A four year old male was jumping in his bed. He jumped one time too many and landed on his dresser, hitting his chin and biting his tongue in the process. He then ran downstairs and bloodied the carpet. Mom grabbed a towel sopped up some mouth blood. Given that we are in the midst of a global pandemic she was wondering if she should risk a trip to the ED. She tried to do a telemedicine visit, but her son wouldn’t hold still for her pediatrician to get a good look – so off to the Emergency Department they go.
On exam he is protecting his airway, the bleeding has stopped, and you see the following:
Which tongue lacerations do I need to repair?
In short, not many of them. The wound in this case does not need to be repaired and will heal wonderfully on its own. Actually suturing a tongue is difficult, painful, and often requires sedation. There is the risk of granuloma formation (local reaction to sutures) which generally (but not always) resolves on its own. You should repair those that cause problems with breathing, speech and/or gustation/swallowing. Based on the cumulative evidence, lacerations that should be repaired include those that are:
- Larger than 2cm and extend into the musculature and/or are through-and-through – these create large flaps/gaps
- Deep laceration through the anterior or lateral border as these may cause dysfunction if not repaired (snake tongue!!)
- Ongoing hemorrhage
- Amputated and partially-amputated tongues (these require a trip to the OR with Dental or Oral Maxillofacial Surgery)
The key when assessing tongue lacerations, according to Seiler et al. is looking at whether or not the laceration gapes when the tongue is in neutral position rather than protruded. Tongue protrusion requires muscle contraction and will generally make the wound look wider.
OK, this this one will heal on its own, right?
Yes, the wound in this example will heal well on its own. The tongue has a great blood supply and is one of the fastest healing parts of the body (less than 3-5 days in many cases). The risk of infection is also incredibly low. The aforementioned study from Seiler et al. was a comparison of children whose tongue lacerations were repaired versus not. They noted in a sample of 73 children with tongue lacerations that 61 were not repaired and 12 were. They did not repair every wound that was at the lateral margin, and when the tongue was “at rest” the used the following schema (which I have colorized for easier interpretation) to help decide when to suture.
This was not strictly speaking, a traditional “case-control” study, nor was it a randomized controlled trial. So the main benefit is the number of cases from an observational standpoint. They followed up all patients by phone and solicited a picture of the healing tongue. They also accepted a verbal description of the wound site in the absence of a photograph. A big limitation of the short term follow up was that “in 81% of cases, the time interval between the ED visit and the standardized telephone interview was twelve months or longer.”
I think that we really need a good set of easily shareable photographs of “what does my child’s tongue laceration look like as it is healing.” This report from the British Dental Journal includes before and after images of a gnarly tongue laceration that has been left to heal by secondary intent. Images are courtesy of Patel – British Dental Journal, 2008.