Dog Bites (periocular)

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Article initiated by:
Meleha Ahmad, MD
All contributors:
Paul O. Phelps, MD, FACS, Anna Murchison, MD, MPH, Grant A. Justin, MD, Michael T Yen, MD, Meleha Ahmad, MD, Wesley Brundridge, DO
Assigned editor:
Paul O. Phelps, MD, FACS, Wesley Brundridge, DO
Review:
Assigned status Up to Date
 by Paul O. Phelps, MD, FACS on June 15, 2024.


Dog bites are common presenting complaints in pediatric and adult emergency rooms. They tend to occur preferentially in young children and are relatively common in the face and periocular region, causing a diverse set of injuries including eyelid lacerations, canalicular trauma, and more rarely open globe and orbital fractures. Infection is rare but potentially devastating complication. Management varies by extent of injury but mainly focuses on infection prevention and cosmetic reconstruction.

Disease Entity

Disease

In the United States of America for example, approximately 4.5 million people are bitten by dogs every year,[1] resulting in significant morbidity and even mortality. The majority of the bites occur on the dog owner's property and most of those bitten are children. Periocular injuries are common with dog bites, particularly from pit bulls. These injuries can result in a diverse set of periocular complications including damage to the canaliculi, facial nerve, levator muscle, lacrimal gland, rectus muscles, bony orbit and globe [2]. [3], [4]. Management of dog bites in the periocular location has some distinct considerations which will be discussed below.

Etiology

Traumatic injury from bite of any variety of Canis lupus familiaris or Canis familiaris. Damage from dog bites include abrasion, puncture, laceration, avulsion and crush injury [5], however most bites are combination of these mechanisms, with crush and laceration being the most common features. Particularly high risk breeds include German Shepard, Doberman, [6] and Pitt Bull Terrier.[7] In young children, most dog bites are perpetrated by dogs familiar to the patient and their family and often occur during seemingly positive, self-initiated interactions. [8] In older children and adults, bites are often sustained by an unfamiliar dog with which they are not voluntarily interaction. Dogs predilection to attack the central area of the face expalins the periocular injuries seen in up to 17% of cases.[9][10]

Risk Factors

Risk factors for dog bites include young age (nearly ¾ of victims are younger than 9 years old [6]), male sex [11], and attention deficit hyperactivity disorder [12]. Younger children are at increased risk for facial involvement due to small stature and underdeveloped motor skills. Other risk factors include injured/ill dog or a dog which feels threatened.

Epidemiology

In the US, stray dogs cause 15.55% of reported dog bites. Just 0.97% of stray dog bites lead to severe injury, while 1.91% of bites from non-stray dogs cause serious injury.[13] Nearly 20% require medical attention [CDC], accounting for approximately 1% of emergency department visits per year and these attacks result in over $100 million in medical bills each year [14]. According to estimates, over 50% of children are bitten by a dog at some point in their lives. [15], [16] The ocular and periocular tissue are affected in 4% to 17% of cases [17].

Primary prevention

Reporting of animal bites to officials is optional, with officials being notified in only 20% of incidents. [18] Nearly 50% of dogs involved in periocular dog bites are euthanized, with nearly 60% of those that were not euthanized biting again over the course of 3 years [19].

Infection Risk

Overall rates of soft tissue infection after dog bites to the head and neck are less than 5% in most major studies [20]. The relatively low risk of infection in this area is attributable to rich vascular supply to the area which increases the rate of healing but can also predispose to catastrophic blood born infection in cases in which infection does occur. Infections can partially be attributed to the valveless venous supply to the face which communicates with the skull base, allowing potential pathogens direct access to the intracranial space. The over 64 species of bacteria found in a canine mouth include aerobic and anaerobic bacteria. Soft tissue infections are classically polymicrobial in nature with a high preponderance of anaerobic organisms [21]. Common orgnaisms include Pastruella, Streptococi, Staphylococci, Moraxella, Corynebacterium and Neisseria [22]. Two especially concerning species, due to potential antibiotic resistance and aggressive nature include Pasteurella multocida, which causes intense pain and abscess formation, and Capnocytophaga canimorsus (formerly known as group DF-2) which can result in a necrotizing infection and fulminant sepsis [23].

Classification

The Lackmann classification has been utilized to grade the level of damage from dog bites.[24]

Lackmann Stage
Stage I  Superficial
Stage II  Skin and Underlying Muscle
Stage III  Traumatic Defects in the Deeper Tissues
Stage IVA Stage III +  vascular and/or nerve damage 
Stage IVB Stage III + bone and/or organ damage

Physical examination

Periocular dog bite resulting in canalicular eyelid laceration

Evaluation of any patient with a dog bite injury beings with complete physical exam to rule out not only periocular involvement but any life-threatening injuries. Most injuries will present with at least two puncture wounds representing upper and lower incisors (Figure 1).

Diagnostic procedures

Given the high risk for canalicular involvement in eyelid lacerations caused by dog bites, medial eyelid lacerations should be appropriately explored for canalicular involvement [22]. In addition, a high suspicion for orbital fractures should be kept in the case of extensive wounds and/or puncture wounds in the maxillary/ malar area [25], and these patients should undergo diagnostic maxillofacial CT scan.

Management

General Management

General principles of management of dog bites includes management of any life-threatening injuries first, followed by disinfection, exploration and wound closure. Initial surgical management focuses on simple wound closure with the opportunity for second stage procedures at a later time [26]. In all injuries listed below, technique of repair does not differ from traditional methods.

Infection Prevention

Infection is a serious concern after dog bite injuries. Management of infection risk

Irrigation

Thorough irrigation can decrease the risk of infection by up to 90% [27]. The suggested technique is using a 30 mL syringe with an 18G catheter or needle to create a forceful stream [28]. A total volume of at least 150 mL is recommended. Povidone-Iodine irrigation is potentially useful in high risk puncture wounds but can otherwise slow wound healing and is not generally recommended [29].

Wound Debridement

Judicial debridement can decrease the risk of infection, particularly in high risk crush and puncture wounds [26].

Wound Closure

Early closure of wounds of the head and neck is recommended and does not seem to[30] increase the risk of infection, as has been suggested in extremity wounds, for example [31]. On the other hand, postponing wound closure by up to 24 hours (such as overnight) does not appear to increase infection rates as long as prophylactic antibiotics are instituted promptly on presentation [32].

Prophylactic Systemic Antibiotic

Use of prophylactic antibiotics is recommended in high risk situations such as deep tissue involvement, bone involvement (including orbital fractures), crush injuries or in patients with immunocompromise, however is controversial in the case of minor injuries. Amoxicillin/ Clavulanate for 3-5 days is first line. Options for patients with penicillin allergy include trimethoprim/ sulfamethoxazole, clindamycin, ciprofloxacin or azithromycin. Longer antibiotic treatment is indicated in the setting of active infection.

Rabies Vaccination

Rabies is extremely rare in the United States due to mass canine vaccinations since 1948. Rabies vaccination and immunoglobulin are only recommended in cases in which there is a high suspicion for infection of the attacking animal.

Tetanus Vaccination

Tetanus spores are relatively common in dog feces and can lie dormant for months. Tetanus vaccination with immunoglobulin is recommended in all patients with an unknown vaccination history, immunocompromise or those who have not received the initial three doses primarily [32].

Open Globe

Open globe injury from dog bites is rare, with only a few case reports in the literature [33]. The low prevalence of ocular injury is attributed to blink reflex which protects the globe. In two other cases, it appears that a distant site (in one case in the cranium [34], in the other on the cheek [2]) acts as a fulcrum for the superior canine jaw, allowing the lower jaw to enter the orbit, usually inferomedially.

Canalicular Laceration

Canalicular lacerations are common injuries from periocular dog bites. One group suggested a higher rate of canalicular injury in eyelid lacerations due to dog bites compared to those by alternative mechanisms [22]. This is most likely due stretching of the eyelid resulting in shear forces at the canaliculus which has been found to be the weakest point of the eyelid [35] or due to puncture wounds in this area [22]. Repair with silicone intubation is indicated.

Orbital Fractures

Orbital fracture are a relatively rare outcome of dog bites, with most sources stating the incidence to be less than 5%. Risk factors include age < 2 years, large dogs and severe bites. The most commonly involved bones are nasal, maxillary and orbital bones and mechanisms include blunt force and puncture wounds [25]. It has been suggested that dog bites causing facial fractures are more likely to involve the nasal bones/ periorbital area [25].

Prognosis

Prognosis depends on extent and mechanism of injury.

Additional Resources

References

  1. ↑ https://www.who.int/news-room/fact-sheets/detail/animal-bites#:~:text=In%20the%20United%20States%20of%20America%20for%20example%2C%20approximately%204.5%C2%A0million%20people%20are%20bitten%20by%20dogs%20every%20year
  2. ↑ 2.0 2.1 Erickson BP, Feng PW, Liao SD, Modi YS, Ko AC, Lee WW. Dog bite injuries of the eye and ocular adnexa. Orbit (London). 2019. doi:10.1080/01676830.2018.1470190
  3. ↑ Weiss HB, Friedman DI, Coben JH. Incidence of dog bite injuries treated in emergency departments. JAMA 1998;279:51-3.
  4. ↑ Bratton EM, Golas L, Wei LA, Davies BW, Durairaj VD. Ophthalmic Manifestations of Facial Dog Bites in Children. Ophthalmic Plast Reconstr Surg 2018;34:106-9.
  5. ↑ Karlson TA. The Incidence of Facial Injuries From Dog Bites. JAMA J Am Med Assoc. 1984. doi:10.1001/jama.1984.03340480047026
  6. ↑ 6.0 6.1 Schalamon J, Ainoedhofer H, Singer G, et al. Analysis of dog bites in children who are younger than 17 years. Pediatrics. 2006. doi:10.1542/peds.2005-1451
  7. ↑ Wladis EJ, Dewan MA. Periorbital trauma from pit bull terrier attacks. Orbit 2012;31:200-2.
  8. ↑ Reisner IR, Nance ML, Zeller JS, Houseknecht EM, Kassam-Adams N, Wiebe DJ. Behavioural characteristics associated with dog bites to children presenting to an urban trauma centre. Inj Prev. 2011. doi:10.1136/ip.2010.029868
  9. ↑ Palmer J, Rees M. Dog bites of the face: a 15 year review. Br J Plast Surg. 1983;36(3):315–318.
  10. ↑ Wei LA, Chen HH, Hink EM, Durairaj VD. Pediatric facial fractures from dog bites. Ophthal Plast Reconstr Surg. 2013;29(3):179–182.
  11. ↑ Borud LJ, Friedman DW. Dog bites in New York City. Plast Reconstr Surg. 2000. doi:10.1097/00006534-200010000-00004
  12. ↑ Mitchell RB, Nañez G, Wagner JD, Kelly J. Dog bites of the scalp, face, and neck in children. Laryngoscope. 2003. doi:10.1097/00005537-200303000-00018
  13. ↑ https://worldanimalfoundation.org/advocate/dog-bite-statistics/
  14. ↑ www.iii.org/media/hottopics/insurance/dogbite
  15. ↑ Beck AM, Jones BA. Unreported dog bites in children. Public Health Rep 1985;100:315-21.
  16. ↑ Burroughs JR, Soparkar CN, Patrinely JR, Williams PD, Holck DE. Periocular dog bite injuries and responsible care. Ophthal Plast Reconstr Surg 2002;18:416-19; discussion 9-20.
  17. ↑ Kizer KW. Epidemiologic and clinical aspects of animal bite injuries. J Am Coll Emerg Physicians. 1979. doi:10.1016/S0361-1124(79)80339-1
  18. ↑ Stevenson TR, Thacker JG, Rodeheaver GT, Bacchetta C, Edgerton MT, Edlich RF. Cleansing the traumatic wound by high pressure syringe irrigation. J Am Coll Emerg Physicians. 1976. doi:10.1016/S0361-1124(76)80160-8
  19. ↑ Burroughs JR, Soparkar CNS, Patrinely JR, Williams PD, Holck DEE. Periocular dog bite injuries and responsible care. Ophthal Plast Reconstr Surg. 2002. doi:10.1097/00002341-200211000-00005
  20. ↑ Wolff KD. Management of animal bite injuries of the face: Experience with 94 patients. J Oral Maxillofac Surg. 1998. doi:10.1016/S0278-2391(98)90009-X
  21. ↑ Dendle C, Looke D. Review article: Animal bites: An update for management with a focus on infections. EMA - Emerg Med Australas. 2008. doi:10.1111/j.1742-6723.2008.01130.x
  22. ↑ 22.0 22.1 22.2 22.3 Savar A, Kirszrot J, Rubin PAD. Canalicular involvement in dog bite related eyelid lacerations. Ophthal Plast Reconstr Surg. 2008. doi:10.1097/IOP.0b013e318177e21f
  23. ↑ Slonim CB. Dog bite-induced canalicular lacerations: A review of 17 cases. Ophthal Plast Reconstr Surg. 1996. doi:10.1097/00002341-199609000-00012
  24. ↑ Lackmann GM, Draf W, Isselstein G, Töllner U. Surgical treatment of facial dog bite injuries in children. J Cranio-Maxillofacial Surg. 1992. doi:10.1016/S1010-5182(05)80472-X
  25. ↑ 25.0 25.1 25.2 Tu AH, Girotto JA, Singh N, et al. Facial fractures from dog bite injuries. Plast Reconstr Surg. 2002. doi:10.1097/00006534-200204010-00008
  26. ↑ 26.0 26.1 Herman DC, Bartley GB, Walker RC. The treatment of animal bite injuries of the eye and ocular adnexa. Ophthal Plast Reconstr Surg. 1987. doi:10.1097/00002341-198703040-00003
  27. ↑ Stevenson TR, Thacker JG, Rodeheaver GT, Bacchetta C, Edgerton MT, Edlich RF. Cleansing the traumatic wound by high pressure syringe irrigation. J Am Coll Emerg Physicians. 1976. doi:10.1016/S0361-1124(76)80160-8
  28. ↑ Wolff KD. Management of animal bite injuries of the face: Experience with 94 patients. J Oral Maxillofac Surg. 1998. doi:10.1016/S0278-2391(98)90009-X
  29. ↑ Callaham M. Prophylactic antibiotics in common dog bite wounds: A controlled study. Ann Emerg Med. 1980. doi:10.1016/S0196-0644(80)80153-3
  30. ↑ Habot-Wilner Z, Desatnik H, Greenbaum A, Barequent IS. An intraocular injury from a dog bite. Isr Med Assoc J. 2006.
  31. ↑ Paschos NK, Makris EA, Gantsos A, Georgoulis AD. Primary closure versus non-closure of dog bite wounds. A randomised controlled trial. Injury. 2014. doi:10.1016/j.injury.2013.07.010
  32. ↑ 32.0 32.1 Akhtar N, Smith MJ, McKirdy S, Page RE. Surgical delay in the management of dog bite injuries in children, does it increase the risk of infection? Arthrosc - J Arthrosc Relat Surg. 1997. doi:10.1016/j.bjps.2005.05.Q05
  33. ↑ Habot-Wilner Z, Desatnik H, Greenbaum A, Barequent IS. An intraocular injury from a dog bite. Isr Med Assoc J. 2006.
  34. ↑ Jones NP. Perforating eye injuries caused by dog bites. J R Soc Med. 1990. doi:10.1177/014107689008300521
  35. ↑ Jordan DR, Ziai S, Gilberg SM, Mawn LA. Pathogenesis of canalicular lacerations. Ophthal Plast Reconstr Surg. 2008. doi:10.1097/IOP.0b013e318183267a
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  3. Wladis EJ, Dewan MA. Periorbital trauma from pit bull terrier attacks. Orbit 2012;31:200-2.
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