Katie is a 4-year-old who presents to your department after a fall off her bike. She landed chin first and has sustained a tongue laceration – she appears to have bitten it. Both she and her mum are very distressed on arrival.
The most common site of injury is the anterior dorsal part of the tongue, which is the surface we see when the tongue is protruded. The next most common is the middle dorsal, and then the ventral aspect. More posterior sites (i.e. the base) are less commonly injured.
When you find one laceration it’s important to look for a second, especially on the other side of the tongue. If there are front and back lacerations, you need to carefully examine them to see if they are connected to make a tract (a through-and-through laceration). These always need to be repaired as they can have poor healing and fistula formation.
The tongue has a large vascular bed and great capacity for regeneration thus making it an ideal candidate for conservative management.
A tongue laceration is usually due to trauma. This can range from a simple fall where the tongue is accidentally bitten, to a more serious mechanism. They can also occur in the context of a seizure where the child bites their tongue – don’t forget a full primary and secondary survey. Look for any evidence of head injury. Always remember to assess the neck (particularly if the point of impact has been the chin, they may have hyperextended the neck).
The next step is to assess bleeding: major haemorrhage from the tongue, particularly if one of the volar blood vessels are injured, can threaten the airway. Swelling of the tongue if extensive can also threaten the airway.
You need to assess other intraoral structures for signs of injury eg pharynx, soft palate, teeth.
If there is evidence of dental injuries (broken teeth, missing teeth) always think about foreign bodies, e.g. teeth, within the tongue wound, or potential for aspirated foreign bodies/teeth.
As with all injuries to children, analgesia should be considered early and often. You are not going to be able to fully assess the tongue and mouth of a distressed/screaming child.
PO/PR paracetamol 15mg/kg and ibuprofen 10mg/kg are a mainstay of treatment.
Intranasal fentanyl or diamorphine is very useful in this scenario. It has a fast onset of action (7 minutes approximately). It is administered intranasally so the child doesn’t have to put anything in their sore mouth. It is a strong opioid so they will get considerable relief, and it will buy time for the other oral analgesics to start working.
Topical anaesthetics have a role. For example, lidocaine soaked gauze can be applied directly to the tongue without a need for injecting it. The parent can hold it in place if this makes the child more comfortable. It does have a bitter taste so potentially may not be well tolerated in a younger child.
Regional local anaesthetic blocks are possible in theory but will be difficult in toddlers/younger children, particularly in their distressed phase when they first arrive.
Once reasonable analgesia has been achieved, the wound needs to be thoroughly irrigated in order to clean the wound but also to remove debris to allow for a full evaluation. During irrigation, you should be looking for evidence of foreign bodies or through-and-through lacerations.
To close or not to close
There is evidence that most tongue wounds do very well without intervention / primary closure, even if they are gaping.
Some studies advocate closure in certain types of wounds :
- Those with bleeding not controllable with simple means
- Those that are >2cm in size,
- Those with >2cm with gaping edges when tongue is at rest.
Wounds that involve the margin or tip still often heal and remodel without closure.
The most recent study published found that larger wounds, with gaping edges, involving the tongue border were more likely to be sutured. However these had a higher rate of complications including wound infections. They also had a longer recovery time (see table). The cosmesis achieved at the end of healing was no better in the sutured group compared to those in the secondary healing group.
If closure is needed
If formal closure is needed, the child will usually need to go to theatre. Oral maxillofacial surgeons will repair these in most hospitals. This is because general anaesthetic is usually needed, and also because an environment where anaesthetics are available to protect the airway due to the risk from bleeding is a must.
A bite block (eg a rolled up piece of gauze, or a repurposed OPA positioned between the teeth) can keep the mouth open and teeth unclenched.
The tongue will need to be held out of the mouth; this can be achieved by using a large suture through the centre that can be used to pull the tongue out. This may cause further trauma. The tongue can also be held out using a towel clamp. It then needs to be kept dry and saliva free to achieve a dry field for suturing.
Lidocaine is usually injected for post-procedure comfort. The wound will be sutured with an absorbable suture, this negates the potentially difficult and distressing removal of sutures. There is no robust evidence that prophylactic antibiotics are needed, as long as the wound is sufficiently irrigated there is not a big infection risk.
There has been one case report of a tongue laceration that did very well when closed with tissue adhesive, however, no robust data supports this.
Obviously, if the child has other illnesses eg bleeding disorder, you need to liaise with their primary team when making a management plan. There may be a lower threshold for closure to control haemorrhage in these cases and the child will likely need factor replacements.
On assessment, Katie has a 1cm wound on her dorsal anterior tongue. It gapes when tongue protrudes but not at rest. She has no broken teeth or other intra-oral damage. She is otherwise well, no evidence of head injury or neck injury. She receives analgesia at triage and is not distressed on examination. You decide to manage conservatively after a discussion with her mother. She is discharged with advice about oral hygiene and a soft diet for the next few days and advised to return if there are any issues.
Presenting characteristics and treatment outcomes for tongue lacerations in children. C. W. Lamell, G. Fraone, P. S. Casamassimo, S. Wilson. Pediatr Dent. 1999 Jan-Feb; 21(1): 34–38. https://www.ncbi.nlm.nih.gov/pubmed/10029965
Ud-din Z, Gull S; Should minor mucosal tongue lacerations be sutured in children? Emergency Medicine Journal 2007;24:123-124. https://emj.bmj.com/content/24/2/123.2
Das UM, Gadicherla P. Lacerated tongue injury in children. Int J Clin Pediatr Dent. 2008;1(1):39–41. doi:10.5005/jp-journals-10005-1007 https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4086539/
Seiler Michellea, Massaro Sandra Letizia, Staubli Georg, Schiestl Clemens; Tongue lacerations in children: to suture or not? Publication Date: 28.10.2018 Swiss Med Wkly. 2018;148:w14683https://doi.org/10.4414/smw.2018.14683
Pediatric Tongue Laceration Repair Using 2-Octyl Cyanoacrylate (Dermabond®) Kazzi, Massoud G. et al. J Emerg Med 45(6):846–848 https://www.jem-journal.com/article/S0736-4679(13)00462-9/fulltext