A 35-year-old female is brought to the emergency department by ambulance after she was the restrained driver in a vehicle that was rear-ended at low speed. Her only notable injury is a complicated tongue laceration that resulted when she bit down on her tongue during impact. There is a moderate amount of bleeding which EMS was unable to completely control but the patient is maintaining her airway.
Educational Objectives:
After evaluating this article, participants will be able to:
1. Develop strategies to determine which tongue lacerations to repair and which not to
2. Incorporate strategies into practice for effective repair of lingual lacerations
3. Develop safe strategies for addressing lingual lacerations
A 35-year-old female is brought to the emergency department by ambulance after she was the restrained driver in a vehicle that was rear-ended at low speed. Her only notable injury is a complicated tongue laceration that resulted when she bit down on her tongue during impact. There is a moderate amount of bleeding which EMS was unable to completely control but the patient is maintaining her airway.
Injuries to the tongue are not an infrequent presentation to the emergency department, often occurring after seizures, blunt force trauma (motor vehicle crashes), or falls. Proper management of these lacerations is important to preserve the tongue’s function in manipulating food, facilitating swallowing, and articulating speech. That being said, management decisions are complicated by conflicting recommendations in the oral-maxillofacial literature and a lack of clear consensus on which lacerations should be repaired.
As in virtually every injury encountered in the ED, assessment of airway, breathing, and circulation is the first priority. Significant tongue lacerations can create airway difficulties, especially if the lingual artery is lacerated. The emergency physician will need to establish a definitive airway if there is compromise due to hemorrhage. Hemostasis can often be achieved with pressure, cold, inactivity, or, failing these, suturing of the laceration.
When proceeding to laceration repair, there are several methods of achieving effective anesthesia. For simpler or smaller lacerations, the area can be covered with a 4% lidocaine-soaked gauze for 5-10 minutes. Local infiltration with lidocaine with epinephrine is another option. For larger or more complicated lacerations, an inferior alveolar nerve block or a lingual nerve block can be more effective.
Although conscious sedation is a consideration we were able to perform the nerve blocks easily with adequate anesthesia. During the course of the repair the patient required a repeat nerve block which allowed us to finish the repair with adequate anesthesia. Adding a long acting local anesthetic may have avoided the need to re-block the patient. The best part of knowing these nerve blocks is that they allow you to avoid conscious sedation in a patient where conscious sedation may worsen any airway issues inherent with lingual and facial injuries.
What to repair in ED
Primary repair in the ED should be considered for tongue lacerations with the following characteristics:
–Bisecting wounds
–Large flaps
–Persistent bleeding
–Larger than 1cm
–Gaping at rest
–U-shaped
Complete or partial amputations should prompt consultation with oral-maxillofacial surgery or otolaryngology for replantation or repair in the operating room. Simple, linear lacerations on the dorsum of the tongue generally heal well without suturing. Additionally, most tongue lacerations in children heal without intervention as well.
Once sufficiently anesthetized, the wound should be thoroughly inspected. Some through-and-through lacerations may not be immediately obvious. Additionally, any tooth fragments must be identified and removed so as not to promote infection. Thorough irrigation is recommended.
Inferior Alveolar Nerve Block (Image 2)
The inferior alveolar nerve is the largest branch of the third division of the trigeminal nerve (V3 or the mandibular nerve). It is covered by the external pterygoid muscle as it descends and passes between the ramus of the mandible and the sphenomandibular ligament, entering the mandibular foramen in the ramus of the mandible. As it does so, it lies in the pterygomandibular triangle. The lingual nerve is the second branch of the mandibular nerve and runs superficially to the internal pterygoid muscle and enters the base of the tongue lingually to the third molar. In practice, the lingual nerve and inferior alveolar nerve are commonly blocked together with one approach and will provide anesthesia to:
- The body of the mandible and lower portion of the ramus
- The mandibular teeth on the side that is blocked
- The anterior two-thirds of the tongue
- The gingiva on the lingual and labial surfaces of the mandible on the side that is blocked
- The mucosa and skin of the lower lip and chin
The patient should be placed upright either in a dental chair or with his head in contact with the back of the stretcher. The anterior border of the mandibular ramus should be palpated with the thumb and the greatest concavity (the coronoid notch) identified. The ramus is grasped with the thumb placed intraorally on the coronoid notch and the index finger placed extraorally behind the ramus so that the pterygomandibular triangle can be exposed.
The barrel of the syringe should be parallel with the occlusive surfaces of the teeth and aligned between the first and second molar premolars on the opposite side. The needle is directed toward the pterygomandibular triangle with point of entry roughly 1cm superior to the occlusal surface of the molars. Bone should be contacted roughly within 2.5cm of insertion (the posterior wall of the mandibular sulcus). The needle should be withdrawn slightly, aspirated, and, if no blood returned, 1-2mL of anesthetic injected. The lingual nerve can be anesthetized by injecting several milliliters of anesthetic while withdrawing the needle, but, given its proximity to the inferior alveolar nerve, successful anesthesia is usually attained using the above technique alone.
Bone must be contacted on initial needle placement. Failure to do so usually signifies that the insertion is too posterior, and injection can result in parotid gland infiltration and facial nerve anesthesia. If bone is not felt, the needle can be redirected more laterally.
Lingual Nerve Block (Image 3)
Some references report that if you have not achieved adequate anesthesia that efforts to block the Lingual nerve can be tried. The Lingual nerve lies inferior and medial to the mandibular 3rd molar alveolus. The approach is visualized in image 3.
How to Repair (Images 4-6)
To maintain the tongue in protrusion, it can be manually held with gauze, grasped with towel clamps, or held in protrusion by a large suture (e.g., 0-silk) passed through the tongue.
Absorbable sutures, such as chromic gut, should be used for primary repair. Nylon sutures have
sharp ends and may irritate the oral mucosa. Several methods of closure have been described. Simple interrupted sutures with wide margins can be used to close all three layers (dorsal epithelium, muscular mucosa, ventral epithelium) with a single suture. In a two-layer technique, one suture closes half the thickness superiorly while a second suture closes half the thickness inferiorly. Finally, the muscular mucosa can be closed with a buried absorbable suture, and the superficial epithelial layers left to heal without sutures.
Tongue sutures frequently untie, rapidly absorb, or fall out, so they do not require removal. Patients should be advised to adhere to a soft diet for 2-3 days and gently swish and spit with an antiseptic mouthwash (e.g., dilute peroxide mouth rinse) daily. Provided there is adequate irrigation, the rate of wound infection is low, and most authors do not recommend routine antibiotics.
Case Conclusion
Since the wound was gaping, bisected the tongue, and had persistent bleeding, we elected to suture it closed. Anesthesia was obtained with bilateral inferior alveolar nerve blocks, and the wound was closed with a two-layer technique with effective hemostasis and a good cosmetic result. In follow up, the patient sent us photos of her repaired tongue. She has continued anesthesia and problems with taste to the anterior portion of the tongue several months out from her injury and repair.
References
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- Patel A. Tongue lacerations. Br Dent J. Apr 12 2008;204(7):355.
- Ud-din Z, Aslam M, Gull S. Towards evidence based emergency medicine: best BETs from the Manchester Royal Infirmary. Should minor mucosal tongue lacerations be sutured in children? Emerg Med J. Feb 2007;24(2):123-4.
- Bringhurst C, Herr RD, Aldous JD. Oral trauma in the emergency department. Am J Emerg Med. Sep 1993;11(5):486-90.
- Roberts JR, Hedges JR (2010). Clinical Procedures in Emergency Medicine. Philadelphia: Saunders Elsevier