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.
You can generally tell parents that the wound will approximate itself over several days, usually less than a week. It will then look like a whitish raised patch on the tongue, before receding into a more normal appearance over days to weeks. Initially the wound will be sensitive, especially to salty, acidic, or spicy foods. A bland, soft diet can help. Acetaminophen or ibuprofen will be sufficient for pain control, and popsicles will help with the pain and swelling too. Sending patients home with a prescription for mouthwash is optional. After eating make sure there are no food particles in the wound. Kids can swish and spit (if able) or parents can irrigate out the area with water via a medication syringe (which I will provide at discharge).
If I have to suture a tongue how do I do it?
Many of these wounds occur in young children – think under kindergarten age. So ask yourself – what will it take to carefully repair this in a way that minimizes risk of airway catastrophe. You’ll need to get everything together beforehand, and consider providing sedation. Local anesthesia can be provided with 4% lidocaine gel on gauze applied for 5 minutes, 1% lidocaine injected into the tongue, or an inferior alveolar nerve block which will block the lingual nerve and the anterior 2/3 of the tongue. You also need to control the tongue and keep it protruded. This can be accomplished by grabbing the tip with forceps, or by placing a large (3-0, 2-0) suture thorough the tip. There is no consensus on how many layers to repair with. Copious irrigation without drowning the patient is important. Certainly length of the procedure is an issue for younger/sedated patients, but you also want the sutures to stay in place as they can become untied due to the normal movements of the tongue. Therefore it is important to use absorbable sutures (I like 4-0 chromic gut) and bury the knots in the tongue itself if possible. In general my biggest concern is getting the sutures to stay in place – so I’ll do 2 or 3 layers. The first is placed as a loop with the knot buried in the deep muscular mucosa. I’ll then suture the lateral edge. It is OK to leave the knot outside the tongue if it is on the lateral side. Using a suction machine to “blow” air on the wound can help keep the tissue dry an avoids having to continually “blot” with gauze. Closing the Gap has a nice page on tongue lacerations that I think is worth checking out.
There are a couple of case reports using Dermabond on tongue lacerations (I linked to them in the references), but in the absence of comparative data I can’t draw any conclusions on the effectiveness of this method outside of anecdotal reports.
Most tongue lacerations do not need to be repaired. Be sure to examine the tongue in a neutral, non-protruded position. Wound healing generally takes less than a week, and complications such as infection are rare. Suturing will require sedation, and is often not worth the trouble.