Invited Review Paper
Trauma
Facial bite wounds: management update

https://doi.org/10.1016/j.ijom.2005.04.001Get rights and content

Abstract

Bite wounds are frequently located on the face; injuries inflicted by dogs are most common, especially in children. Bacteriology of infected dog and cat bite wounds includes Pasteurella multocida, Staphylococcus aureus, viridans streptococci, Capnocytophaga canimorsus, and oral anaerobes. Infected human bites yield a similar spectrum of bacteria except for Pasteurellae and C. canimorsus; instead human bites are frequently complicated by Eikenella corrodens. Antibiotic therapy against these bacteria is indicated both for infected bite wounds and fresh wounds considered at risk for infection. Amoxicillin-clavulanate (and other combinations of extended-spectrum penicillins with β-lactamase inhibitors) and moxifloxacin offer the best in vitro coverage of the pathogenic flora. Initial wound management consisting in irrigation and debridement is at least equally important with antibiotics for prevention of infection. The need for prophylaxis against systemic infectious complications, particularly tetanus, should also be evaluated. Primary surgical repair is the treatment of choice for most clinically uninfected facial bite wounds, whereas delayed closure should be reserved for certain high risk or already infected wounds. Avulsive injuries with significant tissue loss represent the most difficult cases for definitive management and are also those most likely to require hospitalization.

Section snippets

Dog and cat bites

Despite the comparable populations of dogs and cats, dogs are responsible for the vast majority of animal bite wounds2, 66, 96. Furthermore, dog bite-related mortality is a well-recognized aspect of the problem40, 87, amounting to at least 15 deaths per year in the United States22, 89. The peak incidence of dog bites occurs in young children, among which most documented injuries have been to the head, face, or neck region24, 33, 87, 106, whereas in older children and adults dog bites most

Human bites

Most human bites occur during fights whereas a substantial percentage is related to sexual activities42. In addition to occlusional bites, which are analogous to animal bites, human bites include a specific type of wound, the clenched-fist injury, which is sustained by the attacker, most commonly to the third metacarpophalangeal joint of the dominant hand, as a result of a clenched fist clashed against the teeth of the opponent71, 81, 82. The first of the present authors has also witnessed a

Initial evaluation

As with any injury, priorities are given to any life-threatening conditions, according to advanced trauma life support (ATLS) resuscitation guidelines40, 65. Such injuries are usually associated with penetrating neck trauma following mauling by large dogs15, 77. Nevertheless, even apparently minor wounds require careful exploration, because seemingly superficial injuries may well overlie fractures, involve lacerated tendons or nerves or penetrate into joint spaces40, and such complicated wounds

Definitive management

Since all bite wounds are contaminated with the oral flora of the culprit, prevention of local wound infection is the principal treatment concern along with rabies and tetanus prophylaxis74, 105. Proper surgical toilet with wound irrigation followed by careful debridement remains the mainstay of treatment of all bite wounds12, 32, 40, 68, 74, as it significantly reduces the incidence of infection19, 84. Further treatment decisions primarily concern the two most problematic elements of the

Specific management of facial bite wounds

The face and scalp are among the sites most resistant to posttraumatic infection, presumably because of the rich blood supply of the area37, 69, 83, 88. As a result, facial bite wounds, even when sutured, generally are associated with low infection rates, which in most studies are less than 6%16, 33, 34, 37, 59, 63, 72, 91. However, bite wounds in this area may be both severe and disfiguring, especially in children87, and the cosmetic result may be further compromised by inadequate surgical

Conclusions

Although wound infection is the most common complication of bite wounds, those located on the face are at low risk, with the final cosmetic result being the most important consideration. However, the need for thorough irrigation and judicious wound debridement should not be underestimated as it is the most effective means to reduce the incidence of infection. Tetanus prophylaxis for all nonimmunized bite victims is also part of the treatment protocol. Prior to definitive surgical management,

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