A 26-year-old male with no past medical history presented to the emergency department for tongue bleeding for one day. Five days prior he had an elective cosmetic tongue bifurcation completed out-of-state. About two hours prior to arrival, he had been using a swish-and-spit saltwater rinse when he felt a suture break. Ever since he has had copious bleeding, reportedly filling his sink at home with blood. Additionally, he had about 250 milliliters of blood, including large clots, in a container in the emergency department. He denied using any blood thinners. There was no syncope, dizziness, chest pain, nausea, vomiting, shortness of breath, pain of the tongue, or numbness of the tongue. He had some difficulty speaking but said it was due to needing to retrain his bifurcated tongue.
Vitals: BP 116/78; HR 98; RR 18; Oxygen Saturation 98%; Temperature 98.1°F
Constitutional: Calm, cooperative young male, frequently spitting blood into an emesis bag
Eyes: Normal conjunctiva
Mouth/Throat:
- Edematous bifurcated tongue with greater edema of the left bifurcated portion than the right, macerated tissue of left lateral aspect.
- Fibrinous exudate at the midline incision with intact vicryl sutures visualized at the base of the tongue bilaterally; Continuous oozing of blood with site of bleeding difficult to visualize
- Multiple clots in the oropharynx, dried blood around the lips and on the posterior aspect of the oropharynx; Protecting airway; No voice changes or stridor
Cardiovascular: Normal rate, regular rhythm, normal heart sounds
Respiratory: Clear breath sounds bilateral, no respiratory distress
CBC and CMP were unremarkable.
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Tranexamic Acid (TXA)
- Initially, one thousand milligrams of TXA were diluted into one hundred milliliters of normal saline and used to soak a four by four-inch piece of gauze. The gauze was wrapped around the tongue and pressure was applied by the patient for approximately ten minutes.
- Although bleeding slowed, there continued to be oozing from the left aspect of the tongue.
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Silver nitrate
- A left lingular nerve block was performed using 3 milliliters of lidocaine with epinephrine. After appropriate anesthesia of the tongue, silver nitrate was applied generously to the left aspect of the bifurcated tongue until hemostasis was obtained.
TXA ultimately prevents fibrin degradation, which is a key component in clotting. A synthetic derivative of lysine, TXA can reversibly and competitively inhibit the lysine receptor found on plasminogen. Plasminogen is thereby unable to be activated into plasmin (which usually degrades fibrin), leading to inhibition of fibrinolysis. TXA has been well documented in the literature to treat a number of bleeding conditions including hemoptysis, gastrointestinal (GI) bleeding, and vaginal bleeding [1, 2].
Silver nitrate, an inorganic chemical cautery agent, induces formation of an eschar from the binding of free silver ions to tissue. The eschar obstructs small blood vessels, resulting in hemostasis. Silver nitrate is applied topically to the bleeding area to form an eschar [3].
At the follow-up appointment three days later, the patient had routine healing with no signs of infection, and his original vicryl sutures were removed. Elective tongue bifurcation is a form of body modification that has been increasing in popularity. Several methods exist, but a common method, including the one our patient had performed, involves anesthesia of the tongue followed by dissection of the tongue with a scalpel. Absorbable sutures are placed on the medial aspect of each segment to prevent readhesion and to create a more rounded effect of each segment. Often patients travel to certain locations to have the procedure performed, and therefore are not in contact with the initial provider when complications arise. As tongue bifurcation becomes more popular, it is important for emergency medicine providers to become familiar with the complications and treatment methods.
Take-Home Points
- Tongue bifurcation is an increasingly popular method of body modification.
- Complications include bleeding, infection, and nerve damage.
- In the otherwise stable patient, topical TXA and silver nitrate are two options for achieving hemostasis intraorally.
- Topical TXA can help obtain hemostasis by inhibition of fibrinolysis.
- Silver nitrate achieves hemostasis by forming an eschar, which obstructs small blood vessels.
- Levy JH, Koster A, Quinones QJ, Milling TJ, Key NS. Antifibrinolytic Therapy and Perioperative Considerations. Anesthesiology. 2018;128(3):657-670. PMID: 209200009
- Cai J, Ribkoff J, Olson S, et al. The many roles of tranexamic acid: An overview of the clinical indications for TXA in medical and surgical patients. European Journal of Haematology. 2019;104(2):79-87. PMID: 31729076
- Ho C, Argáez C. Topical Silver Nitrate for the Management of Hemostasis: A Review of Clinical Effectiveness, Cost-Effectiveness, and Guidelines. Canadian Agency for Drugs and Technologies in Health. October 2018. PMID: 30817105
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