Surgical versus conservative management of tongue lacerations in the acute care setting: A systematic review of the literature

Abstract

Objective

The objective of this study was to determine whether suturing or conservative management of tongue lacerations results in differences in wound healing and functional outcome. The secondary aim was to identify whether antibiotics are required in the treatment of tongue lacerations.

Methods

Studies published between December 1954 and August 2020 were extracted from MEDLINE via PubMed, Embase via OVID, CINAHL via EBSCO, Web of Science, and the Cochrane Library and evaluated for inclusion based on predetermined inclusion and exclusion criteria by two independent reviewers in accordance with PRISMA guidelines.

Results

The search yielded a total of 16,111 articles, 124 of which were evaluated by full-text review, resulting in 11 articles included in this systematic review representing 142 unique cases of tongue lacerations. At least 26 lacerations (18.3%) included penetration of the muscle layer of the tongue, and 24 (16.9%) were classified as full-thickness lacerations. Thirty-five of the 142 tongue lacerations (24.6%) were sutured. The remaining lacerations underwent some form of conservative management. The majority of studies reported excellent healing of tongue lacerations regardless of the management method, with minimal scarring and excellent return to normal functional status. No cases of infection were reported.

Conclusions

Current literature is inconsistent with regards to indications and guidelines for primary repair of tongue lacerations. The majority of tongue lacerations reported in the literature heal with excellent outcomes regardless of management method. Physician judgement along with patient and parental preference based on potential risks of the procedure should be used when deciding whether a tongue laceration requires primary repair. Tongue lacerations in otherwise healthy individuals are at very low risk of infection.

Graphical Abstract

Graphical Abstract.

Injuries to the oral cavity are often preceded by traumatic events and are a frequent presentation among the paediatric population in the acute care setting (1,2). Most tongue injuries are self-induced from mastication but may also result from falls, seizures, and other trauma. Potential complications of tongue injuries include infection, bleeding, and airway occlusion. Due to the rich vascular supply, injuries to the tongue generally heal well. However, bleeding and swelling of the tongue can result in airway occlusion (3).

Currently, there is a lack of consensus in the literature regarding the optimal management of tongue lacerations. Ud-din et al. reported that there are an insufficient number of high-quality studies examining the suturing management of tongue lacerations, with their literature review in 2007 yielding only one relevant result (4). Similarly, the literature describing the management of oral lacerations contains limited discussion on the efficacy of antibiotic prophylaxis or the clinical outcomes following injuries to the oral cavity, including tongue lacerations specifically (5). As such, the primary aim of this review was to systematically identify studies of the outcomes of tongue laceration repairs in order to determine whether suturing or conservative management leads to better wound healing and functional outcome. The secondary aim was to identify whether antibiotics are indicated in the treatment of tongue lacerations.

MATERIALS AND METHODS

This systematic review was conducted in accordance with the Preferred Reporting Items for Systematic Reviews and Meta-analyses (PRISMA) guidelines where applicable (6).

Search strategy

A literature search was developed with the help of a medical librarian and was performed through the following databases: MEDLINE via PubMed, Embase via OVID, CINAHL via EBSCO, Web of Science, and the Cochrane Library. The search strategy was developed using keywords consisting of variations of ‘tongue’, ‘mouth’, ‘maxillofacial injury’, ‘oral injury’, ‘laceration’, ‘trauma’, ‘injury’, ‘wound’, and ‘bite’. Full search strategy can be found in Supplementary Appendix A.

Eligibility criteria

Articles were deemed eligible for inclusion if they were original articles published in English before August 26, 2020. Original articles relevant to tongue lacerations in humans of any age were included as long as the article included details on whether the tongue was repaired with sutures or was treated conservatively with or without antibiotics, and report outcomes.

Exclusion criteria

Review articles, recommendations, expert statements, and technical reports were excluded. The following tongue injuries were also excluded: ulcerations, intentional self-inflicted injury, amputation, injury including involvement of the oropharynx or associated vasculature, iatrogenic causes such as tongue lacerations that occurred secondary to intubation or transesophageal echocardiography, and traumatic causes such as gunshot wounds or vaping device injuries. In addition, papers describing tongue laceration repair methods without patient outcomes were excluded.

Study selection and identification

Duplicates were removed. Title and abstracts were screened by two reviewers (CG and JZ) to select ones that warranted full text review. Full-text screening was then completed for any articles that mentioned tongue laceration. All conflicts were resolved by an independent third-party reviewer. Finally, the bibliographies of all included articles were reviewed for additional relevant studies (Supplementary Appendix B).

Data collection

The following data were collected where available from eligible studies: geographical location, age, sex, injury characteristics including mechanism of injury, and wound characteristics including size, bleeding at time of presentation, and contamination of the wound. Finally, data related to management and outcomes were extracted, including antibiotics or any other medications given, the type of sutures that were used and method for wound closure where applicable, time until follow-up, and functional status achieved following treatment.

RESULTS

Seven thousand one hundred and thirty were duplicates, so 16,111 titles and abstracts were screened. Full text was screened for 124 articles, of which 10 met the inclusion criteria. One additional eligible article was identified from the screening of all bibliographies (Supplementary Appendix B).

The 11 included articles were observational studies published 1996 through 2020. Five were from the USA, three were from the United Kingdom, one from Switzerland, one from India, and one from Japan. They included case reports (n=7), retrospective reviews (n=2), one prospective observational study, and one case series. A case series was defined as a publication in which multiple cases of tongue lacerations were each individually described, whereas retrospective review was defined as articles in which aggregate data were collected retrospectively but details pertaining to individual cases were not able to be isolated. All studies were peer-reviewed and the majority (n=7) described patients who presented to an emergency department. Given the limited quality of evidence, a meta-analysis was not performed.

The 11 articles described 142 patients with tongue lacerations, of which 79 (56%) were male, 29 (20%) were female, and 34 (24%) were of unknown sex. At least 106 (76%) of these cases occurred in children (aged 18 years and younger). The mean age of patients was 20.8 years with a range of less than 1 year of age to 86 years old. Eight of the eleven studies described the management of tongue lacerations while three studies formally compared suturing to conservative management with or without the use of antibiotics, via retrospective reviews or prospective observational study designs (Table 1).

Table 1.

Tongue lacerations, management and outcomes

Study characteristics				Patient demographics		Wound characteristics		Management and outcome
Author	Location	Study type	Sample size	Age (years)	Sex	Wound etiology	Laceration characteristics	Repair	Outcome
Baurmash et al. 2005(7)	USA	Case series	2	53	Male	Severe seizure (epilepsy)	Mid-portion of the left side of the tongue, involving muscle layer, extending from dorsum to the ventral surface.	Wound was debrided of necrotic tissue, wound margins were injected with hyaluronidase, wound was dressed in wet gauze. Laceration was compressed until margins flattened/softened. Mucosa and muscle were trimmed then closed in layers. Postoperative care included Amoxicillin 500 mg for 5 days and soft diet.	Complete healing at 18 days following primary closure
				28	Male	Bite wound as a result of a fistic altercation (presented 5 days after injury)	Dorsal surface of the anterior one-third of the tongue. Wound was widely dehisced with swollen rolled borders.	Wound was cleansed and debrided. Wound margins were injected with hyaluronidase. Laceration was compressed until margins flattened/softened. Mucosa and muscle were closed in layers (gut and silk sutures). Postoperative care included penicillin VK 500 mg 4 times daily for 5 days and soft diet.	Excellent healing at 17 days following primary closure
Coyne et al. 2002(8)	UK	Case report	1	2	Male	Hypoxic encephalopathy, teeth grinding and biting during recovery phase (after sedation withdrawn and extubated)	Lateral borders of the tongue	Chlorhexidine 2% applied to lesions daily, every 3 h.	Healed, no complications.
Das et al. 2008(9)	India	Case report	1	1.5	--	Fall from first floor of building	Left lateral border of tongue measuring 1.5 cm × 1 cm × 0.5 cm	Sutured with catgut 3-0 under monitored anesthesia. Follow-up included antibiotics and chlorhexidine mouthwash.	Healing satisfactorily
Hino et al. 2008(10)	Japan	Case report	1	25	Male	Motocross accident with helmet, without mouthguard	Dorsal and ventral surfaces extending from right molar region to left molar region. Laceration contaminated with dirt.	Rinsed with saline. Sutured (deep sutures with 3-0 Vicryl were placed in the muscle layer and then both ventral and dorsal surface mucosal layers were closed with 3-0. Vicryl).	No complications with speaking or eating
Kang et al. 2020(11)	USA	Case report	1	3	Male	Fall onto cement floor	Midline full-thickness laceration measuring 3.5 cm. Extended to between one-half to two-thirds of the free tongue	Operative repair under general anesthesia by plastic surgery. Wound edges were debrided. Homeostasis obtained. Halves of tongue aligned with silk sutures.	Healing process uneventful. No loss of sensation, mobility, taste or speech
								Buried 2-0 vicryl used to approximate the middle muscular layer. 3-0 chromic running sutures used for dorsal and ventral epithelium.
Kastsetos et al. 2016(5)	USA	Retrospective review	32	Unclear	Unclear	Trauma mechanism not otherwise described	32 (10%), 25 were ‘simple’, 7 were complex (through and through or greater than 2 cm)	All complex lacerations received absorbable sutures.	No infection in tongue laceration cohort
Kazzi et al. 2013(12)	USA	Case report	1	7	Male	Pushed to the floor in the schoolyard	Superior surface of tongue measuring 1.3 cm (~40% of the tongue’s width). Minimal penetration into the muscular layer. Gaping wound requiring re-approximation	Three layers of 2-octyl cyanoacrylate (Dermabond) were applied and allowed to dry.	Healed with excellent cosmetic results. No evidence of injury. No complications reported.
Lamell et al. 1999(2)	USA	Prospective observational	28			Fall or unknown	Mean size was 13 × 2 × 4 mm	Suturing vs. no suturing based on specific criteria detailed. No antibiotics.	No statistically significant difference for quality of result or post-trauma morbidity between sutured lacs and not sutured lacs.
Oluwole et al. 1996(13)	UK	Case report	1	86	Female	Domestic argument	Ventral surface of the tongue extending from one retro-molar region to the other. Mid-line laceration on the undersurface of the tongue extending from the transverse laceration toward the tongue tip.	Sutures were placed in two layers. 2-0 chromic catgut sutures applied to the muscle bulk and 2-0 Vicryl (used for mucosal closure).	3 days intubated in the ICU. Tongue was very swollen and lay permanently outside mouth for 8 weeks. At 3 months, tongue was once more intra-oral with little or no active retraction required.
Patel A. 2008(14)	UK	Case report	1	11	Male	Fall onto concrete	Dorsal surface of tongue measuring 3.5cm in length. Gaping 1cm at rest.	Conservative management	Healed extremely well with evidence of a minor scar.
Seiler et al. 2018(15)	Switzerland	Retrospective review	73	4 +/-2.6 years, range 6 months to 13.5 years	55 (75.3%) male	Variable, not otherwise described	Tongue borders in 51 cases (69.9%). The mean size was 12.4 ± 8.3 mm. Through-and-through laceration in 23 patients (31.5%).	Primary wound repair was performed for 12 lacerations. Tongue lacerations were sutured with Vicryl 3-0 or 4-0 (coated polyglactin 910, Ethicon) as well as with a single and recessed button suture. Antibiotics were not prescribed.	The group with wound suturing needed longer to recover (median 13 days compared to 6.2 days) and had a higher rate of complications (25 vs. 3.3%). No wound infection occurred. A scar was noticed in 38.4% of patients (higher in the surgical management group 58.3% vs. 34.4%) . Granuloma formation was noted in four children (5.5%) but self-resolved in three of the four.

Injuries

Of the 37 tongue lacerations for which mechanism of injury was reported, the majority of tongue lacerations were the result of a fall (n=28). Other etiologies included hypoxic encephalopathy, seizures, and altercations. The majority of lacerations were to the lateral borders of the tongue. At least 26 lacerations (18%) in this review included penetration of the muscle layer of the tongue and 24 (17%) were classified as full-thickness lacerations. Mean laceration length was reported for 105 cases (74%) and was 2.05 cm.

Management

Thirty-five of the 142 tongue lacerations (25%) were sutured and the remaining were managed conservatively including treatment with three layers of 2-octyl cyanoacrylate (Dermabond) (n=1), application of chlorhexidine (n=1), and no treatment (n=105). Of the sutures used for repair, the most common were Vicryl (2-0 and 3-0). Other sutures used included 2-0 and 3-0 chromic gut (not otherwise specified), 3-0 catgut and 4-0 coated polyglactin 910 Ethicon.

Antibiotic prophylaxis

Of the 35 patients who had their laceration sutured, 3 were treated with antibiotics. Of the 107 patients who received conservative management, 67 patients (47%) definitively did not receive any antibiotics. We were unable to determine how many patients were treated with antibiotics only as this data was only present in aggregate form of all oral injuries and could not be isolated to only tongue lacerations. Two studies that reported the use of antibiotics included amoxicillin or penicillin for a duration of 5 days. In an isolated case, 2% chlorhexidine mouthwash was used and in one case, both antibiotics (not otherwise described) and chlorhexidine were used.

Outcomes

The majority of patients were reported to have excellent healing of tongue lacerations regardless of their method of management, with minimal scarring and excellent return to normal functional status. Significant swelling resulting in the tongue lying outside of the mouth for a prolonged period of time was reported in one case. However, it is unclear whether the swelling was from the tongue laceration itself or other underlying injuries (13).

Of the studies that compared suturing to conservative management (2,5,15), one study (15) reported that the cohort requiring sutures required longer time for recovery, with a median of 13 days for the primary closure group versus 6.2 days for the conservative management group. This study also found that the cohort of children who underwent primary wound closure experienced higher rates of complications (25%) when compared to the conservative management group (3.3%). These complications included granuloma development in four children (5.5%) (of which three spontaneously resolved), and in another case, the development of a lisp. In this same study, scar formation occurred in 38.4% of patients overall, although the instance of scar formation was 58.3% in the primary closure group versus 38.4% in the conservative management group. It is also of note that in this study, children who underwent primary repair were found to have a longer duration of symptoms (2 weeks) compared to 1 week in the conservative management group. Lamell et al. found no statistically significant difference in quality of result or post-trauma morbidity between sutured lacerations and lacerations left to heal secondarily (2).

No cases of infection were reported.

Discussion

Of the 142 unique cases of tongue lacerations available in the literature, 106 of which occurred in children, only 25% were sutured while the remaining underwent some type of conservative management. The vast majority of studies reported excellent healing of tongue lacerations and regain of functional status regardless of the management method, with minimal scarring, excellent return to normal functional status, and no reported cases of infection. Reported complications included granuloma formation, scarring, and development of a lisp. Lacerations that did not require suturing (n=107) uniformly healed without sequelae. Prophylactic antibiotics were rarely prescribed yet no infections occurred in the 142 cases, suggesting that there is not an indication for antibiotic prophylaxis.

In children, there may be higher rates of complications with primary repair versus conservative management of tongue lacerations (15). However, those who require repair have more severe injuries than do those who do not. The current literature is inconsistent regarding characteristics of tongue lacerations that should prompt repair with sutures, with lack of clear guidelines and the presence of contradictory guidance (15). Historical teaching has recommended repair of tongue lacerations with sutures for wounds involving the lateral borders, having a large flap or gap at rest, length greater than 2 cm, and those without hemostatic control (16,17). The present review revealed one case of a paediatric tongue laceration that met criteria for primary repair based on these recommendations as it was gaping at rest but was treated conservatively with excellent outcomes including minimal scarring and normal functional status (14). Additionally, one case as reported by Kazzi et al. achieved satisfactory results through the off-label use three layers of 2-octyl-cyanoacrylate (Dermabond) on a gaping 1.3 cm tongue wound (12). Our review also found that the majority of tongue lacerations involve the lateral borders but rarely require repair with sutures for adequate healing. This supports the conclusion that physician judgement along with patient and parental preference and risks of the procedure itself should be used when deciding whether or not a tongue laceration requires primary repair. In the cases that were judged to require sutures, it is assumed that the benefits of primary repair, such as achieving hemostatic control and risk of infection for large, gaping wounds, outweigh the risks associated with surgical management.

The major limitation of this study is the small number of available studies, few of which compare one management strategy to another. It was not possible to pool data from the different studies. This review did not address lacerations that were the result of accidental injury and those of self-inflicted or iatrogenic causes.

Tongue lacerations represent an important and frequent cause of presentation to the emergency department, especially in the paediatric population. Although limited, the literature shows no clear benefit of primary repair when compared to conservative management for equivocal wounds and demonstrates that tongue lacerations in otherwise healthy individuals are at very low risk of infection. Given the paucity of literature on this topic, future directions include the need for prospective, case-controlled, comparative studies comparing primary repair to conservative management of tongue lacerations based on similar mechanism of injury and wound characteristics, to assess for differences in complication rates, regain of function status, and rates of infection as well as long-term studies to assess for functional outcomes following either management strategy.

Funding: There are no funders to report for this submission.

Potential Conflicts of Interest: All authors: No reported conflicts of interest. All authors have submitted the ICMJE Form for Disclosure of Potential Conflicts of Interest. Conflicts that the editors consider relevant to the content of the manuscript have been disclosed.