Evaluation and repair of tongue lacerations

INTRODUCTION — This topic will discuss the evaluation and repair of tongue lacerations. Wound preparation, wound closure with sutures, closure of facial lacerations, and dental injury are discussed separately:

●(See "Minor wound evaluation and preparation for closure".)

●(See "Skin laceration repair with sutures".)

●(See "Assessment and management of facial lacerations".)

●(See "Evaluation and management of dental injuries in children".)

EVALUATION

Initial stabilization — Although uncommon, large tongue lacerations in the setting of major facial trauma may lead to hemorrhage that can potentially threaten the airway and/or cause hypovolemia. In this situation, the airway should be evaluated and secured if compromised. Cervical spine motion restriction must be maintained in patients in whom cervical spine injury has not been excluded. (See "Basic airway management in children" and "Rapid sequence intubation (RSI) in children for emergency medicine: Approach" and "Pediatric cervical spinal motion restriction".)

As in all trauma patients, once the airway is assessed and secured as needed, the initial clinical assessment should provide rapid identification and management of life-threatening conditions. The approach to the injured child is discussed in detail separately (table 1). (See "Trauma management: Approach to the unstable child", section on 'Primary survey'.)

History — The clinician should identify the following aspects of the injury:

●Traumatic force (eg, motor vehicle collision or a physical assault with significant likelihood of associated injuries versus an isolated injury from a bite to the tongue during a fall or minor blow to the head with no other symptoms)

●Associated symptoms of head injury (eg, altered mental status, vomiting, headache) (see "Minor blunt head trauma in infants and young children (<2 years): Clinical features and evaluation", section on 'History' and "Minor blunt head trauma in children (≥2 years): Clinical features and evaluation", section on 'History')

●Associated symptoms of mandibular or maxillary injury (eg, malocclusion, trismus, or facial pain and swelling)

●Age of wound

●Likelihood of wound contamination; all tongue lacerations should be considered to have been exposed to intra-oral bacteria, and additional exposures (eg, dirt, foreign bodies) should also be determined

●Potential presence of foreign body (eg, dislodged teeth, fall onto glass or gravel)

The history should also include a comprehensive review of underlying medical history (eg, diabetes mellitus in adults, cancer), medication use (eg, immunosuppressive agents), and social habits (eg, tobacco use) that may negatively affect healing and increase the risk for a poor outcome. (See "Minor wound evaluation and preparation for closure", section on 'Risks for poor outcome'.)

In addition, the clinician should inquire about allergies to any medications (especially local anesthetics), timing of last oral intake, and tetanus immunization status. (See "Allergic reactions to local anesthetics", section on 'Evaluation' and "Assessment and management of facial lacerations", section on 'Tetanus prophylaxis'.)

Examination — For patients with high-force facial trauma, the initial clinical assessment should first provide rapid identification and management of life-threatening injuries. (See 'Initial stabilization' above.)

Wound assessment should initially occur with the tongue at rest rather than protruding. Subsequently, the clinician should ask the patient to stick out the tongue, move it side to side, and place the tip of the tongue on the roof of the mouth to fully visualize all surfaces.

In young children and otherwise uncooperative patients suspected of having more than a superficial laceration (eg, deep dorsal laceration with bottom not visualized or active bleeding), the examiner may use a surgical gauze bandage to gently grasp the tongue and permit full exposure of the ventral surface; a bite block or side mouth gag may be necessary in uncooperative patients.

This examination should determine the following:

●Laceration location:

•Tip of tongue

•Side of tongue

•Dorsum of tongue

●Laceration depth:

•Superficial to the muscle layer

•Into the muscle layer

•Through-and-through the tongue

●Length of wound

●Presence of:

•Tissue avulsion

•Foreign body

•Ongoing brisk bleeding that does not stop easily versus oozing

The clinician should also evaluate for the following associated injuries to the face, oropharynx, teeth, and jaw:

●Midface fracture – Suggested by (see "Initial evaluation and management of facial trauma in adults", section on 'Midface' and "Nasal trauma and fractures in children and adolescents", section on 'Physical examination'):

•Malocclusion

•Midface instability

•Ecchymosis over the cheek

•Anesthesia of the region supplied by the infraorbital nerve (upper lip, alveolar ridge, lateral nose, lower eyelid) (figure 1) or enophthalmos

●Oropharynx – Any associated intraoral mucosal or gum lacerations and the presence of penetrating oropharyngeal foreign bodies. (See "Oropharyngeal trauma in children".)

●Dental trauma – Loose, displaced, fractured, or missing teeth; loose or avulsed teeth can present an aspiration hazard. Definitive management is determined by type of tooth (primary [baby] versus permanent tooth (table 2)). Emergency management of tooth avulsions and guidance on pediatric dental injuries that require urgent referral are provided in the rapid overview (table 3) and discussed in detail separately. (See "Evaluation and management of dental injuries in children", section on 'Examination' and "Initial evaluation and management of facial trauma in adults", section on 'Dental injury'.)

●Jaw fracture – Suggested by malocclusion, trismus, pain over the temporomandibular joint, or jaw tenderness. (See "Mandibular (jaw) fractures in children" and "Initial evaluation and management of facial trauma in adults", section on 'Temporomandibular joint'.)

Ancillary studies — Patients with clinical features suggestive of associated fractures warrant additional studies as follows:

●Midface fractures – When suspected, visualization of fractures among the complex curves of facial bones is best achieved using computed tomography (CT). CT scans of the face should include fine cuts and both coronal and sagittal reconstructions. CT angiography may be useful if the patient has a significant or expanding facial hematoma or if injury to or dissection of the carotid artery is a concern. (See "Initial evaluation and management of facial trauma in adults", section on 'Facial injury'.)

●Mandibular and dental fractures – The U-shape of the mandible and the presence of adjacent bony structures make it impossible to isolate the mandible on a flat radiograph film. Therefore, simple radiographs of the mandible are less sensitive for detecting fractures than CT or panoramic radiographs (ie, Panorex) and can miss fractures of the condyle. CT is the most appropriate imaging study for patients with facial trauma and a concern for mandible fracture. If available, Panorex imaging can be used for isolated mandibular fractures, dental fractures, or fractures of the alveolar ridge. (See "Initial evaluation and management of facial trauma in adults", section on 'Mandibular injury'.)

DECISION TO REPAIR — The decision of whether or not to repair the laceration depends upon the extent of the laceration and the risk of compromised function and appearance after healing.

For patients with tongue lacerations, we suggest suture repair of lacerations with the following characteristics:

●Large lacerations (>2 cm in length) on the dorsum of the tongue that extend into the muscular layers or pass completely through the tongue

●Deep lacerations on the lateral border of the tongue

●Large flaps or gaps in the tongue

●Lacerations associated with significant bleeding

●Lacerations that may cause dysfunction if healed improperly (anterior split tongue)

Lacerations that generally do not require repair include:

●Non-gaping lacerations on the dorsum of the tongue

●Gaping lacerations on the dorsum of the tongue that are ≤2 cm in length and come together when the tongue is at rest in the mouth [1]

Because of the risk of infection, tongue lacerations that are more than 24 hours old should be left open to heal by secondary intention.

Evidence is limited but suggests that outcomes for most tongue lacerations in young children are not improved by suturing [1-4]. For example, in a retrospective study of 73 children (mean age four years) with tongue lacerations, 12 underwent primary closure; wound findings of sutured lacerations consisted of gaping at rest, being through-and-through in depth, involving the tip or lateral portion of the tongue, and/or having a longer length (mean length 2.1 cm) [1]. Lacerations left to heal by secondary intention were shorter (mean length 1.1 cm), but many had similar characteristics as sutured wounds. Sutured lacerations were associated with greater scarring and longer duration of complaints, although these findings may be explained by the larger size of these wounds.

INDICATIONS FOR SPECIALTY CONSULTATION — Clinicians with experience managing simple lacerations may perform closure of most tongue lacerations that meet criteria for repair.

Consultation with an oro-maxillo-facial or oral surgeon is warranted for severe lacerations that warrant operative repair, such as partial or total amputations or midline, full-thickness lacerations through the median fibrous septum (traumatic splitting of the tongue) [5,6].

Consultation with an appropriate specialist (eg, plastic or maxillofacial surgeon, dentist), if available, is also warranted in patients with the following associated injuries:

●Luxation injuries in which the teeth are extruded or displaced with malocclusion (see "Evaluation and management of dental injuries in children", section on 'Other luxation injuries')

●Permanent (secondary) tooth avulsion (see "Evaluation and management of dental injuries in children", section on 'Avulsions')

●Mandibular fracture (see "Mandibular (jaw) fractures in children", section on 'Management')

●Midface fracture (see "Initial evaluation and management of facial trauma in adults", section on 'Midface')

PREPARATION

Equipment — Necessary equipment for repair of tongue lacerations includes:

●Suction (frequent suctioning of the mouth decreases the possibility of aspiration of saliva and blood)

●Bite block or side mouth gag

●Anesthetic agent of choice (eg, 2% lidocaine)

●5-mL syringe for anesthetic

●27-gauge needle for injection of anesthetic

●Tongue depressors

●Gauze

●Normal saline

●30-mL syringe for irrigation

●18-gauge angiocatheter or splash guard for irrigation

●Absorbable suture material (3-0 or 4-0 chromic gut or Vicryl)

Local or regional anesthesia — The wound should be anesthetized before irrigation, debridement, and closure of the laceration using either direct local infiltration or an inferior alveolar nerve block [7]. (See "Subcutaneous infiltration of local anesthetics".)

Inferior alveolar nerve block — The inferior alveolar nerve block anesthetizes the pulp of all mandibular teeth to the midline, the anterior two-thirds of the tongue, and regions innervated by the mental nerve. In experienced hands, it provides excellent anesthesia for anterior tongue lacerations.

The inferior alveolar block is a deep injection, with local anesthetic deposited adjacent to the mandibular foramen as follows:

●The mandibular ramus is grasped between the thumb (intraoral, on the coronoid notch) and index finger (extraoral) (figure 2).

●The target area for tissue entry is the mucosa lateral to the pterygomandibular raphe, medial to the anterior border of the mandibular ramus, and approximately 6 to 10 mm above the occlusal plane of the mandibular teeth.

●The needle is inserted parallel to the mandibular occlusal plane and is rotated during the injection to approximately 30 degrees in a horizontal plane so that the syringe barrel rests on the anterior teeth.

●The depth of injection is approximately one-half the anteroposterior dimension of the ramus. Aspiration to rule out intravascular injection should be accomplished before injecting anesthetic.

Sedation — Procedural sedation may be necessary in young children and other uncooperative patients. If there are no contraindications, ketamine has the advantage of preserved airway reflexes (see "Procedural sedation in children: Selection of medications", section on 'Moderately or severely painful procedures'). Sedated patients still require local or regional anesthesia as well as diligent attention to suctioning of saliva, blood, and irrigant solution from the anterior pharynx during the procedure to avoid aspiration and laryngospasm. The clinician should avoid deep suctioning of the posterior pharynx because it may cause laryngospasm.

Extensive lacerations that need a prolonged repair time and those associated with copious bleeding are best managed with proper airway control under general anesthesia in the operating room.

Site (wound) access — A bite block or side mouth gag may be necessary to prop open the mouth during irrigation and laceration repair. The patient should be sitting upright as much as possible during the procedure to support the airway and reduce the risk of aspiration of blood or irrigant.

A bite block can be made by securing gauze around a tongue depressor and placing it between the upper and lower teeth. An assistant can also use a 2 x 2-inch gauze pad to grip the protruding tongue and hold it in place for suturing.

Alternatively, a large-gauge traction suture (eg, 3-0 nonabsorbable suture) can be placed through the anterior portion of the anesthetized tongue to provide better positioning (figure 3). If the clinician expects to apply a large amount of traction, then placement of two sutures occasionally reduces the chance of pulling through the tongue.

Irrigation and debridement — The wound should be examined for fractured teeth or other foreign bodies, which should be removed, if present. To remove debris and necrotic material, the wound should be carefully irrigated with approximately 50 to 100 mL of normal saline using a 30-mL syringe and 18-gauge angiocatheter or splashguard. Ensure that drainage is controlled by positioning the patient upright as much as possible and have a functioning suction setup with a Yankauer tip suction catheter to control drainage.

Tissue that is clearly necrotic should be debrided. However, tissue with unknown viability should be debrided cautiously, because excessive debridement may cause additional bleeding.

LACERATION REPAIR WITH SUTURES

Procedure — Tongue lacerations should be repaired as follows:

●Dorsal tongue lacerations – With 3-0 or 4-0 absorbable sutures, such as chromic gut or Vicryl, take full-thickness bites of the mucosal surface and the lingual muscle to prevent dehiscence.

●Through-and-through lacerations – With 4-0 or 5-0 chromic gut or Vicryl, perform a two- or three-layered closure to prevent formation of a hematoma. The deep muscle should be sutured first, followed by the submucosa and mucosa.

●Tip or large lateral border tongue lacerations – Carefully approximate the margins and avoid overlapping the tissue edges.

Sutures should be placed loosely to permit swelling. Sutures that are placed too tightly are liable to pull through or cause necrosis of the wound edges. Each suture should be tied with at least four square knots to prevent the constant motion of the tongue from untying sutures [8].

Alternatively, submucosal sutures to approximate the wound edges can help prevent chewing and breaking of the sutures.

Tetanus prophylaxis — Tetanus prophylaxis may be indicated for dirty wounds and should be considered in children who have avulsed teeth, deep lacerations, or intrusion injuries (table 4).

Prophylactic antibiotics — Most tongue lacerations heal well without prophylactic antibiotics, especially small lacerations that are not sutured [9].

We suggest prophylactic antibiotics for patients with tongue lacerations and any one of the following risk factors [10]:

●Heavily contaminated wounds

●Delay in debridement for more than 24 hours

●Wounds associated with jaw fractures requiring open reduction

●Immunocompromised patients

●Wounds sustained in human or animal bites (see "Animal bites (dogs, cats, and other mammals): Evaluation and management" and "Human bites: Evaluation and management")

Treatment should provide Gram-positive and anaerobic bacterial coverage (eg, amoxicillin-clavulanic acid, cephalexin, or clindamycin, orally for five days).

Although it is reasonable to assume that all tongue lacerations are contaminated by microorganisms and/or foreign bodies, there is little evidence that prophylactic antibiotics affect the rate of infection in mucosal wounds [1,2,4,9,11]. For example, in a retrospective study of 73 children with tongue lacerations (12 undergoing repair), none received prophylactic antibiotics, and no infections were reported [1].

COMPLICATIONS — Within the first 48 hours, complications of tongue laceration can include edema, hemorrhage, and aspiration of saliva and blood. Mild lingual edema may be controlled by application of cold (ie, ice chips, Popsicles). A single dose of intravenous (IV) steroids (eg, Decadron 0.6 mg/kg) may be considered in more severe cases if no contraindications are present; hospitalization may be warranted until airway patency is ensured.

Other complications of tongue laceration include dehiscence and infection. Dehiscence of tip of the tongue or through-and-through lateral lacerations may result in poor appearance and function. Prevention of dehiscence entails placing sutures loose enough to permit swelling. (See 'Procedure' above.)

DISCHARGE INSTRUCTIONS — The post-emergency department care of tongue lacerations, whether or not they are closed primarily, involves maintenance of good oral hygiene, ingestion of a soft diet, prevention of swelling, and monitoring the wound for signs of infection.

●If the local anesthesia was used, avoid eating or drinking until the local anesthetic has worn off and oral sensation has returned.

●Eat a soft diet for two to three days to ensure rapid healing.

●The patient should drink or gently rinse their mouth with water after eating.

●Frequent application of cold (by sucking on ice chips) may help prevent tongue swelling.

●Take care when using a toothbrush, especially in young children.

●The patient should be advised to watch for signs of wound infections (eg, fever, increased pain, and/or swelling).

Although often a standard recommendation, evidence is lacking to indicate that sucking on a straw increases the risk of bleeding or delayed healing in patients with tongue lacerations.

Follow-up — Before the patient leaves the emergency department, follow-up within 48 hours should be arranged. This follow-up may occur with the patient's primary care provider or in the emergency department (if primary-care follow-up cannot be arranged). In addition, patients with dental injuries should be seen by a dentist within 24 hours.

SOCIETY GUIDELINE LINKS — Links to society and government-sponsored guidelines from selected countries and regions around the world are provided separately. (See "Society guideline links: Human bites".)

SUMMARY AND RECOMMENDATIONS

●Evaluation – During evaluation, rapidly identify and stabilize respiratory, circulatory, or neurologic compromise and brisk tongue bleeding. Patients should also have careful determination of tongue laceration location, depth, and length and any associated injuries to the head, neck, and oral cavity (eg, dental fractures, dental avulsions, jaw fractures, or midface fractures). (See 'Evaluation' above.)

●Decision to repair – The majority of tongue lacerations heal without intervention.

•For patients with tongue lacerations, we suggest repair of lacerations with the following characteristics (Grade 2C) (see 'Decision to repair' above):

-Large lacerations (>2 cm in length) that extend into the muscular layers or pass completely through the tongue

-Deep lacerations at the lateral border of the tongue

-Large flaps or gaps in the tongue

-Lacerations with significant hemorrhage

-Lacerations that may cause dysfunction if healed improperly (anterior split tongue)

•Lacerations that do not require repair include (see 'Decision to repair' above):

-Non-gaping lacerations on the dorsum of the tongue

-Gaping lacerations on the dorsum of the tongue that are ≤2 cm in length and come together when the tongue is at rest in the mouth

●Preparation – Necessary equipment for tongue laceration repair is provided. Prior to irrigation and debridement, anesthetize the tongue by direct local infiltration or an inferior alveolar block. Important considerations include (see 'Preparation' above):

•Procedural sedation may be necessary in young children and other uncooperative patients. Ketamine has the advantage of preserved airway reflexes in not contraindicated. Sedated patients still require local or regional anesthesia as well as diligent attention to suctioning of saliva, blood, and irrigant solution from the anterior pharynx during the procedure to avoid aspiration and laryngospasm. Extensive lacerations that need a prolonged repair time and those associated with copious bleeding require repair with proper airway control under general anesthesia in the operating room. (See "Procedural sedation in children: Approach" and "Procedural sedation in children: Selection of medications", section on 'Moderately or severely painful procedures'.)

•During the procedure, use a bite block or side mouth gag, as needed, to prop open the mouth during irrigation and laceration repair. A large-gauge traction suture (eg, 3-0 nonabsorbable placed through the anterior portion of the anesthetized tongue) can also help provide better positioning (figure 3). Sit the patient upright as much as possible to support the airway and reduce the risk of aspiration of blood or irrigant. (See 'Site (wound) access' above.)

●Procedure – Repair techniques according to the location and depth of the tongue laceration are provided above. (See 'Laceration repair with sutures' above.)

●Aftercare – Most tongue lacerations heal well without prophylactic antibiotics, especially small lacerations that are not sutured.

•We suggest prophylactic antibiotics for patients with tongue lacerations and any one of the following risk factors (Grade 2C) (see 'Prophylactic antibiotics' above):

-Heavily contaminated wounds in which debridement is suboptimal

-Delay in debridement for more than 24 hours

-Wounds associated with jaw fractures requiring open reduction

-Immune-compromised patients

-Wounds sustained in human or animal bites

Treatment should provide Gram-positive and anaerobic bacterial coverage (eg, amoxicillin-clavulanic acid, cephalexin, or clindamycin, orally for five days).

•Before discharge from the emergency department, provide tetanus prophylaxis, as needed (table 4), and arrange follow-up within 48 hours for a wound check. Instruct patients to eat a soft diet and monitor the oral cavity for signs of infection. (See 'Tetanus prophylaxis' above and 'Discharge instructions' above.)

ACKNOWLEDGMENT — The UpToDate editorial staff acknowledges Erin Endom, MD, who contributed to an earlier version of this topic review.