Tongue Laceration

Yes, as we’ve mentioned before, kids are often Gravitationally Challenged. Toddlers, toddle and tumble constantly. Often, this leads to simple bumps and bruises and minor injuries. Occasionally, these injuries appear rather dramatically though. One that will always catch parents’ attention is when the fall leads to a Tongue Laceration.

 

Tongue Laceration: The Bad

  • As always, consider worse first…
  • Airway Compromise
    • The tongue is highly vascular and can bleed substantially.
      • This is good, as it will allow the wound to heal rapidly, but…
    • This bleeding can cause significant tongue swelling.
    • Naturally, oral bleeding can also endanger the airway.
  • Retained Foreign Bodies
    • Just like any wound, consider that the object that caused the wound may still be lingering within it!
    • Fragments of teeth
    • Fragments of other objects that were in the mouth during the trauma (ex, Popsicle stick)

 

Tongue Laceration: The Common

  • The most common location is the anterior, dorsal portion of the tongue.
  • Next most common is middle of the dorsal portion and the anterior, ventral aspect.
  • More posterior locations are less common. [Lamell, 1999]
  • When you find one laceration, always look for another… especially on the other side of the tongue.

 

Tongue Laceration: The Management

  • Think worse first…
    • Don’t get distracted by the obvious tongue injury.
    • It’s a trauma… So assess the Airway.
    • Are there other signs of intracranial, facial, or neck trauma?
  • Assess other intra-oral structures
    • Is there a oral floor hematoma?
    • Is there posterior pharyngeal trauma?
    • Is the base of the tongue involved (possible hypoglossal nerve injury)? [Mohan Das, 2008]
  • Think about possible Foreign Bodies…
    • If there is evidence of tooth fracture, worry that that missing piece is in the tongue.
    • Ask about other objects that may have been in the mouth.
  • Don’t Be Cruel… Treat the pain
    • NSAIDs are reasonable.
    • Topical Lidocaine applied to the wound (ex, 4% lidocaine soaked gauze for 5 min).
    • Regional blocks are possible, but more challenging in toddlers.
  • Irrigate the Wound
    • Infection is rare… but irrigation will help you evaluate the injury also.
    • After care should include continued dental hygiene and oral care with antiseptic mouth wash.
  • To Close or Not To Close
    • This has not been well researched, but has dogmatic teachings.
      • “If a piece of corn fits in it, it needs to be closed.”
        • But… what size piece of corn… are we talking about little baby corn, or giant corn kernels?
      • “If it crosses the side margin of the tongue, it needs to be closed.”
        • But… what about those post-seizure tongue lacs that always seem to involve the margin?… they seem to do well without closure.
      • “If it gapes open, it needs to be closed.”
        • But… what if it only gapes open when the tongue is protruded?
    • There is evidence that even wounds that gape or include tongue margin can be managed without suturing. [Lamell, 1999]
    • Some advocate for closing wounds that: [Ud-din, 2007; Mohan Das, 2008]
      • Bleed uncontrollably 
      • Endanger the airway
      • Are a “Significant” segment of severed tongue; 2cm or greater
    • Wounds that involve the margin or tip still often heal and remodel without closure. [Mohan Das, 2008]
  • Patients with Bleeding Disorders?
    • Bleeding disorders (ex, Hemophilia) should heighten your concern.
    • Have a lower threshold to close these wounds to help control hemorrhage.
    • Don’t forget the possibility of intracranial hemorrhage.
    • Give Factor replacements!!

 

Tongue Laceration: Time to Close

  • The vast majority do NOT require closure… but some will. When that time comes, be kind.
  • Will require some type of sedation.
  • Use a bite block to help keep mouth open safely.
  • Use towel clamp to grasp tongue and immobilize it.
    • Can also use large suture to pull tongue out, but put another hole in the tongue.
  • Close with absorbable suture (ex, 5-0 Chromic Gut). [Brown, 2007]
    • Or, you may even consider 2-octyl cyanoacrylate (aka, Dermabond) (see case report). [Kazzi, 2013]

 

References

Kazzi MG1, Silverberg M. Pediatric tongue laceration repair using 2-octyl cyanoacrylate (dermabond(®)). J Emerg Med. 2013 Dec;45(6):846-8. PMID: 23827167. [PubMed] [Read by QxMD]

Das UM1, Gadicherla P1. Lacerated tongue injury in children. Int J Clin Pediatr Dent. 2008 Sep;1(1):39-41. PMID: 25206087. [PubMed] [Read by QxMD]

Lamell CW1, Fraone G, Casamassimo PS, Wilson S. Presenting characteristics and treatment outcomes for tongue lacerations in children. Pediatr Dent. 1999 Jan-Feb;21(1):34-8. PMID: 10029965. [PubMed] [Read by QxMD]

Sean Fox

I enjoy taking care of patients and I finding it endlessly rewarding to help train others to do the same. I trained at the Combined Emergency Medicine and Pediatrics residency program at University of Maryland, where I had the tremendous fortune of learning from world renown educators and clinicians. Now I have the unbelievable honor of working with an unbelievably gifted group of practitioners at Carolinas Medical Center. I strive every day to inspire my residents as much as they inspire me.

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10 Responses

  1. Brian says:

    Hi Sean, it looks like we posted on the same topic in the same week! (http://wp.me/P3KCqK-iG) Nice job, you did a much better job remembering to emphasize that many of these lacs really don’t need repair. We should consider a collaborative post in the future!

    Best,
    Brian Lin, MD, FACEP

    • Sean Fox says:

      Hello Brian!
      I would like to say that “great minds think alike,”… but my mind is not great… so I guess I got lucky to be on the same page as you.

      I’m always happy to collaborate on topics… the more minds the merrier.
      Have a great day,
      sean

  2. MDfor911 says:

    Sean, some good comments. If I sedate, and what I recommend to the residents, is to use Ketamine for it’s analgesic properties, as well as maintenance of swallowing reflexes. I also give a dose of Zofran, as almost all these kids swallow a good amount of blood during the initial injury. The Zofran helps prevent the emesis that comes with swallowing the blood. B/C I’m limiting their ability to swallow as a restrain the tongue, I used to dose a bit of atropine as well. But I’ve gotten away from this over the years, as I’ve become better and more efficient with my repairs. Thanks for the great Morsels!

    • Sean Fox says:

      MDfor911,
      I couldn’t agree more… love Ketamine for sedation (I may have mentioned this before a few times in the Morsels). I generally do not use atropine (or glycopyrrolate for that matter) any more either. I just haven’t seen that it makes a big clinical difference. That being said, some would argue that atropine may actually be to blame for some of the “emergence reactions” that can be seen… so if I do choose to use an antisialogogue, I favor glycopyrrolate.

      Also concur with use of odansetron. I think most sedations go better with some odansetron.
      Thank you,
      sean

  3. Todd Listwa says:

    Sean, nice review. Something to add might be that needle choice is very important. A cutting or reverse cutting needle will likely pull out of the tissue of the tongue and can result in repeated procedures. I learned this the hard way four years ago. It is important to recommend a tapered needle so that the shape of the puncture as the needle enters the tongue does not support an easy path for the suture to break through.

    • Sean Fox says:

      Dr. Listwa,
      Brilliant point about the selection of the type of needle! I think that there are times we forget that we need to select not just the type of suture material, but also the type of needle that suture is attached to!
      Brilliant!
      Thank you,
      sean

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