Introduction

Dog bites occasion complicated craniomaxillofacial damages. Functional, cosmetic impairment and probable septicity are demanding for maxillofacial specialists (¹). Children under ten years are the most usual victims of dog bites (²), in whom, the most regular damaged parts are the head, face, and neck (³), where the principal affected zones are the nose and the auricles (²). The tissue damage may be on the surface, but they could provoke amputations (²). The handling for children affected by trauma produced by bites of dogs merits singular care. Besides, aesthetic implications are relevant (¹). Considering that the bite injuries are repeatedly situated on the face, an oral and maxillofacial surgeon requires being well known with the therapy of animal bites (⁴).

This case presents the maxillofacial management of multiple lacerations on mouth, face, and head caused by dog bites in an infant; besides, most pertinent aspects for the management of dogs bites are commented.

Case report

A three-year male infant was received at the service of Stomatology and Maxillofacial Surgery at the San Vicente Hospital in Medellin, Colombia, as a victim of a Pit Bull terrier biting. Before any intervention, written permission of the parents rendering to ethical criterion was signed; also, the Helsinki Declaration guidelines were followed in this case. The patient had multiple wounds at the level of the upper eyelid of the right eyeball, left hemisphere with the involvement of the auricular pavilion, wounds with multiple detachments on face and scalp, several abrasions and ecchymosis in the bilateral infraorbital and mouth region (Figure 1).

Figure 1 Soft-tissue injuries provoked by the dog-bite confrontation. a. Multiple wounds at the level of the upper eyelid of the right eyeball, cheeks, and lips; abrasions and bilateral infra-orbital ecchymosis. b. Multiple injuries at the left hemisphere with the involvement of the auricular pavilion. c. Wounds with multiple detachments on the scalp. d. Auricular pavilion detachment. 

The clinical intervention was completed under general anesthesia in the first 24 hours after injury. The affected zones were cleaned and irrigated with saline solution, and iodopovidone. The wounds were sutured in layers, including muscles, using vicryl (4-0) and monocryl (5-0) (Figure 2).

Figure 2 The first closure of the wounds. a. At the left hemisphere. b. At the level of the upper eyelid of the right eyeball, cheeks, and lips. c. On the lower edge of the jaw. d. At the left ear. 

Tetanus and anti-rabies vaccination, and antibiotic (ampicillin with sulbactam) and analgesic (tramadol) were administered. On the fifth postoperative day, the stitches (except the left auricular pavilion) were removed, and the infant was discharged from the hospital. His parents were guided on the administration of the medicine (antibiotic and analgesic) and attention on sanitization and antisepsis of the lesions. One week after the trauma, the child showed adequate wound curing absent of aggravation (Figure 3).

Figure 3 One week follow up at frontal views (a) and lateral left (b). 

Table 1 Most relevant aspects for the management of canine bites. 

Table 1 highlights the most relevant aspects for the management of canine bites

Discussion

As was described in this case, children are the most injured by dog’s attacks, affecting principally kids less than five years old [4]. Besides, this report confirms previous works that informed that Pit Bull Terrier is the significant species implicated in this kind of injuries; this dog is characterized by ferociousness and corporeal imposture (⁵).

As occurred in the present case, lesions caused by canine’s bite involve superficial tissues, including or no loss of substance, to facial and cranial harm (⁶); besides, the lacerations are seldom related to facial bone fractures (⁷). Nevertheless, sometimes the wounds can conduct to amputations, counting serious vascular and nerve or bony affection (⁸). In the present case, the left auricular pavilion had a grave detachment (Figure 1d).

Reasons as the number of wounds made and their position, impact the therapeutic conduct to be assumed (⁹). As was implemented in this case, the initial management of bites was direct suture; however, grafting or flaps could be needed depending on the seriousness of the damage (¹⁰). Besides, the recommendation about irrigation with a saline solution was applied; this advice reduces microbial load and to subtract undesirable elements and remains (^11-13).

Considering that most infections related to dog bites are a combination of anaerobic and aerobic microorganisms, antimicrobials are recommended, suggesting penicillin the first select; however, amoxicillin and clavulanic acid (gold standard) are the most regularly suggested, succeeded by IV generation cephalosporin and ampicillin with sulbactam (^1,12,14). In cases of hypersensitivity, alternative antimicrobials must be advocated.

The management of anti-rabies vaccination continues the gold standard of therapy for animal bite lesions (^9,15). Besides, a tetanus vaccination must be considered in the case the child has not been immunized in the preceding five years (²).

Finally, postoperative checks could guarantee an optimum result for the wounded tissue (⁸). Besides, inter-consultation with other medical specialties as plastic surgery, ophthalmology, orthopedics, neurosurgery, and psychology, among others, it is recommended for severe harms, particularly those concerning disfigurement (^4,15).

Conclusions

It is relevant to highlight that in this case, the principal recommendations to the management of dog bites were applied, as they are described in Table 1, which allowed obtaining satisfactory results. Moreover, public health policies must be enforced to prevent dog bites.