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Pediatric Tongue Laceration Repair Using 2-Octyl Cyanoacrylate (Dermabond®)
The Journal of Emergency Medicine, Vol. 45, No. 6, pp. 846–848, 2013 Copyright Ó 2013 Elsevier Inc. Printed in the USA. All rights reserved 0736-4679/$ - see front matter
http://dx.doi.org/10.1016/j.jemermed.2013.05.004
Clinical Communications: Pediatrics PEDIATRIC TONGUE LACERATION REPAIR USING 2-OCTYL CYANOACRYLATE (DERMABONDÒ) Massoud G. Kazzi, MD and Mark Silverberg, MD Department of Emergency Medicine, State University of New York Downstate/Kings County Hospital, Brooklyn, New York Reprint Address: Mark Silverberg, MD, Department of Emergency Medicine, Kings County Hospital, 451 Clarkson Avenue, Brooklyn, NY 11203
, Keywords—DermabondÒ; 2-octyl cyanoacrylate; tongue laceration repair; tissue adhesive; intraoral laceration repair
, Abstract—Background: Tongue lacerations provide a challenge for emergency physicians, especially in the case of pediatric patients. Traditional wound closure typically involves local anesthesia or procedural sedation in children, which is time consuming and often anxiety provoking for providers, patients, and parents. 2-Octyl cyanoacrylate (DermabondÒ; Ethicon, Inc., Sommerville, NJ) has been used in the context of the emergency department for successful repair of lacerations, however, is not marketed for use on mucosal or intraoral surfaces. This case report describes an alternative manner of tongue laceration repair by the use of 2-octyl cyanoacrylate. Objective: 2-Octyl cyanoacrylate is generally not indicated for intraoral use. Our case demonstrates a situation in which it was used safely and effectively to repair a tongue laceration. Case Report: A 7-year-old boy presented to the emergency department after sustaining a large tongue laceration requiring repair. The boy’s parent refused traditional wound repair with suturing due to concerns regarding the pain of local anesthesia administration, as well as risks posed by procedural sedation. The wound was repaired using the tissue adhesive 2-octyl cyanoacrylate. The patient tolerated the procedure well and there were no complications in the patient’s course. Good cosmetic results were achieved using this method. Conclusions: Tongue lacerations and other intraoral lacerations are challenging to repair, especially in pediatric patients. The use of tissue adhesives such as 2-octyl cyanoacrylate is very likely safe and may provide an expedient manner in which to repair such lesions with good cosmetic results. Ó 2013 Elsevier Inc.
INTRODUCTION Tongue lacerations are anxiety-provoking injuries for the patient and provider and, in the case of injured children, the parent as well. Closure usually requires some degree of sedation and analgesia and is painful if these measures are not taken. Although many tongue lacerations do not require closure, certain injuries will. Indications for tongue laceration repair include large gaping wounds, profuse bleeding, muscle involvement, the presence of flaps or a ‘‘through and through’’ injury of the tongue edge. In our review of the English language literature, the use of 2-octyl cyanoacrylate (DermabondÒ; Ethicon, Inc., Sommerville, NJ) has not been documented to close a tongue laceration. Our case report describes a way to close large tongue defects in the emergency department (ED) without the use of local anesthetics or sedation, by employing 2-octyl cyanoacrylate. Case A 7-year-old boy presented to the emergency department (ED) with a tongue laceration sustained after being
RECEIVED: 12 April 2012; FINAL SUBMISSION RECEIVED: 24 January 2013; ACCEPTED: 1 May 2013 846
Tongue Laceration Repair Using DermabondÒ
Figure 1. Tongue laceration at initial emergency department evaluation.
pushed to the floor in the schoolyard. The laceration was 1.3 cm (40% of the tongue’s width) on the superior surface of the tongue with minimal penetration into the muscular layer (Figure 1). There was no active bleeding or
847
lateral border involvement, but given the ‘‘gaping’’ nature of the wound, it was believed to require reapproximation. The need for repair and accompanying procedural sedation, risks included, were discussed with the boy’s mother. However, the parent was unwilling to expose her child to the sedation risks and further refused local anesthetic given its painful nature. The mother inquired about ‘‘skin glue,’’ which prompted the treating physician to perform a review of the package insert provided by the manufacturers of 2-octyl cyanoacrylate (DermabondÒ). An explanation was provided to the mother of the product’s reported lack of indication for use on mucosal surfaces. However, the mother insisted on not exposing the child to procedural sedation or local anesthetic. It was decided a trial of 2-octyl cyanoacrylate would be attempted and in the case of treatment failure, local anesthetic and traditional suture repair would be performed. The child’s tongue was grasped with gauze and thoroughly dried of oral secretions. Compressed air was further used to dry the tongue surface. The wound edges were held in approximation and three layers of 2-octyl cyanoacrylate were applied and allowed to dry. Excellent apposition was obtained and the child was instructed not to manipulate the closure or he ‘‘might have to get an injection to fix it if the glue fell off.’’ The child was observed in the ED for approximately 1 h to confirm that the closure material remained in place. The mother was instructed to return to the ED in any case of wound dehiscence and, barring any complication, to return in 24–36 h for a wound check. At the 24-h wound check visit, the wound was well approximated and the polymerized 2-octyl cyanoacrylate was noted to be adhering to the tongue surface with minimal detachment of the glue’s outer edges. The mother reported that the ‘‘glue had been holding well until the child drank a cup of hot tea.’’ Upon examination, the wound was felt to require at least 1 more day of assisted apposition. The original adhesive was removed with forceps and another applied in the manner described previously. Upon discharge, the parent was again instructed to return to the ED for severe pain, swelling, or wound dehiscence and to avoid hot beverages. The same treating physician evaluated the child again 14 days later. The tongue healed with excellent cosmetic results and without evidence of previous injury (Figure 2). No complications from the 2-octyl cyanoacrylate were reported by mother or child. DISCUSSION
Figure 2. Second follow-up visit 14 days after initial repair.
Tissue adhesives have a multitude of benefits: decreased procedure time, ease of use, less invasiveness, decreased pain, and higher patient satisfaction. Additionally,
848
numerous randomized controlled trials have demonstrated that wound closure by tissue adhesives achieves equivalent cosmetic results as compared with sutures in repairing simple wound lacerations (1). The benefits and established successes of tissue adhesives has prompted numerous innovative uses. Smaller trials and case series describe its successful use in cardiac surgery for intraoperative hemostasis, as well as for surgical wound closure in saphenous vein harvesting for coronary artery bypass grafting and abdominal operations (2–4). The earliest generations of tissue adhesives introduced in the 1950s displayed histotoxicity in vitro. Newer-generation adhesives, 2-octyl cyanoacrylate included, contain longer alkyl chains, the advantage of which is a slower degradation, limiting exposure of the patient to byproducts (5). The potential tissue toxicity of newer tissue adhesives is likely speculative and based on concerns of previous-generation products. There has not been any prospective evaluation of its toxicity and given the U.S. Food and Drug Administration approval and widespread use of tissue adhesives in wound repair without reported consequences, these concerns are likely unfounded (6). Notably, according to the product use and safety information provided by its manufacturer, DermabondÒ is not indicated for use on mucosal surfaces. This is presumably due to suspected higher failure rates (per personal phone conversation with a representative at Johnson & Johnson). Although 2-octyl cyanoacrylate may not be officially indicated for use on mucosal surfaces, it is likely safe for intraoral use. The Material Safety Data Sheet on 2-octyl cyanoacrylate reports no expected effects with ingestion. It further notes that ingestion of its liquid form is highly unlikely due to the rapidity of polymerization upon contact with oral tissue. Once polymerized, if the adhesive is swallowed, no adverse effects are to be expected. This was echoed in personal phone communication with a representative of the local Poison Control Center, who reaffirmed the generally benign nature of 2-octyl cyanoacrylate ingestion. The representative proposed as a hypothetical consequence of ingestion the risk of bowel injury due to contact with the edges of the hardened glue. Nevertheless, no such injury has been reported and was believed to be of very low likelihood. 2-Octyl cyanoacrylate has been used successfully and without toxic consequences on mucosal surfaces. One article by Knott et al. describes successful use of 2-octyl cyanoacrylate in the repair of congenital cleft lip/palate, and the dental field has numerous examples
M. G. Kazzi and M. Silverberg
of safe and effective application of 2-octyl cyanoacrylatein the intraoral setting (7,8). The benefits provided to our patient were multiple, including no risk of sedation, no pain of local anesthetic injection or wound repair, faster procedure time, and shorter ED length of stay. The potential downside is failure of the wound closure necessitating sutures and the possible risk of swallowing the hardened glue. This is the first case report, to our knowledge, that describes the use of 2-octyl cyanoacrylate to repair a tongue laceration. Further studies will be needed to draw a more definitive conclusion on its utility for repairing tongue lacerations and other intraoral injuries. Of note, if 2-octyl cyanoacrylate is used intraorally, patients should be instructed upon discharge to avoid exposure to high temperatures due to a possible increased failure rate. CONCLUSIONS 2-Octyl cyanoacrylate may be a useful way to approximate intraoral lacerations that require closure. If the mucosal surface is dried appropriately before application, the likelihood of success increases and will offer a way to avoid procedural sedation, as well as the pain of local anesthetic and suture repair. This adhesive needs to be better studied in the intraoral setting and on mucosal surfaces before definitive conclusions can be drawn. REFERENCES 1. Farion KJ, Osmond MH, Hartling L, et al. Tissue adhesives for traumatic lacerations: a systematic review of randomized controlled trial. Acad Emerg Med 2003;10:110–8. 2. Aziz O, Rahman MS, Hadjianastassiou VG, et al. Novel applications of Dermabond (2-octyl -cyanoacrylate) in cardiothoracic surgery. Surg Technol Int 2007;16:46–51. 3. Krishnamoorthy B, Najam O, Khan UA, et al. Randomized prospective study comparing conventional subcuticular skin closure with Dermabond skin glue after saphenous vein harvesting. Ann Thorac Surg 2009;88:1445–9. 4. Ong J, Ho KS, Chew MH, et al. Prospective randomised study to evaluate the use of Dermabond ProPen (2-octylcyanoacrylate) in the closure of abdominal wounds versus closure with skin staples in patients undergoing elective colectomy. Int J Colorectal Dis 2010;25:899–905. 5. Toriumi DM, Raslan WF, Friedman M, et al. Histotoxicity of cyanoacrylate tissue adhesives: comparative study. Arch Otolaryngol Head Neck Surg 1990;116:546–50. 6. Hile LM, Linklater DR. Use of 2-octyl cyanoacrylate for the repair of a fractured molar tooth. Ann Emerg Med 2006;47:424–6. 7. Knott DP, Zins JE, Banbury J, et al. A comparison of Dermabond tissue adhesive and sutures in the primary repair of the congenital cleft lip. Ann Plast Surg 2007;58:121–5. 8. Perez MC, Guerra RM, Fernandez M, et al. Effectiveness and safety of tisuacryl in treating dentin hypersensitivity. MEDICC Rev 2010; 12:24–8.
http://dx.doi.org/10.1016/j.jemermed.2013.05.004
Clinical Communications: Pediatrics PEDIATRIC TONGUE LACERATION REPAIR USING 2-OCTYL CYANOACRYLATE (DERMABONDÒ) Massoud G. Kazzi, MD and Mark Silverberg, MD Department of Emergency Medicine, State University of New York Downstate/Kings County Hospital, Brooklyn, New York Reprint Address: Mark Silverberg, MD, Department of Emergency Medicine, Kings County Hospital, 451 Clarkson Avenue, Brooklyn, NY 11203
, Keywords—DermabondÒ; 2-octyl cyanoacrylate; tongue laceration repair; tissue adhesive; intraoral laceration repair
, Abstract—Background: Tongue lacerations provide a challenge for emergency physicians, especially in the case of pediatric patients. Traditional wound closure typically involves local anesthesia or procedural sedation in children, which is time consuming and often anxiety provoking for providers, patients, and parents. 2-Octyl cyanoacrylate (DermabondÒ; Ethicon, Inc., Sommerville, NJ) has been used in the context of the emergency department for successful repair of lacerations, however, is not marketed for use on mucosal or intraoral surfaces. This case report describes an alternative manner of tongue laceration repair by the use of 2-octyl cyanoacrylate. Objective: 2-Octyl cyanoacrylate is generally not indicated for intraoral use. Our case demonstrates a situation in which it was used safely and effectively to repair a tongue laceration. Case Report: A 7-year-old boy presented to the emergency department after sustaining a large tongue laceration requiring repair. The boy’s parent refused traditional wound repair with suturing due to concerns regarding the pain of local anesthesia administration, as well as risks posed by procedural sedation. The wound was repaired using the tissue adhesive 2-octyl cyanoacrylate. The patient tolerated the procedure well and there were no complications in the patient’s course. Good cosmetic results were achieved using this method. Conclusions: Tongue lacerations and other intraoral lacerations are challenging to repair, especially in pediatric patients. The use of tissue adhesives such as 2-octyl cyanoacrylate is very likely safe and may provide an expedient manner in which to repair such lesions with good cosmetic results. Ó 2013 Elsevier Inc.
INTRODUCTION Tongue lacerations are anxiety-provoking injuries for the patient and provider and, in the case of injured children, the parent as well. Closure usually requires some degree of sedation and analgesia and is painful if these measures are not taken. Although many tongue lacerations do not require closure, certain injuries will. Indications for tongue laceration repair include large gaping wounds, profuse bleeding, muscle involvement, the presence of flaps or a ‘‘through and through’’ injury of the tongue edge. In our review of the English language literature, the use of 2-octyl cyanoacrylate (DermabondÒ; Ethicon, Inc., Sommerville, NJ) has not been documented to close a tongue laceration. Our case report describes a way to close large tongue defects in the emergency department (ED) without the use of local anesthetics or sedation, by employing 2-octyl cyanoacrylate. Case A 7-year-old boy presented to the emergency department (ED) with a tongue laceration sustained after being
RECEIVED: 12 April 2012; FINAL SUBMISSION RECEIVED: 24 January 2013; ACCEPTED: 1 May 2013 846
Tongue Laceration Repair Using DermabondÒ
Figure 1. Tongue laceration at initial emergency department evaluation.
pushed to the floor in the schoolyard. The laceration was 1.3 cm (40% of the tongue’s width) on the superior surface of the tongue with minimal penetration into the muscular layer (Figure 1). There was no active bleeding or
847
lateral border involvement, but given the ‘‘gaping’’ nature of the wound, it was believed to require reapproximation. The need for repair and accompanying procedural sedation, risks included, were discussed with the boy’s mother. However, the parent was unwilling to expose her child to the sedation risks and further refused local anesthetic given its painful nature. The mother inquired about ‘‘skin glue,’’ which prompted the treating physician to perform a review of the package insert provided by the manufacturers of 2-octyl cyanoacrylate (DermabondÒ). An explanation was provided to the mother of the product’s reported lack of indication for use on mucosal surfaces. However, the mother insisted on not exposing the child to procedural sedation or local anesthetic. It was decided a trial of 2-octyl cyanoacrylate would be attempted and in the case of treatment failure, local anesthetic and traditional suture repair would be performed. The child’s tongue was grasped with gauze and thoroughly dried of oral secretions. Compressed air was further used to dry the tongue surface. The wound edges were held in approximation and three layers of 2-octyl cyanoacrylate were applied and allowed to dry. Excellent apposition was obtained and the child was instructed not to manipulate the closure or he ‘‘might have to get an injection to fix it if the glue fell off.’’ The child was observed in the ED for approximately 1 h to confirm that the closure material remained in place. The mother was instructed to return to the ED in any case of wound dehiscence and, barring any complication, to return in 24–36 h for a wound check. At the 24-h wound check visit, the wound was well approximated and the polymerized 2-octyl cyanoacrylate was noted to be adhering to the tongue surface with minimal detachment of the glue’s outer edges. The mother reported that the ‘‘glue had been holding well until the child drank a cup of hot tea.’’ Upon examination, the wound was felt to require at least 1 more day of assisted apposition. The original adhesive was removed with forceps and another applied in the manner described previously. Upon discharge, the parent was again instructed to return to the ED for severe pain, swelling, or wound dehiscence and to avoid hot beverages. The same treating physician evaluated the child again 14 days later. The tongue healed with excellent cosmetic results and without evidence of previous injury (Figure 2). No complications from the 2-octyl cyanoacrylate were reported by mother or child. DISCUSSION
Figure 2. Second follow-up visit 14 days after initial repair.
Tissue adhesives have a multitude of benefits: decreased procedure time, ease of use, less invasiveness, decreased pain, and higher patient satisfaction. Additionally,
848
numerous randomized controlled trials have demonstrated that wound closure by tissue adhesives achieves equivalent cosmetic results as compared with sutures in repairing simple wound lacerations (1). The benefits and established successes of tissue adhesives has prompted numerous innovative uses. Smaller trials and case series describe its successful use in cardiac surgery for intraoperative hemostasis, as well as for surgical wound closure in saphenous vein harvesting for coronary artery bypass grafting and abdominal operations (2–4). The earliest generations of tissue adhesives introduced in the 1950s displayed histotoxicity in vitro. Newer-generation adhesives, 2-octyl cyanoacrylate included, contain longer alkyl chains, the advantage of which is a slower degradation, limiting exposure of the patient to byproducts (5). The potential tissue toxicity of newer tissue adhesives is likely speculative and based on concerns of previous-generation products. There has not been any prospective evaluation of its toxicity and given the U.S. Food and Drug Administration approval and widespread use of tissue adhesives in wound repair without reported consequences, these concerns are likely unfounded (6). Notably, according to the product use and safety information provided by its manufacturer, DermabondÒ is not indicated for use on mucosal surfaces. This is presumably due to suspected higher failure rates (per personal phone conversation with a representative at Johnson & Johnson). Although 2-octyl cyanoacrylate may not be officially indicated for use on mucosal surfaces, it is likely safe for intraoral use. The Material Safety Data Sheet on 2-octyl cyanoacrylate reports no expected effects with ingestion. It further notes that ingestion of its liquid form is highly unlikely due to the rapidity of polymerization upon contact with oral tissue. Once polymerized, if the adhesive is swallowed, no adverse effects are to be expected. This was echoed in personal phone communication with a representative of the local Poison Control Center, who reaffirmed the generally benign nature of 2-octyl cyanoacrylate ingestion. The representative proposed as a hypothetical consequence of ingestion the risk of bowel injury due to contact with the edges of the hardened glue. Nevertheless, no such injury has been reported and was believed to be of very low likelihood. 2-Octyl cyanoacrylate has been used successfully and without toxic consequences on mucosal surfaces. One article by Knott et al. describes successful use of 2-octyl cyanoacrylate in the repair of congenital cleft lip/palate, and the dental field has numerous examples
M. G. Kazzi and M. Silverberg
of safe and effective application of 2-octyl cyanoacrylatein the intraoral setting (7,8). The benefits provided to our patient were multiple, including no risk of sedation, no pain of local anesthetic injection or wound repair, faster procedure time, and shorter ED length of stay. The potential downside is failure of the wound closure necessitating sutures and the possible risk of swallowing the hardened glue. This is the first case report, to our knowledge, that describes the use of 2-octyl cyanoacrylate to repair a tongue laceration. Further studies will be needed to draw a more definitive conclusion on its utility for repairing tongue lacerations and other intraoral injuries. Of note, if 2-octyl cyanoacrylate is used intraorally, patients should be instructed upon discharge to avoid exposure to high temperatures due to a possible increased failure rate. CONCLUSIONS 2-Octyl cyanoacrylate may be a useful way to approximate intraoral lacerations that require closure. If the mucosal surface is dried appropriately before application, the likelihood of success increases and will offer a way to avoid procedural sedation, as well as the pain of local anesthetic and suture repair. This adhesive needs to be better studied in the intraoral setting and on mucosal surfaces before definitive conclusions can be drawn. REFERENCES 1. Farion KJ, Osmond MH, Hartling L, et al. Tissue adhesives for traumatic lacerations: a systematic review of randomized controlled trial. Acad Emerg Med 2003;10:110–8. 2. Aziz O, Rahman MS, Hadjianastassiou VG, et al. Novel applications of Dermabond (2-octyl -cyanoacrylate) in cardiothoracic surgery. Surg Technol Int 2007;16:46–51. 3. Krishnamoorthy B, Najam O, Khan UA, et al. Randomized prospective study comparing conventional subcuticular skin closure with Dermabond skin glue after saphenous vein harvesting. Ann Thorac Surg 2009;88:1445–9. 4. Ong J, Ho KS, Chew MH, et al. Prospective randomised study to evaluate the use of Dermabond ProPen (2-octylcyanoacrylate) in the closure of abdominal wounds versus closure with skin staples in patients undergoing elective colectomy. Int J Colorectal Dis 2010;25:899–905. 5. Toriumi DM, Raslan WF, Friedman M, et al. Histotoxicity of cyanoacrylate tissue adhesives: comparative study. Arch Otolaryngol Head Neck Surg 1990;116:546–50. 6. Hile LM, Linklater DR. Use of 2-octyl cyanoacrylate for the repair of a fractured molar tooth. Ann Emerg Med 2006;47:424–6. 7. Knott DP, Zins JE, Banbury J, et al. A comparison of Dermabond tissue adhesive and sutures in the primary repair of the congenital cleft lip. Ann Plast Surg 2007;58:121–5. 8. Perez MC, Guerra RM, Fernandez M, et al. Effectiveness and safety of tisuacryl in treating dentin hypersensitivity. MEDICC Rev 2010; 12:24–8.