Dr Kyle McGivery, PGY2, iFMEM, Saint John NB, Dalhousie University

Reviewed by: Dr David Lewis

Tongue lacerations, often the result of falls, trauma, and seizures, are injuries requiring careful evaluation in the ED in order to preserve mobility and articulation. In patients with an appropriate mechanism of injury, a careful oral cavity exam should be performed looking for foreign bodies, dental injury, and tongue injury. Given the vascular supply and healing ability of the tongue, not all lacerations must be repaired.

Indications:

Though many suggest closing lacerations >2cm, successful conservative management for larger wounds has been reported:

Figure 1. 3.5cm anterior tongue laceration (left). Minor scar following conservative management (right).

Procedure

Anesthesia
Anesthesia should be achieved before irrigation and closure of a tongue wound. Options include topical lidocaine, local infiltration, nerve blocks, or a combination of these. For smaller wounds, consider using lidocaine-soaked gauze on the tongue for 3-5 minutes. This can be followed by local infiltration of the wound. For larger lacerations, consider a lingual or inferior alveolar nerve block:

Figure 2. Inferior alveolar nerve block; lingual nerve block

Technique

For optimal visualizing of the tongue, use an assistant to pull the tongue inferiorly using gauze. Alternatively, if appropriate analgesia has been achieved, a sponge clamp may be used. Using airflow to dry off the tongue can also be helpful (e.g. a yankauer connected to an air source).

After careful irrigation, inspect for necrotic tissue that may require debridement (especially if delayed presentation). Small, linear lacerations can be repaired with simple interrupted sutures. Absorbable 4-0 or 5-0 sutures are preferred, with each suture passing through at least half of the tongue’s thickness. For tongue bisection lacerations, use a multi-layered approach to suture the deep muscle, submucosa, and mucosa. For larger lacerations, non-absorbable silk is preferred. The tongue tends to swell and therefore care should be taken not to over tighten sutures. Lastly, extra knots are preferred due frequent manipulation of the sutures and chance of dehiscence.

Figure 3. Closure of a tongue laceration. (a) towel clamp to hold tongue. (b) layers of tongue. (c) suture should include minimum half of the tongue’s thickness. (d) sutured laceration

Note: 2-octyl cyanoacrylate (Dermabond®) has also been used successfully to treat small lacerations. While no evidence exists to support this method, it may offer an alternative which does not require anesthetic.

After Care

Despite the oral cavity flora, routine antibiotic therapy has not been shown to reduce the rate of infections. High-risk lacerations requiring antibiotic prophylaxis include:

o Heavily contaminated wounds
o Delayed presentation >24hrs
o Immunocompromised individuals
o Lacerations from animal/human bites

Ensure both gram-positive and anaerobic coverage. Discharge instructions should focus on a soft food diet as well as frequent application of ice.

Bottom Line:

The indications for tongue laceration repair exclude small lacerations in which hemostasis has been achieved. If repair is necessary, use an assistant as well as drying of the tongue to give adequate exposure. Absorbable sutures are preferred and should be tied relatively loose with extra knots. Routine antibiotic prophylaxis is not recommended.

References

Brown, D. J., Jaffe, J. E., & Henson, J. K. (2007). Advanced Laceration Management. Emergency Medicine Clinics of North America, 25(1), 83–99. http://doi.org/10.1016/j.emc.2006.11.001

Juneja, M. (2008). Communication failure. Bdj, 204(7), 351–351. http://doi.org/10.1038/sj.bdj.2008.253

Mark, D. G., & Granquist, E. J. (2008). Are Prophylactic Oral Antibiotics Indicated for the Treatment of Intraoral Wounds? Annals of Emergency Medicine, 52(4), 368–372. http://doi.org/10.1016/j.annemergmed.2007.12.028

MD, M. G. K., & MD, M. S. (2013). Pediatric Tongue Laceration Repair Using 2-Octyl Cyanoacrylate (Dermabond®). Journal of Emergency Medicine, 45(6), 846–848. http://doi.org/10.1016/j.jemermed.2013.05.004

Ud-din, Z., & Gull, S. (2007a). Should minor mucosal tongue lacerations be sutured in children? Emergency Medicine Journal, 24(2), 123–124. http://doi.org/10.1136/emj.2006.045211

Ud-din, Z., & Gull, S. (2007b). Should minor mucosal tongue lacerations be sutured in children? Emergency Medicine Journal, 24(2), 123–124. http://doi.org/10.1136/emj.2006.045211

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