Complex Tongue Laceration 

The tongue is enveloped by mucosa and contains glands, sensory organs, and 4 pairs of extrinsic muscles. The tongue is essential for several important functions, including normal articulation of the jaw, manipulation of food, swallowing, and the production of normal speech. See image below.

From anterior to posterior, the tongue has 3 surfaces: tip, body, and base. The tip is the highly mobile, pointed anterior portion of the tongue. Posterior to the tip lies the body of the tongue, which has dorsal (superior) and ventral (inferior) surfaces. For more information about the relevant anatomy, see Tongue Anatomy.

Injuries to the tongue, are often treated in the emergency department or other acute care settings. A tongue laceration is often the result of a fall, seizure, or other blunt force mechanism.^[1] Lacerations secondary to seizures are most often found to the side of the tongue.^[2] Because of the tongue’s generous blood supply, most tongue lacerations do not become infected and heal well without repair. However, repair is required when the injury has certain characteristics (see Indications).

The goals of laceration repair of the tongue are to attain adequate closure, minimize complications, preserve mobility, and optimize articulation and deglutition.

Most children with intraoral trauma have not suffered any abuse. However, practitioners should keep in mind that such injuries can certainly be the result of physical abuse.^[3]

Characteristics of tongue lacerations that require repair include the following:^{[4, 5, 6]}

• Bisecting wounds
• Large flaps
• Persistent bleeding
• Wounds larger than 1 cm
• Gaping wounds
• U-shaped lacerations
• Avulsion or amputation injuries (The tongue may be primarily closed if the defect is less than 30% of the tongue.)

• Most tongue lacerations do not require sutures.

  • Small flaps may be simply excised.
  • Tongue lacerations in children are known to heal well without intervention.^[7]
  • Simple linear lacerations, especially if centrally located, heal with minimal risk of infection.
• Amputations or avulsions of more than 30% require a flap procedure, which should be performed by a specialist.^{[8, 9]}

• Any of the following anesthesia techniques may be employed:

  • Topical anesthesia with lidocaine 4% on gauze for 5 minutes (See Anesthesia, Topical for more information.)
  • Local infiltration with lidocaine 1% (See Local Anesthetic Agents, Infiltrative Administration for more information.)
  • Lingual nerve block for the anterior two thirds of the tongue
  • Procedural sedation
  • General anesthesia
• The pain associated with local anesthesia injections can be diminished if the practitioner uses a smaller gauge needle and administers the anesthetic slowly.^[10]

Personal protective equipment

• Gloves
• Face shield
• Gown

Anesthesia equipment

• Lidocaine
• Syringe, 10 mL
• Needle, 27 gauge (ga)
• Needle, 18 ga
• Topical anesthetic

Irrigation equipment

• Saline or water
• Syringe or irrigation device
• Splash shield
• Basin

Suture material

• Absorbable sutures (eg, plain gut, chromic gut), 4-0
• Suture tray
• Suture kit
• Towel clip

Other equipment

• Side mouth gag (eg, Denhardt, Dingman)
• Bite block
• Towel clip
• Gauze, 4 X 4 in

• The supine position is preferable for most repairs.
• The patient may sit in an ENT chair, if necessary.

Preparation

• Once the patient is anesthetized, inspect the wound carefully.
• Some through-and-through lacerations may not be obvious without gentle probing.
• Always check for chipped, missing, or mobile teeth in mouth injuries. Tooth fragments may be lodged inside the wound and, if not removed, may serve as a nidus for infection.
• Intraoral wounds are prone to considerable contamination, and thorough irrigation is necessary.
• The major difficulty in closing a tongue laceration is maintaining control of the area being sutured. To stabilize and hold in protrusion for repair, the tip of the tongue can be grasped with gauze or a towel clip or punctured and withdrawn with a large suture.
• A bite block may be used to protect both the patient and physician, as necessary.

Suturing

Through-and-through lacerations may be closed in 1-3 layers.

As long as the muscular layer is closed, bleeding is sufficiently controlled, motor function is returned, and the mucosal layers heal rapidly. See images below.

Three-layer technique

• Using 4-0 absorbable sutures, first close the muscular mucosa.
• The inferior mucosa is then sutured.
• The repair is then extended up and around the lateral aspect of the tongue to close the superior mucosa. See images below.Cross-section: Three-layer closure technique.

  Closure of the muscular mucosa as the first step of a three-layer technique.

Two-layer technique

• Use one stitch to approximate half the thickness of the tongue superiorly.
• Use another stitch to approximate half the thickness inferiorly.
• Close the edges of the tongue.
• Sutures do not have to be buried. See image below.Cross-section: Two-layer closure technique.

One-layer technique

• Some suggest using a deep absorbable suture to close only the muscular layer, leaving the other layers open to heal without sutures.
• This technique is successful because of the rapidly healing superficial mucosa. See image below.Cross-section: One-layer closure technique.

The frequent movements of the tongue often untie the sutures.

• This can be avoided by burying the stitches or tying many knots.
• Avoid nylon in the mouth and tongue.

Aftercare

• After repair, the patient should eat a soft diet for 2-3 days.
• Daily dilute peroxide mouth rinses should be used.
• Healing occurs very rapidly.

• Update the patient's tetanus vaccination, if necessary.
• The use of prophylactic antibiotics for tongue injury is controversial, but they should be used in any contaminated wound.^[11] Ultimately, as one current review of the literature concluded, "treatment decisions must be guided by clinical and scientific rationale rather than evidence-based medicine."^[12] For more information, see Medscape Reference article Human Bite Infections.

• Infection
• Impaired articulation
• Impaired deglutition