distortion errors you report are normal for a three year old. Due to her age, jaw structure, and possible airway issues, I do not recommend speech therapy. I would also defer any work on feeding until you have a clear medical view of her status, especially the airway. An orthodontist may need to be a member of the team to identify, with a lateral cephalometric x-ray film the size of the tonsils and adenoids and the specifics of jaw structure. The lateral ceph can also provide an excellent view of the cervical vertebrae. In the event that there is a syndromic component to the jaw discrepancies, some variation is often noted in the upper cervical spine.

SUMMARY. This three year old girl presents with an atypical jaw development relationship, a forward rest posture of the tongue, and feeding issues. All of these findings suggest the need for a thorough assessment that may involve an ENT (preferred for the airway), a pediatrician (preferred for the eating issues) and possibly an orthodontist (for jaw development and documenting the airway size and cervical spine). Your findings also raise suspicion about the presence of a neuromotor development lag. On the basis of the above issues, it is recommended that you defer speech therapy for now, perhaps for a year or more, until other issues are fully described or addressed that would impact your work in providing speech services. The decision to work, or not, on language stimulation would depend upon assessments not provided in your report here.

I also recommend that if you desire to work on retraining the tongue rest posture or swallow of this child at a later date, that you obtain training in orofacial myology, as stipulated in the 1993 ASHA position statement on knowledge and skills with orofacial myofunctional disorders (ASHA Supplement #10). If you are interested in this area, I recommend that you check out the website (www.iaom.com.) of the International Association of Orofacial Myology, a related professional organization with ASHA that provides education and support for orofacial myology issues. I also recommend that attempting to retract the tongue at rest posture or in function should not be attempted where there is a small oral isthmus or any other airway issue (including a history of upper respiratory infections). In many individuals, and perhaps including this three year old, the rest posture and swallow pattern will depend upon the morphology present and may require an adaptation in swallowing that should not be considered as abnormal; that is, some individuals swallow the best way they can at various times in their development, depending on the status of the airway.

I appreciate the challenges that you and other resources will face in sorting out the overlapping issues with this child. I hope my comments here will be of help. Thanks for asking, and good luck

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Robert M. Mason, DMD, Ph.D. is a speech-language pathologist (CCC-ASHA Fellow), a dentist, and orthodontist. He is a Past President of the American Cleft Palate-Craniofacial Association, a professional, interdisciplinary organization specializing in problems associated with facial and oral deformities. Dr. Mason has studied and written extensively about orofacial examination, developmental problems related to the tongue, and the anatomy and physiology of the speech and hearing mechanisms. His reports have appeared in speech, dental, medical, and plastic surgical journals and texts. He is considered to be an expert in tongue thrusting, tongue tie, and other problems related to tongue functions and speech.