|Year : 2015 | Volume
| Issue : 4 | Page : 241-244
Management of maxillofacial injuries in humans due to animal bites and mauling: A report of three cases
Pulkit Khandelwal1, Neha Hajira2, Shirish Dubey3
1 From the Consultant Oral and Maxillofacial Surgeon, Metrocity Hospital, Jaipur, Rajasthan, India
2 Consultant Prosthodontist, Khushi Dental Care and Implant Centre, Bengaluru, Karnataka, India
3 Consultant Oral and Maxillofacial Surgeon, Iris Hospital, Kolkata, West Bengal, India
|Date of Web Publication||14-Jan-2016|
From the Consultant Oral and Maxillofacial Surgeon, Metrocity Hospital, Jaipur, Rajasthan
Source of Support: None, Conflict of Interest: None
Animal attacks and bite injuries are common occurrences as the natural habitat of animals is diminishing due to human encroachment. Individuals injured in animal attacks present with different types of injuries. Urgent and effective management of these injuries would have a significant effect on the final outcome. Rabies is a fatal disease in humans, and, till date, only those that received vaccination before the onset of illness survived this disease. The goal of the case reports presented in the article was to document the injuries suffered in animal bite injuries and add to the literature on the management with minimal complications.
Keywords: Animal bite injuries, infection, prophylaxis, rabies, wounds
|How to cite this article:|
Khandelwal P, Hajira N, Dubey S. Management of maxillofacial injuries in humans due to animal bites and mauling: A report of three cases. Niger Postgrad Med J 2015;22:241-4
|How to cite this URL:|
Khandelwal P, Hajira N, Dubey S. Management of maxillofacial injuries in humans due to animal bites and mauling: A report of three cases. Niger Postgrad Med J [serial online] 2015 [cited 2019 Jan 22];22:241-4. Available from: http://www.npmj.org/text.asp?2015/22/4/241/173981
| Introduction|| |
Bites and maulings by animals, sometimes fatal, are a worldwide problem. Animal bite injuries to the orofacial region can result in grotesque facial deformity with inevitable physical, functional and psychological consequences. Animal bite wounds are quite distinctive from wounds which are inflicted by human assaults and accidents. These wounds can be puncture type deep wounds, injected by the bite force  or may range from minor scratches to major trauma to face involving skin and deep tissue injuries or sometimes, fracture of facial bones.  These injuries are always considered complex injuries and highly susceptible for infection due to inoculation of pathogenic microorganisms from the saliva of attacking animal and also due to the presence of devitalised tissues.  Dog and cat bite injuries are particularly more common in children than in adults. Children are also more likely to be bitten on the face, neck and head in up to 70% of cases. Dog bites more likely causes superficial abrasions and lacerations, whereas cat bites mostly lead to deep puncture wounds. 
Cervicofacial region (36%) is the most common site involved in animal attacks, followed by lower extremity (31%), upper extremity (19%) and chest (14%).  The lips, nose and cheeks comprise the 'central target area'. The biting force varies from 30 to 32 kg/cm 2 delivered by teeth of the animals. This amount of force can result in three main types of soft tissue injuries - punctures, lacerations and avulsions with or without soft tissue defect. The typical animal bite injury is mostly a combination of puncture type wound with tearing of adjacent soft tissues leading to 'hole and tear effect'.  In this 'hole and tear' effect, canine teeth hold the victim whereas other teeth bite, shear and tear the tissues resulting in stretch lacerations.  Facial animal bite wounds were classified by Lackmann et al. based on the extent of injury [Table 1]. 
The puncture wounds are at higher risk of infection because microorganisms get inoculated at a depth of wound which has a narrow entry point. This provides an environment which is ideal for the growth of anaerobic bacteria. Typically, these infections are polymicrobial in origin, comprising mixed aerobic and anaerobic species. Aerobic bacterial flora isolated from infected dog bites include α and β haemolytic Streptococcus (24-46%), Staphylococcus (10-25%), Pasteurella (0-50%), Pseudomonas, Escherichia More Details coli and Moraxella More Details species. Anaerobic flora includes Bacteroides, Prevotella and Fusobacterium species (13-76%). In more than 50% cases, anaerobic organisms cause infection. ,
Facial animal bite injuries pose a challenge from the point of aesthetics, infection and function. Hence, the goal of maxillofacial rehabilitation should be restoring the aesthetic and functional defects of the patient. Here, we present our experience with three cases of animal bite injuries and their management.
| Case Reports|| |
A 35-year-old male reported with alleged history of being attacked and bitten by a stray dog while he was removing debris from garbage. History revealed that the dog attacked him after provocation. The victim suffered multiple injuries over face, neck, back and extremities. The patient suffered from Class IIIA bite injury over the face. On the right side, there were multiple lacerations involving lower third of the face. There was associated tear extending from nasolabial crease to 2.0 cm lateral to oral commissure. Multiple small lacerations were present over upper lip. There was a loss of cutaneous portion of one-third of lower lip [Figure 1]a. There were multiple small lacerations over the bridge and left ala of nose. There was no evidence of communication with the oral cavity or facial nerve deficit on either side. Underlying facial bones were intact.
|Figure 1: (a) Case 1 ultiple bite injuries over face involving nose, upper lip, lower lip and cheek. (b) Case 1 ne month follow-up with well settled facial scar|
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A 45-year-old female was attacked and bitten by a stray dog while she was sitting in the park with her children. The dog attacked the female after she pelted stones at the dog to scare and drive him away. Patient suffered from Class IIA bite injury over the face. There was laceration involving middle third of face, associated with tear extending from right ala of nose till malar region [Figure 2]a. There was no evidence of intra-oral communication or facial nerve deficit or fracture of any underlying bones.
|Figure 2: (a) Case 2 re-operative photograph showing dog bite injury over right malar region. (b) Case 2 mmediate post-operative photograph showing tension-free primary closure and good repair|
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A 40-year-old male reported with alleged history of being attacked and bitten again by a dog. Patient suffered from Class IIIB bite injury over the face. Extensive facial lacerations were present mainly involving right side of the lower face. Through and through laceration was present over lower half of face involving columella, right philtrum column, upper lip and lower lip region. Nasal cartilage was exposed [Figure 3]a. There was no evidence of facial nerve deficit or fracture of any underlying bones.
|Figure 3: (a) Case 3 re-operative photograph showing extensive dog bite injury over face. (b) Case 3 mmediate post-operative photograph showing tension-free primary closure and good repair. (c) Case 3 ne month follow-up with well settled barely visible facial scar|
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In all these three cases, after administration of local anaesthesia, the wounds were meticulously cleaned and debrided of foreign bodies. Rabies immunoglobulin was administered locally as well as intramuscularly (IM). Devitalised and mutilated tissue tags were excised, and wound margins were freshened. Haemostasis was achieved. Lower lip was reconstructed in the first case. Tension-free primary closure was achieved [Figure 2]b and [Figure 3]b. Tetanus toxoid was administered, and patients were started on the anti-rabies vaccine regimen and antibiotics (augmentin 625 mg TID). Patients were followed up regularly and after 1 month, there was a good wound healing without any complications [Figure 1]b and [Figure 3]c.
| Discussion|| |
Invasion of animal territory by humans has increased interaction between animals and humans, hence causing injuries to humans. The major type of attack by an animal is defensive, as a result of sudden, unexpected encounter that follows in reaction to a perceived threat to their offspring or individual space. Information regarding the identification of the attacking dog and its behaviour is significant. An attempt should be made to capture and quarantine the dog responsible for the attack. 
Following injury, the ultimate treatment depends on the type of wound, depth of the wound, time elapsed since injury, site of the wound and amount of tissue loss, if any.  The principle steps in the management of facial animal bite injuries include meticulous and thorough surgical toilet of the wound by irrigation, meticulous but not overzealous debridement of devitalised tissues, primary closure of the wound except in high-risk cases, appropriate antibiotic therapy, and tetanus and rabies immunisation wherever indicated for post-exposure prophylaxis (PEP). ,
The animal bite injuries involve considerable struggle by the victim, which forces mud, gravels, grass and other contaminants into the wounds, so vigorous irrigation and removal of all foreign matter is of paramount importance.  Thorough immediate irrigation of contaminated bite wounds with soap and water or water alone decrease the bacterial load, remove particulate matter and reduce infection rate and chances of rabies considerably.  A 20-35 ml syringe equipped with 18-20-gauge needle is widely recommended for manual irrigation with pulsatile jet lavage at a pressure of 50-70 psi.  Normal saline is the ideal irrigant because it does not interfere with the normal wound healing. Povidone-iodine wash should follow normal saline wash.  Following irrigation, the wound should always be carefully examined in depth to identify any devitalised tissue. However, surgical debridement of the devitalised tissue should be kept to a minimum in the facial region because the face has rich vascularity which makes survival of small pedicles possible. Eyebrows, vermilion border, philtral column and nasolabial fold should not be trimmed inadvertently.  The majority of wounds sustained by the victims in the present study involved face. These wounds were meticulously cleaned and debrided of foreign bodies and devitalised tissue tags were excised.
In last few years, the concept and philosophy of closure of bite wounds have changed from healing by secondary intention to more aggressive primary closure. Because of the excellent blood supply, facial wounds are at low risk for infection and should be closed primarily.  In addition, primary closure gives best cosmetic results. Subcutaneous sutures may act as foreign bodies and can cause infection, so these sutures should be kept to a minimum. Primary closure or reconstruction should be done in relatively clean wounds or wounds that have been cleaned effectively.  Healing by secondary infection is reserved only for highly infected wounds, delay of more than 24 h, grossly edematous wound and wounds in immunocompromised individuals. Soft tissue defects can be managed by local flaps, regional flaps, skin grafts or microvascular reconstruction.  According to our experience, primary wound closure is the treatment of choice as it gives best aesthetic result, provided thorough and meticulous wound debridement and cleaning is performed.
Due to the presence of the large number of microorganisms in the oral cavity and saliva of animals, a major concern in all bite wounds is infection. Hence, all bite injuries should be considered contaminated. The relative risk of contamination is determined by species of the attacking animal, location of injury, time until primary wound management, type of wound, host factors and local wound care.  Antibiotic therapy is mandatory from prophylactic as well as therapeutic point of view. Antibiotic therapy should be started for infected bite wounds and wounds at risk for infection, such as large wounds, large haematoma, full-thickness skin lacerations and wounds with loss of tissue. The National Health Service guidelines recommend amoxicillin-Clavulanate as the drug of choice for antibiotic prophylaxis against animal bite wound infection since it is active against most aerobic and anaerobic flora and also covers all commonly expected organisms among the canine oral flora. ,,, Prophylactic antibiotics should be administered for 3-5 days. For therapeutic purpose, antibiotics should be administered for 7-14 days.  In case of allergy to penicillin, effective alternatives include tetracycline or doxycycline plus metronidazole, cephalosporin such as ceftriaxone or clindamycin plus a fluoroquinolone. Pregnant women with a history of allergy to penicillin should be prescribed ceftriaxone.  We recommended administration of antibiotics in all our patients because none of the animal bite wounds could be considered clean. Augmentin 625 mg thrice a day was given for 5 days to prevent any secondary infection. There was no infectious complication reported later in our cases during post-operative follow-up.
For all bite wounds, tetanus and rabies prophylaxis is mandatory. Tetanus immunoglobulin should be administered, if a booster injection has not been taken within last 5 years or the patient had received less than three doses of adsorbed tetanus toxoid.  Rabies PEP includes passive immunisation with human rabies immunoglobulin (HRIG) and active immunisation with the rabies vaccine. HRIG should be administered on day 0 as single 20 IU/kg dose. If anatomically feasible, the full dose of HRIG should be thoroughly infiltrated in the area around and into the exposed wounds. Remaining quantity should be injected IM at a site at a distance from the site of vaccine administration, for instance, contralateral deltoid muscle, with no more than 4 ml per injection site. The purpose of administering HRIG is to provide patients with antibodies that begin to neutralise the virus during the time when their immune system produces active antibodies in response to the doses of rabies vaccine. HRIG can be administered up to 7 days following the first dose of rabies vaccine received, in case it is not administered on day 0 of the PEP regimen. Active antibodies are present in response to vaccine after 7 days, so HRIG is not indicated after 7 days. 
Rabies vaccine (each dose - 1 ml) should be administered IM in the deltoid (or anterolateral upper thigh in infants) over 1 month (0, 3, 7, 14 and 28 days). ,, The vaccine should never be administered in the gluteal muscle because it may result in lower neutralising antibody titres. The vaccine should also never be administered at the same site where immunoglobulins were administered.  All three patients were attacked and injured by stray dogs which could not be captured. As the rabid status of the attacking animal was not clear, PEP was mandatory. Tetanus toxoid and rabies immunoglobulins were administered, and anti-rabies vaccine regimen was started.
Rabies is a fatal disease of human beings and till date, only those that received vaccination before the onset of illness survived this disease. It is a zoonotic infectious disease caused by a virus that attacks the nervous system and later excreted in saliva. Rabies affects central nervous system with prodromal symptoms such as fever, headache, flu but the infection progresses rapidly to hallucinations, paralysis and eventually death from respiratory distress.
In the presented case reports, the animals might have attacked the patients as a defensive measure. Appropriate primary wound care and prophylaxis gave us a good aesthetic and functional outcome with satisfied patients.
| Conclusion|| |
Animal bites are very common but potentially preventable. Animal bites have a very broad spectrum of presentation and management. In developing countries like India, a more aggressive approach with respect to local wound care, antibiotic prophylaxis and PEP against tetanus and rabies is required as most of the individuals are not immunised, bites are from stray non-immunised animals and mostly have a delayed presentation. In addition, a good aesthetic result is of utmost importance in facial wounds which demands good local wound care and meticulous repair.
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Conflicts of interest
There are no conflicts of interest.
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[Figure 1], [Figure 2], [Figure 3]