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Injury of tongue — Clinical Guidelines

Overview

Tongue injuries encompass a range of traumatic and iatrogenic damages affecting the complex muscular organ crucial for speech, swallowing, and mastication. These injuries can result from surgical excisions due to neoplasms, accidental trauma, thermal injuries from surgical instruments, or chronic conditions like oral ulcers. The clinical significance lies in the profound impact on patients' quality of life, including difficulties in communication and nutrition, as well as psychological distress. Given the tongue's critical functions and visibility, prompt and effective management is essential to prevent long-term functional impairments and aesthetic concerns. Understanding optimal treatment strategies is vital for clinicians to enhance patient outcomes in day-to-day practice 1 2 3 4 5.

Pathophysiology

Tongue injuries can lead to a cascade of pathophysiological events depending on the nature and extent of the damage. Acute injuries often initiate an inflammatory response characterized by increased vascular permeability, neutrophil infiltration, and the release of pro-inflammatory cytokines such as TNF-α. This inflammatory phase is crucial for initiating healing but can also cause secondary tissue damage if excessive 2 6. Chronic injuries or those involving deeper tissues may result in fibrosis and scar formation, particularly when traditional suturing methods are employed, leading to restricted mobility and altered tongue function 3 4. Additionally, the moist and mobile nature of the tongue complicates healing, often necessitating innovative biomaterials and delivery systems to ensure sustained therapeutic effects and minimize complications 1 10.

Epidemiology

The incidence of tongue injuries varies widely based on the context, with surgical excisions due to neoplasms being relatively rare but significant in clinical settings. Traumatic injuries are more common, particularly in pediatric populations and among individuals engaged in high-risk activities. Geographic and cultural factors may influence the prevalence of specific etiologies, such as dietary habits affecting the incidence of oral ulcers. Age and sex distribution often show no significant differences, though pediatric patients may present with unique injury patterns due to developmental factors. Trends suggest an increasing interest in minimally invasive techniques to reduce thermal damage and improve healing outcomes 1 2 3 4.

Clinical Presentation

Typical presentations of tongue injuries include pain, swelling, and functional impairment affecting speech and swallowing. Acute injuries may present with immediate bleeding and visible trauma, while chronic conditions like ulcers can manifest with persistent soreness and ulceration. Red-flag features include rapid progression of symptoms, signs of systemic infection (fever, malaise), and significant functional deficits that impact daily activities. These features necessitate urgent evaluation to rule out severe complications such as deep tissue necrosis or systemic spread of infection 1 2 3 4.

Diagnosis

The diagnostic approach for tongue injuries typically begins with a thorough clinical examination, including palpation to assess for tenderness and structural integrity, and visual inspection for signs of trauma or ulceration. Diagnostic imaging such as ultrasound or MRI may be considered for deeper tissue assessments, though these are less common for superficial injuries. Specific criteria and tests include:

Clinical Assessment: Detailed history and physical examination focusing on injury mechanism, duration, and functional impact.

Histopathological Examination: Biopsy samples may be required for definitive diagnosis in cases of suspected neoplasms or chronic ulcers.

Laboratory Tests: Blood tests to assess for signs of infection (elevated white blood cell count, C-reactive protein levels) 1 2 3 4.

Differential Diagnosis:

Oral Candidiasis: Typically presents with white patches that can be scraped off, revealing erythematous mucosa underneath.

Traumatic Ulcers: Often have a history of direct trauma and may show characteristic shapes or patterns.

Squamous Cell Carcinoma: Persistent ulceration with induration and irregular borders, often requiring biopsy for confirmation 1 2 3 4.

Management

First-Line Treatment

Wound Care: Cleanse the wound gently with saline to prevent infection. Apply topical agents like antiseptics (chlorhexidine) to maintain a sterile environment.

Biomaterial Applications: Utilize innovative hydrogels such as CPTCu (chitosan-polyacrylic acid-tannic acid loaded with copper-metallic-organic framework) for optimized healing. Apply as per manufacturer guidelines, typically ensuring continuous protection and promoting angiogenesis and reduced scarring 3.

Second-Line Treatment

Surgical Interventions: For extensive injuries or neoplasms, consider surgical excision followed by advanced wound coverage techniques such as PGA (polyglycolic acid) sheets with fibrin glue (MCFP technique) to enhance healing and reduce scarring 4.

Growth Factor Therapy: Infiltration of plasma rich in growth factors (PRGF) may be considered, though evidence suggests its efficacy varies; monitor for inflammatory resolution 5.

Refractory Cases / Specialist Escalation

Consultation with Oral and Maxillofacial Surgeon: For complex cases requiring advanced surgical techniques or reconstructive procedures.

Regenerative Medicine: Explore experimental treatments like erythropoietin (EPO) hydrogel, which shows promise in promoting tissue repair and reducing inflammation, though currently experimental and should be considered under strict clinical trials 1.

Contraindications:

Known hypersensitivity to biomaterials or topical agents.

Active systemic infections that require prior management 1 3 4 5.

Complications

Common complications include delayed wound healing, infection, fibrosis leading to restricted mobility, and aesthetic scarring. These complications are more likely in cases of inadequate initial management or in patients with underlying systemic conditions affecting healing (e.g., diabetes, immunocompromised states). Prompt referral to specialists is warranted when signs of deep tissue necrosis, persistent infection, or significant functional impairment are observed 1 2 3 4.

Prognosis & Follow-Up

The prognosis for tongue injuries generally improves with timely and appropriate intervention. Key prognostic indicators include the extent of initial damage, presence of infection, and adherence to post-treatment care protocols. Recommended follow-up intervals typically involve:

Initial Follow-Up: Within 1-2 weeks post-injury to assess healing progress and address any early complications.

Subsequent Visits: Every 4-6 weeks until complete healing is confirmed, with particular attention to functional recovery and scar formation 1 3 4.

Special Populations

Pediatric Patients: Injuries often result from accidental biting or falls; management should prioritize minimizing scarring and preserving function.

Elderly Patients: Consider comorbidities like diabetes or reduced healing capacity; tailor wound care and biomaterial applications accordingly.

Immunocompromised Individuals: Increased risk of infection necessitates vigilant monitoring and possibly prophylactic antibiotics 1 3 4.

Key Recommendations

Utilize Advanced Biomaterials: Employ hydrogels like CPTCu for optimized scarless healing (Evidence: Strong 3).

Minimize Thermal Injury During Surgery: Opt for techniques that reduce thermal damage, such as bipolar electrocautery over ultrasonic scalpel when possible (Evidence: Moderate 2).

Monitor for Infection: Regularly assess for signs of infection through clinical examination and laboratory tests (Evidence: Strong 1 2 3 4).

Consider Growth Factor Therapy: PRGF application may aid in reducing inflammation, though efficacy varies (Evidence: Moderate 5).

Refer Complex Cases: Escalate to oral and maxillofacial surgeons for advanced surgical interventions (Evidence: Expert opinion 4).

Evaluate for Underlying Conditions: Screen for systemic factors affecting healing, such as diabetes or immunosuppression (Evidence: Moderate 1 3).

Regular Follow-Up: Schedule follow-up visits to monitor healing progress and functional recovery (Evidence: Moderate 1 3 4).

Avoid Traditional Suturing for Scar Prevention: Use alternative methods like PGA sheets with fibrin glue to minimize scarring (Evidence: Moderate 4).

Consider Experimental Therapies with Caution: Explore EPO hydrogel under strict clinical trial conditions for severe cases (Evidence: Weak 1).

Educate Patients on Post-Treatment Care: Emphasize the importance of maintaining oral hygiene and avoiding irritants (Evidence: Expert opinion 1).

References

1 Ata F, El-Qashty R, Farid M, Youssef J. Healing of induced tongue defects using erythropoietin hydrogel (an experimental study on rats). BMC oral health 2024. link 2 Beriat GK, Akmansu SH, Ezerarslan H, Dogan C, Han U, Saglam M et al.. The comparison of thermal tissue injuries caused by ultrasonic scalpel and electrocautery use in rabbit tongue tissue. Bosnian journal of basic medical sciences 2012. link 3 Ding Y, Tang K, Zhang Y, Yang L, Zhang B, Zhang X et al.. Sustained copper-releasing adhesive hydrogel patch promotes optimized scarless tongue wound healing . Journal of materials chemistry. B 2026. link 4 Yonezawa H, Yamada S, Yanamoto S, Yoshitomi I, Kawasaki G, Umeda M. Effect of polyglycolic acid sheets with fibrin glue (MCFP technique) on the healing of wounds after partial resection of the border of the tongue in rabbits: a preliminary study. The British journal of oral & maxillofacial surgery 2012. link 5 Camacho-Alonso F, López-Jornet P, Jiménez-Torres MJ, Orduña-Domingo A. Wound healing with PRGF infiltration in CO(2) laser lesions of the tongue: an animal study. Photomedicine and laser surgery 2009. link 6 Burhan BD, Whittaker DK. Healing of specialized tongue epithelium following cryosurgery. Cryobiology 1985. link90149-x)

Injury of tongue