Yes, as we’ve mentioned before, kids are often Gravitationally Challenged. Toddlers, toddle and tumble constantly. Often, this leads to simple bumps and bruises and minor injuries. Occasionally, these injuries appear rather dramatically though. One that will always catch parents’ attention is when the fall leads to a Tongue Laceration.

Tongue Laceration: The Bad

• As always, consider worse first…
• Airway Compromise
  • The tongue is highly vascular and can bleed substantially.
    • This is good, as it will allow the wound to heal rapidly, but…
  • This bleeding can cause significant tongue swelling.
  • Naturally, oral bleeding can also endanger the airway.
• Retained Foreign Bodies
  • Just like any wound, consider that the object that caused the wound may still be lingering within it!
  • Fragments of teeth
  • Fragments of other objects that were in the mouth during the trauma (ex, Popsicle stick)

Tongue Laceration: The Common

• The most common location is the anterior, dorsal portion of the tongue.
• Next most common is middle of the dorsal portion and the anterior, ventral aspect.
• More posterior locations are less common. [Lamell, 1999]
• When you find one laceration, always look for another… especially on the other side of the tongue.

Tongue Laceration: The Management

• Think worse first…
  • Don’t get distracted by the obvious tongue injury.
  • It’s a trauma… So assess the Airway.
  • Are there other signs of intracranial, facial, or neck trauma?
• Assess other intra-oral structures
  • Is there a oral floor hematoma?
  • Is there posterior pharyngeal trauma?
  • Is the base of the tongue involved (possible hypoglossal nerve injury)? [Mohan Das, 2008]
• Think about possible Foreign Bodies…
  • If there is evidence of tooth fracture, worry that that missing piece is in the tongue.
  • Ask about other objects that may have been in the mouth.
• Don’t Be Cruel… Treat the pain
  • NSAIDs are reasonable.
  • Topical Lidocaine applied to the wound (ex, 4% lidocaine soaked gauze for 5 min).
  • Regional blocks are possible, but more challenging in toddlers.
• Irrigate the Wound
  • Infection is rare… but irrigation will help you evaluate the injury also.
  • After care should include continued dental hygiene and oral care with antiseptic mouth wash.
• To Close or Not To Close
  • This has not been well researched, but has dogmatic teachings.
    • “If a piece of corn fits in it, it needs to be closed.”
      • But… what size piece of corn… are we talking about little baby corn, or giant corn kernels?
    • “If it crosses the side margin of the tongue, it needs to be closed.”
      • But… what about those post-seizure tongue lacs that always seem to involve the margin?… they seem to do well without closure.
    • “If it gapes open, it needs to be closed.”
      • But… what if it only gapes open when the tongue is protruded?
  • There is evidence that even wounds that gape or include tongue margin can be managed without suturing. [Lamell, 1999]
  • Some advocate for closing wounds that: [Ud-din, 2007; Mohan Das, 2008]
    • Bleed uncontrollably 
    • Endanger the airway
    • Are a “Significant” segment of severed tongue; 2cm or greater
  • Wounds that involve the margin or tip still often heal and remodel without closure. [Mohan Das, 2008]
• Patients with Bleeding Disorders?
  • Bleeding disorders (ex, Hemophilia) should heighten your concern.
  • Have a lower threshold to close these wounds to help control hemorrhage.
  • Don’t forget the possibility of intracranial hemorrhage.
  • Give Factor replacements!!

Tongue Laceration: Time to Close

• The vast majority do NOT require closure… but some will. When that time comes, be kind.
• Will require some type of sedation.
• Use a bite block to help keep mouth open safely.
• Use towel clamp to grasp tongue and immobilize it.
  • Can also use large suture to pull tongue out, but put another hole in the tongue.
• Close with absorbable suture (ex, 5-0 Chromic Gut). [Brown, 2007]
  • Or, you may even consider 2-octyl cyanoacrylate (aka, Dermabond) (see case report). [Kazzi, 2013]

References

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